From Kerkow media coming up on the show, you can't not move, you have to move the legs.
I can't convey in simple words the experience is beyond anything any of us can imagine unless you actually have had the disease. And I can tell you, you become so, so desperate to get rid of the sensation that.
Do you have any of these issues, daytime drowsiness can't fall asleep, can't stay asleep, you don't wake up refreshed in the morning snoring, she says you stop breathing. You may even be one of those people who joke around about how you haven't had a good night's sleep in years. So if you were anyone, you know, one of the hundred million people who don't get a proper night's sleep. This is your episode of Medicine. We're still practicing. I'm Bill Kurtis.
Johns Hopkins is one of the highest regarded health care institutions in the country. There seems to be no end to the roster of specialists who bring us the edge of the art in research, medicine and patient care. Today, we continue our Johns Hopkins series with the issues that keep you up at night or have us yawning our way through the day. First, of course, my co-host, Doctor Stephen Tayback. He's the quadruple board certified doctor of internal medicine,
pulmonary disease, critical care and neuro critical care. And he's also my very best friend, Dr. Tayback. How are you holding up these days?
Hayesville actually doing a lot better. Things are looking up.
Oh, that's good to hear. I look forward to getting into that a little bit. Dr. Christopher Lee joined Johns Hopkins almost three decades ago. He's board certified in internal medicine and psychiatry and neurology. He's also a professor of neurology at Johns Hopkins and he specializes in sleep or the lack thereof.
Welcome. Nice to have you, Doctor early. Thank you for having me. I wonder, Chris, can you just help us define the phases of sleep? What are those?
The sleep studies are published on the grounds that we have more or less broken step up into two big bits, which is what's called non REM sleep and REM sleep. And REM stands for Rapid Eye Movement. And in about a quarter of your sleep is involved in this REM state, which is the dreaming state. The non REM state can be partitioned into what's called stage one, stage two, three and four with stage three and four is really called
slow wave sleep. Stage one would be drowsiness. We spend most of our time in stage two sleep the deeper sleep so-called stage three four tends to be of a larger proportion of sleep when you're younger. And so when you're in your teens and twenties, that's about 20 percent of your sleep. If you're in the 50s and 60s, that's about three or four percent, obviously.
Did you say that the really quality sleep goes down to like three percent when you're old?
Well, well, the deeper sleep our ability to maintain sleep in general from an age point of view is a little complex. But essentially the elements of sleep when we talk about stage three for sleep, that is much higher in the younger and gets less and less as we get older, fertility gets down to a few percentage, as I mentioned, after the age of 50.
So for the lay public, what's the significance of those stages and and what should they be targeting and what do we do on a day to day basis that is either helpful or harmful to the stages that we actually require?
The biggest element of sleep is consolidation of sleep, whether you're in stage two, stage three, stage four, it's how consolidate your sleep is. What is what does that mean? Consolidated. So humans, unlike cats and dogs, really need a continuous period of sleep. Now, we might be able to break that up into two sections, a four hour and a four hours. But generally most people need between seven and
eight hours of sleep. And it needs to be fairly consistent from start to finish if you're awakening frequently at night, that sleep fragmentation. So the first and foremost thing is trying to get a consolidated amount of sleep. That is from the time your head hits the pillow to the time you wake up in the morning. That period of time should be seven to eight hours and basically you should be able to have slept through that full duration
of the night. The second issue is that it's not clear if the different stages of sleep are relevant to you experiencing a certain good quality of sleep as much as it may be involved in memory and memory consolidation. So the deeper sleep is in stage three four might be relevant to how you hold on to certain memory. Generally, if you're spending most of your time in stage two, three or four sleep, that's good. If you're spending too much time in what's called stage one sleep, that's bad
because stage one sleep would be drowsy. You're sort of in sleep, but you're never really you're not quite into sleep yet. And so if you have a disproportionate amount of stage one sleep, then you're more likely to experience a sense of not feeling rested, tired, memory problems, things like that.
Now, is this in our control at all? Can the layperson do something so that they make sure that they don't linger in stage one and can optimise their stage three and stage four sleep?
We talk about the brain resting and the importance of the brain and sleep. The truth is, sleep is really a total biological rest and your sleep is looking to the metabolic demands you put on your body during the day. As much as it's looking at the metabolic demands you put on its brain each day, a significant amount of physical activity during the day, we're. Well, to improve the quality of sleep, the timing of sleep is equally important, not all of us are designed to be going to
bed at 10:00, getting up at 6:00. Some of us are called night owls. So our biological clock doesn't make us ready for sleep until 1:00 in the morning or two in the morning or three in the morning.
Have you helped people to adjust that? Yes. How do you do that?
There are two basic ways. The use of lights in the morning, particularly if you're getting up early. So you have a large urban society which gets up at whatever time, four or five, six in the morning in order to get to work. You spend an hour or two driving, so you've got to get up work. You have to be in work by 8:00, then you've got to be up at six, five or six. So using artificial lights, high intensity looks, lights to mimic the sunlight can help
what's called phase advance. Move your clock back to something that's more socially acceptable.
That's one thing. Melatonin appears to have some value. I know people use melatonin at high doses to try to get them to sleep.
But the purpose of melatonin really is a biological marker to sort of indicate that sleep is about to happen in three or four hours. And you take it one to three milligrams, three or four hours before bedtime. That also might help the brain.
Your phase delayed biological clock back to something that's a little bit more in line with your early bird tendency to get what is melatonin do and don't we make that naturally into the melatonin is tied to what you're called your circadian rhythm based on your circadian rhythm is your internal biological clock, which is ticking away over a
twenty four hour period. That's sort of in the beginning decides to activate everything so you can be busy, inactive, ready to go and then start slowing things down as you approach sleep within that curve. There was a period of time in which it triggers this melatonin to be produced and have a peak. And that peak basically should appear three to four hours before you're actually ready for your brain to hit the go to sleep.
So the purpose of the melatonin is to let the rest of the body. So when the melatonin goes up, your your heart rate starts going down, your metabolism, your liver, your muscle, those all start going down in terms of their metabolic need long before your head hits the pillow. The brain's the last organ on board about three or four hours later to get the sleep. So the purpose of that melatonin really is a biological signal to set that into motion for that given period of time.
What about people who chronically have trouble falling asleep? Is it helpful to use sleep AIDS? Is it counterproductive? Is it better to only use natural means or no sleep aids? What's your perspective on sleeping pills and other sleeping AIDS?
I'm not completely anti sleeping pill. I just think there are a lot of really good alternatives that will work for like 90 percent of people. I just think that the sleeping pill is a quick answer. You walk into a doctor's office, I can't fall asleep. I can enhance a prescription for a pill. There are a couple fairly straightforward approaches. Again, some really good data demonstrating the value of what's called sleep hygiene.
What sleep hygiene.
Sleep hygiene is trying to get the person to think in terms of what they need to do behaviorally in efforts to prepare for sleep. The simple things are about caffeine. There are some people that are very, very sensitive to caffeine. If they take a cup of coffee at 1:00 in the afternoon, it still affects them at night. So I understand how sensitive you are, but basically you shouldn't be drinking caffeine four or five hours before sleep onset time.
That straightforward exercise exercise is something that you should be doing as a product of your arousal state, your awake state. What do you want to do in the morning or the afternoon? But you shouldn't be doing significant aerobic exercise for hours before bedtime or otherwise. You're just activating your system.
The other issues and the most common problem and it has been very successful is what I call blue screen habits, iPhones, iPads, computers. People live in their bedrooms with these devices and they don't know how to disconnect. My general is no blue screens three hours before bedtime, no TV. The last hour before bedtime, people said, what do I do? I said, I'll read, listen to music. If you have a bit of a hobby, do something that relaxes. And they said, well,
I'm going to get bored. So that's perfect. That's exactly what you you want to get bored and tired and ready to go to sleep. So sleep hygiene is really effective for the majority of people because I think many people have difficulty getting to sleep because they've developed bad habits around using their iPhones up until the last minute and things like that.
What are the long term ramifications, then, of sleep fragmentation? Is it going to shorten your life expectancy or is it just a nuisance?
There are three major consequences that come as a consequence of any sleep loss. The first and foremost is attention and concentration, and most of us attention. Concentration might not be a big deal. If you're in a job that's fairly routine, it's reflexive. It will impact learning significantly in the younger age groups because that's what kids are trying to do, is learn multitasking is probably the biggest consequence
for the more working individual. The second element is moved off the state and increased problems with decreased interest, decreased drive, lack of motivation. It can aggravate or cause an anxiety or depression. And both those elements are pretty early in the process within weeks, if not months, of you having chronic sleep loss. The third element is sleepiness, which, interestingly enough, is really poor as a measure of one's sleep quality.
It is the least reliable. There are plenty of people out there who are not getting quality sleep, who don't feel tired.
Let's talk about sleep aids like Restoril and Ambien and challenges that people have had with that. And just to be straightforward, many years ago I pulverized my ankle on a ski slope and had trouble sleeping, was prescribed sleeping pills. I was told that you don't really get the same quality of sleep on something like Ambien, a Restoril. Is that so?
Yes and no. There really there to suppress arousal. They don't necessarily induce sleep. We go back to my original discussion about the difference between sleep is not just the absence of arousal sleep. It's its own biological state. It has to exist.
That biological phenomena has to exist for you to enter it just by knocking yourself out. I mean, I could I could knock myself out with a fifth of whiskey. Does that mean I'm sleepy?
So the issue is the sleeping pills in general with respect to which one you choose, are there to suppress arousal such that if sleep is sitting there waiting, you can enter sleep. So I think the sleeping pills work well if you have a certain type of person, just can't turn it off, you know, sleep is there. Their the biology sitting there waiting for them. They're just waiting for them to finally turn off that arousal mechanism.
Sleeping pills may be a value in that situation, but believe me, that's a very, very small number of people for which it has some value.
Do you actually convince yourself, is it a psychological thing? You convince yourself that you're going to sleep well or you convince yourself, well, I'm not going to sleep well, and then you wake up at whatever time you think you're going to wake up?
Yes, I think that there's a lot of cognitive machinations that go on to create an environment. I mean, the very nature that you go to your doctor for an answer and they give you an answer, you'll come to believe that that's the right answer. And therefore, you believe if I stop this, I won't be able to sleep. And unfortunately, what happens is if you try to stop, you'll get a rebound that is coming off the medications. There'll be a period of time which you will go
back to some degree of insomnia. Thus it's sort of fulfilling your belief that I can't get off this medication.
I wonder, could you talk to us a little bit about, well, that noise that you hear from your partner, that snoring kind of. So I understand that that falls into two categories. There's the snoring and there's sleep apnea. Can you explain the difference dynamically?
The snoring really comes from the upper part, the soft palate. It's basically air rushing through your nasal passages versus your mouth at different pressure differences. So you get this flap, that's the the snore. Any time you have to pull the air fast across the soft palate, you're likely to get the snoring. So if you have a little bit of nasal congestion, you open your mouth a little bit to breathe and you're going to snore. If you have
obstruction farther down in the upper part of the airway. Again, if there some resistance, you can breathe harder. And again, the air is going to rush across the soft power and cause you to snore. Sleep apnea, persay really involved in that upper part of our weight, sort of below the tonsils for want of a better word. That's basically a muscular tube. And essentially, when you have sleep apnea, that muscular tube is very collapsible. There's nothing to support it.
So when you breathe in, that tube starts to collapse. The example I give is when we were kids, we used to have paper straws. And if you left the paper straw in the soda long enough, you want to suck it. What would happen? The straw would collapse in the middle. The same, too. If you have a tube going down to your lungs and that tube is relatively flabby and you take a breath in, it's going to collapse and cause obstruction. Thus the term obstructive sleep apnea.
And so sleep apnea really has to deal with that lower part for want of a better anatomical term. Blow your where your tonsils are. The snoring is more or less above where the tonsils are into that soft part of your tissue.
So other than divorce court, what are the other ramifications of snoring?
There's a lot of associations and I will point out to people listening in an association doesn't mean it's causally related. That means there's some relationship. We just don't know what that relationship is. So there's an association between snoring and risk of high blood pressure, snoring and risk of stroke. But in general, most studies don't tie any specific health concerns to snoring persay. If it is not associated with sleep apnea, what if it wakes you up?
You are not aware of your own snoring. If it wakes you up, it's because you have.
Yeah, I keep telling her I don't snore. That's right.
It is a problem to degree that you're awake in your bed partner up. So that's the critical Mexia. When people come to me from the snoring point of view, it's usually he comes to me, he's snoring and the answer is, I can't wake my wife. I, I keep getting nudged in the middle of the night. If you share a bed with someone, someone's going to have a consequence on the other bed partner unless the other bed partners are really good sleep as well.
So, OK, so let's go to the more difficult one. Sleep apnea, the act of actually stopping breathing often many times a minute is that destructive.
So when we talk about sleep apnea, even though the term apnea means to stop breathing, most of the events are partial obstructions and not always complete obstructions. So what we refer to as Hypponen is so the airway partially collapsed, doesn't completely collapse. So it's a range between the partial all the way up to 100 percent collapse. So when you talk about obstructive sleep apnea, we talk about some degree of collapse, maybe 40, 50 percent collapse, up to 100 percent collapse.
And so sleep apnea by the numbers. So we can talk about having 20 events per hour, 30 events per our normal is considered less than five events per hour. So we all have a little bit during the night. The data is fairly strong for suggesting that untreated obstructive sleep apnea, if your rate is above 30 per hour, probably has risk of at least hypertension, stroke. And it's also about the heart disease at rates less than 15 per hour. It's probably not a long term health risk
between 15 and 30. It's unclear.
What about position in sleep? Are there things that that an individual can do without using mechanical devices that might improve their sleep apnea and their quality of sleep?
So obstructive sleep apnea tends to be worse on your back versus side versus your stomach. If you have a tendency to be a backslapper trying to recondition yourself to your side, there are wedge pillows and things like that that people can buy online. There are these special shirts that have a sort of rubber ball in the back of it that makes it very uncomfortable for you to roll over on your back. So those are positional things
that you can do. A few people for whom they've never been able to tolerate PAP and I think their apnea is bad. I tell them to get a lounge chair and to start sleeping. So the more upright you sleep, the more the jaw and the tongue comes forward, basically reduces the degree of obstruction. So.
We're going to take about a 30 second break. I'm going to go grab a coffee. We'll be right back with Dr. Christopher Lee from Johns Hopkins.
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OK, we're back, Dr. Christopher, let's talk about kind of the opposite side of the coin, I'm going to tell you a quick story.
I once sold advertising for a career, and I was in a very important meeting for probably the largest advertising contract that I had ever even imagined. And the CEO of the company was all excited and actually took out the contract, took out a pen, was prepared to sign that contract. The salesperson and I were all excited.
He put the pen to the paper and fell asleep. And he was he was gone. What happened, Chris?
Given the acute nature of it, I sort of does raise the question of whether or not he had narcolepsy.
He did have that narcolepsy. He later talked about that. But what is that?
Narcolepsy actually has some really nice, good understanding of the pathophysiology. It is now within the category of what's called autoimmune diseases, type one diabetes, narcolepsy. Basically, you develop antibodies for whatever reason. There are a couple concerns that certain viruses may trigger this, but basically develop an antibody to a very, very specific set of cells in your brain. The cells produce a peptide called Eareckson. What happens is this destroys those cells
either completely or to a significant degree diminishes them. And therefore, you don't have enough of this peptide Orexigen to maintain alertness. And as I mentioned earlier, one of the parts of the brain that's relevant to wakefulness is this posterior hypothalamus and these cells sit in that posterior part and that erection is an important factor in maintaining alertness.
So it wasn't contract avoidance, it was actually something more specific. So let's move from there and talk about some of your other specialties. One of the things I understand you've been researching and working on for some time is RLC know. Some of us didn't know anything about our last till we saw a commercial, the Restless Leg Syndrome. What exactly is that? And is it prevalent or just we see a lot of commercials for it on CNN.
So the the estimated prevalence for the US is about five percent of the population, with about half of them having, I think, clinically relevant symptoms requiring some treatment. Basically, it is a motor sensory disorder. It's associated with this often hard to describe, very irritating, uncomfortable sensation in your legs that almost compulsives you. You can't not move. You have to move the legs. The reward is as soon as you move the legs, the sensation drops off and disappears,
but may crescendo and Amanor start to increase again. So people, after moving the legs a couple times, often get out of bed and actually just walk for a while to get enough relief to get back in bed again. So.
So you've been studying it quite a bit. What are some of the things that you found out about it? What causes it, who has it, who doesn't have it? And what are you guys doing about it?
Well, essentially, it's about three to four times more common in women than men.
It basically increases in prevalence over the age group, probably coming to a plateau at about 50 to 60 years of age. But there is a progressive increase through childhood, adolescence and up through the younger adult ages. Most of our research for the last 30 years has been trying
to understand the pathophysiology of this disease. And what we know is that there is a association and what we believe is part of the primary pathology is that the brains of patients with restless syndrome have lower levels of iron in certain regions of the brain. So it's an insufficient state of brain and insufficient state, despite the fact that their blood levels of iron are normal. So it's
very organ specific phenomena. And this iron insufficiency leads to a couple of changes in your brain, one of which is an alteration in this chemical called dopamine. By altering, it doesn't specifically decrease the overall amount of dopamine. It basically changes its circadian change in dopamine. So don't levels
are right in the morning and low at night. And it seems to make that nater the lower point at night, lower or decreased, so that you start having symptoms of that lower level of dopamine at night that triggers the symptoms. And therefore, some of the first treatments that we had available back 30 years ago was the use of some of the agents commonly used in Parkinson's disease, generate RAPEX,
reequip the agonists. The symptoms are somewhat different in the younger age group, particularly men whose symptoms start before the age of thirty five have a very vicious form of disease. I mean, it will come on basically affect the whole life within a year or two. I mean, I mean, it was not just happen at night or during the evening and eventually they'll have it 24/7. It is. It's in women at a younger age under 40. It starts
to be an intermittent. So the symptoms come and go in coming and going, but becoming a nightly problem by the time they reach somewhere between 40 and 50.
So early on, you alluded to the earliest reported sleep aid and I'd like to know where that fits in to all of these syndromes, that being alcohol, how does that impact our sleep, our restless legs, our sleep apnea, good, bad, indifferent, chronic use of alcohol will actually make your sleep worse.
The usual scenario is you're using to get the sleep and it may work months, years, but then you start having problems with awakening from having a difficult time getting back sleep as regards to restless leg syndrome. About a third of patients, even a few sips of alcohol, would drive their legs nuts. In fact, seven is one that came out with the value of the Parkinson drug Sinemet
being a significant value in treating Arless patients. Part of that time there were people who were suffering with our loss for 20, 30, 40 years who were getting no more than two or three hours sleep a night, and some of them used alcohol and the way they did.
So if you take alcohol and it makes it worse, what you have to do is drink it fast enough and get enough down you to learn to become an anesthetic. But to clarify, you're not advising that? No, I'm not advising, no. It's a very unfortunate situation.
That's how desperate I mean, I can't convey in simple words the experience is beyond anything any of us can imagine unless you actually have had the disease. And I can tell you, you become so, so desperate to get rid of the sensation. And obviously during the day you can walk. That's fine, but you can't walk and sleep at the same time. And so when you've missed night after night for years on end, you will do what
you need to do. And some people have resorted to the use of figured out, if I drink this half this year, the whiskey straight down, I can get some sleep.
How are you affecting treatment here?
So one of the outcomes of that research I talked about was to see if I raised your body iron stores, whether a certain percentage of that could get over into the brain or your brain probably only constitutes about five percent of your total body in stores. But if I increase, the total amount, even of that fraction may not change the amount obviously would. We started with some simple studies, mostly Open-Ended designs, demonstrating the value of iron, initially oral iron.
Then we went to intravenous iron and there's been several, essentially three randomized placebo controlled trials of intravenous iron in patients who were not anemic, who did not necessarily have an iron deficiency, and demonstrated that you can get about 45 percent of patients who are going to demonstrate a much greater improvement in symptoms with intravenous iron. And so that's one of the things I think, as was an outcome of all of our basic research, that we can improve symptoms.
But that sounds kind of temporary because you're not going to have intravenous iron permanently.
It's a one off experience. And then I usually evaluate the patient at eight weeks after the infusion. If they've had improvement in symptoms, I will check their current iron status and then I will follow. And it may be six months, it may be two years before they contact me and say my symptoms have worsened. I will repeat a set of iron labs and if it has dropped in a reasonable degree, I will give them another iron infusion.
I have a patient who developed a bad gastritis and for whatever reason developed severe inefficiency, developed our and he calls me every 22 to 24 months, say they are less back time for our infusion. Check his blood guarantee. I know where it's going to be is iron is going to be a certain level given the iron infusion four or five weeks later, it's gone. And I don't hear from another two years.
So I'm not trying to lead the witness here, Chris. But one of the things that we try to do on this show is debunk and misinformation that is often presented to our listeners. So these commercials that you're seeing all over the place for some prescribed pill for RLC, what is that? How does it work and does it work? And is that something that our listeners should be paying attention to?
There are pills or creams there, devices out there. There's no shortage of information about our less about things that will work at the current time. I am not comfortable with any device. Is there are PADDs vibrators, there's leg sleeves. So far, none of my patients have ever found any success with any of them. There are numerous different creams out there which again, in general I don't see any harm in use them, but I don't have anyone for
whom it's worked. There's a whole thing about magnesium pills. There's one clinical trial demonstrates the value of magnesium. I generally have no problems with my patients trying standard magnesium Oxlade or something like that, four 800 milligrams. Again, I have one person out of my experience for whom she swears by it. That's why the treatments that are out there that are value include those medications that are used
for the Parkinson's disease, which are called dopamine agonist. They they mimic or they are both mean, they are valuable and some of them have been approved. Actually, all three have been approved by the FDA for us. Like, so do you have what's called the Alpha to. Delta agents, these are medications which bind to the protein called Alpha to Delta, which is calcium channel and modifies calcium and
thus the intensity or discharge of the sensory nerves. And they fall into the categories of what's called gabapentin pregabalin. Many people have heard about them from they're used often used for pain, are often used for neuropathy, nerve pain. So those are value.
There are so many patients who are awakened by troubling leg cramps, foot cramps, and the folklore is all your low in potassium. And yet when you checked people's potassium level, it turns out to be normal. What are these cramps and how do you avoid them?
So leg cramps. Some people refer to them as Charlie Horace's.
They are not exclusively but almost consistently in the lower extremities of a few of my patients. Get them in their upper extremities.
Things like overly exercising, particularly if you're not really used to exercising, may cause some dehydration and dehydration may be relevant to the salt question about potassium, sodium, potassium, maybe low. There's a big family history. Family history plays into it in a big way. You know, I used to be for years used as the treatment option, but you can't get quinine over the counter anymore. So you can get tonic, you know, the sorts of stuff, the tonic that has
quinine in it. Some people will take that. It's interesting because actually when you look at the data for treatment options, there's been a couple good, though not perfectly great studies that looked at the various treatments. And the only one that has consistently demonstrated some value in reducing the cramps is doing about five, six minutes of stretching exercises before you go to bed at night of that muscle group that's involved.
So across a couple of different, smaller studies, that's the one that has been at least the most consistent and interesting. So, Chris, are you online? How can people follow you?
We have a website, AAPA Less at Hopkins's, our primary website.
Great. And how do they contact you for care? If you go through the Hopkins Sleep Disorder Clinic, they have a website for Hopkins' Sleep Disorders Medicine, which has the appointment number of things like that.
Dr. Christopher, earlier, we want to thank you for joining us today. And Dr. Tayback, thank you for joining us as well. And we're still practicing is produced and edited by A.J. Mosley, mastering his by Steve Rickey Bird Music for We're Still Practicing is composed and performed by Celeste Anorectic. Don't forget to hit the subscribe button so you don't have to wait around for our next episode. We'll catch you next time, everyone. And OK, tonight, shut off the TV, get a good night's sleep.
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