The Story of Sleep From A to Zzzz

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 CONTENTS

Acknowledgments

Introduction

M
N

About the Authors

 ACKNOWLEDGMENTS

FirstThank
of all, I would like to thank God, who makes all things possible.
you to Mom and Dad, for your love and support through the
years and for always believing in me. But I’m not sure where you will
display this book—the den cabinet is filled!
Thank you to my sister, Laura, my biggest supporter. “Sometimes life can
be tough. And I know that sometimes it’s hard ‘Keeping the Faith’”—but
you manage to do so every day. Love ya!
Thank you, Larry Armour, for your enthusiasm, patience, and expertise in
making our second book a reality. If you had not convinced me to give it a
second go-around, this book would not have happened.
I want to thank Joan Parker for your belief in our little team and for your
guidance, as well as your diligence and effort to help us get published a
second time.
Thank you to Suzanne Staszak-Silva and all at Rowman & Littlefield
Publishing for once again taking a chance on us.
Thank you to Molecule Mattresses and Comfort DTC Inc. for their
support not only of myself but also of our writing team. Your mattress and
bedding products are second to none, and I am grateful to work with such
an integrous and dynamic company.
I would like to express my gratitude to Weill Cornell Medical College,
New York-Presbyterian Hospital, the Weill Cornell Center for Sleep
Medicine, and all the colleagues and staff members who provide such
wonderful service to our patients.
Speaking of which, I want to sincerely thank all of my patients for
trusting me with your care and for teaching me the most important lessons
about being a doctor.
 Last, but definitely not least, I want to sincerely thank my mentors,
friends, and loved ones for believing in me along the way—you know who
you are! Thank you for your love and support from the bottom of my heart.
It means the world to me.
Daniel A. Barone, MD, FAASM, FANA
June, 2022

Be who God meant you to be and you will set the world on fire.
—St. Catherine of Siena
 INTRODUCTION

Infascinated
the introduction to my first book, I wrote that I have always been
by sleep. I also mentioned that my goal in writing Let’s Talk
About Sleep was to share my enthusiasm for the subject and to highlight
what I have learned about sleep during my years as a neurologist. If the
phone calls, letters, and emails I have received since the publication of the
book are any indication, it’s clear that many of you not only share my
fascination with sleep but are also eager to learn more.
The Story of Sleep: From A to Zzzz is designed to fill that gap by
providing additional guidance for those who understand how critical sleep
is to their health and who want to do all they can to improve the quality of
their sleep. Seeing a physician to ensure that what you are doing is safe is
always the best place to begin. And while what is written here will not be
the answer for everyone, I hope that it will at least inspire you to examine
new approaches that may help you and your loved ones sleep better.
As you will soon see, The Story of Sleep: From A to Zzzz is alphabetized.
Many of the entries are short and bite-sized. You may find that as you are
reading, there are terms or phrases you are not familiar with—and this is
okay. I have written the book this way so that you can pick it up at any
point, read about a topic that interests you or you want to know more about,
and then put it down and start another entry whenever you like. For
convenience, you will see a fair number of parenthetical instructions (i.e.,
“see…”), which are there to help this process along. In my own life, I find I
get the most out of books that break things up in this manner.
Any discussion of what can be done to improve sleep health must first
address what the problems are. That being the case, let’s take a moment to
look at a few of the main topics we will be addressing in this book.
 The most prominent condition patients tell me they would like to
improve is insomnia. Depending on the medical literature you read, most
people have experienced some form of insomnia at one point or another in
their lives, and many experience a chronic form (defined as one that occurs
for more than three months). As we get into the subject, you will see that
while certain medications and over-the-counter substances can be used, the
“real” answer lies in improving behaviors and habits long-term.
Another bread-and-butter condition I often see is obstructive sleep apnea
(OSA). Best described as a repetitive, temporary stoppage of breathing that
occurs throughout the night, OSA can lead to short-term and long-term
consequences. We don’t usually think of medications as ways to combat
OSA, but we often use technology in the form of continuous positive
airway pressure (CPAP) machines. It should be noted, however, that in June
2021, Philips, one of the CPAP manufacturers, recalled 3.4 million CPAP
machines that were allegedly blowing small particles into the air tubes and
then into the lungs of patients, raising concerns of lung irritation and cancer.
Since then, the process of replacing these machines has led to a shortage of
CPAP machines produced by other manufacturers. I am hopeful that by the
time this book comes out, these issues will have been resolved. That said,
while most patients do not have a problem with CPAP, many find it
uncomfortable or intrusive. Fortunately, there are ways to deal with this, as
well as many other options we will discuss throughout the book.
One note on the use of the term “OSA” and “sleep apnea”—there are
various forms of sleep apnea, including central sleep apnea (see “Central
sleep apnea”). We usually group all forms of breathing problems in sleep
under the umbrella term “Sleep-disordered breathing” (see “Sleep-
disordered breathing [SDB]”). As you read through this book, you may see
“OSA” and “sleep apnea” used interchangeably, and for the most part, they
are interchangeable. But just be aware of other types of sleep apnea, with
central sleep apnea being the most prominent. When we are discussing
central sleep apnea, it will be clearly stated.
Many people have heard about narcolepsy through television and movies,
where, unfortunately, it is usually portrayed in a comedic or dramatic way.
By definition, narcolepsy is a condition combining unrelenting sleepiness
with other symptoms, such as dreams and hallucinations, as people drift
into sleep or are about to wake up; it additionally can include sleep
paralysis (which is exactly what it sounds like). There may also be present a
bizarre phenomenon known as cataplexy. Cataplexy is a loss of muscle tone
in the context of a very emotional or funny situation, leading some people
to fall or have other embarrassing consequences. The classic way to treat
narcolepsy is with medications, but there are other ways to improve sleep
and daytime function, which we will get into.
Another condition that is sometimes misunderstood is restless legs
syndrome (RLS). This is a condition in which patients complain of an
uncomfortable feeling in their legs, which usually comes on around
bedtime. By getting up and moving around the bedroom, the symptoms
often abate. As you can imagine, this repetitive and annoying phenomenon
can inhibit a patient’s ability to get to sleep. If that weren’t enough, people
with RLS can have the “asleep” version, called periodic limb movements of
sleep (PLMS). These are, as you can guess, leg (or sometimes arm)
movements that occur throughout the sleep period and can disturb the
patient’s and/or the bed partner’s sleep. Fortunately, like the other
conditions above, there are ways to treat this—again, mostly with
medications, but natural, non-medication regimens also exist that we will be
discussing in detail.
Other lesser-known conditions include those related to our circadian
rhythm, also known as our internal clock. People can have trouble if their
sleep clock is set too early, also known as advanced sleep phase disorder
(ASPD), or if it is set too late, it is known as delayed sleep phase disorder
(DSPD). In both ASPD and DSPD, there can be disturbances in a person’s
social and work life. In the case of DSPD, there can be a particularly
fruitless and quite disheartening lack of improvement when the condition
gets misdiagnosed and is treated as simple insomnia. To that end, as you
can guess, there are other things to try either in conjunction with medication
or on their own.
 Finally, there are habits and behaviors that are not necessarily sleep
“diseases,” but ones that can impair our ability to sleep well and feel well. I
am referring to the usage of electronics, alcohol, other substances, and other
forms of stimulation. We will go over all of these and discuss ways to lessen
their negative impact on your sleep health.
Although sleep is vital for healthy human functioning, studies show that
most American adults get around six hours of sleep per night, which is less
than the seven to nine hours per night that most experts say are needed.
Studies also suggest that approximately one-third of adults report sleep
difficulties, making insufficient sleep one of the most pressing, critical
issues of the times.
Insufficient quality or quantity of sleep increases a person’s susceptibility
to disease and chronic illness. It also harms psychological and cognitive
functioning. Regular and sufficient sleep performs a crucial role in
maintaining and restoring the human body. At a physiological level, sleep
loss can undercut the intake of new knowledge, the repair of skeletal
muscles, and the efficient removal of waste from the brain. Insufficient
sleep may also affect mood, negatively impact metabolism, and increase
systemic inflammation, as well as contribute to a weakened immune
system. These aspects of proper sleep have always been vital, of course, but
even more so now in the wake of the COVID-19 pandemic.
Before we begin, one item must be mentioned in the interest of full
disclosure. Please note that I am a consultant to Molecule, one of the
leading producers of mattresses, pillows, and related items. Several of its
products are mentioned in the relevant sections of this book.
But enough background—let’s get to the specifics.
 A

Accidents. Sleep deprivation is a rampant problem these days, and it’s easy
to see why. As a society, we sleep one hour less per night than our
ancestors. That doesn’t sound like much, but it’s actually very significant.
The average person needs seven to nine hours of sleep per night. If
someone who needs eight hours a night is only getting six, this means they
have been getting two hours less than they need per night. As a result, after
only four nights, they are essentially eight hours “behind.” That equates to
basically one night a week without sleep, which has a potentially dangerous
effect over time: blood pressure is likely to go up, excess inflammation may
occur, the risk of catching a cold or other viruses (like COVID-19) goes up,
and cardiovascular risk increases.
As for car accidents, we know there’s an association between lack of
sleep and cognitive performance. Driving requires good reaction time,
avoiding risky behavior, and being vigilant. It is well-known that people
who are sleep deprived, either from quantity or from things like sleep
apnea, are at increased risk for car accidents. Reaction time, judgment,
vigilance, and overall decision making may be affected. In fact, studies
have shown a disconnect between our subjective feeling of being sleepy
compared to our objective impairment; in plain English, we don’t realize
how sleepy we are at times. An unfortunate example of this is that the
Monday after daylight savings time kicks in is the number one day for car
accidents in America. As of the writing of this book, the US Senate passed a
bill called the Sunshine Protection Act, which would make daylight saving
time permanent starting in November of 2023. But that still leaves the
problem of sleep deprivation the other 364 days, and car and heavy
machinery accidents may be the result.

Acid reflux is also known as gastroesophageal reflux disease (GERD)

and/or heartburn. Why does it develop? We breathe in by expanding our
chest cavity, which generates negative pressure and causes us to suck in air
from the environment. In the case of obstructive sleep apnea (OSA), there is
a blockage of the airway—that is, an obstruction typically resulting from
the tongue falling backward. When this happens, the chest has to work extra
hard to generate negative pressure, which can cause acid to be sucked up
from the abdomen. Especially when lying flat, that acid can irritate the
esophagus and lead to heartburn. The only clues that a person may have
OSA could be coughing at night or frequent awakenings without an
explanation. If you have either of these symptoms, talking to your clinician
is important. A sleep test might also be useful.

Acupuncture is a form of traditional Chinese medicine in which thin

needles are inserted into the body in an attempt to relieve pain as well as
improve conditions like insomnia. The theory is based on the ancient Taoist
Wuxing, otherwise known as the five elements in the West. The life force
energy called qi, acupuncturists believe, flows from the organs to the skin,
muscles, tendons, bones, and joints through channels called meridians; the
acupuncture needles are placed around these meridians. Furthermore,
disease is thought to be a disharmony in the energies (such as yin and yang)
and in the meridians. The therapeutic approach is to find the pattern of
disharmony by looking at aspects of the body such as the color and shape of
the tongue, the strength of pulse-point, or the sound of the voice.
As an interesting aside, the logo of the American Academy of Sleep
Medicine is the yin/yang symbol. However, treatments such as acupuncture
are not listed as recommended in the clinical practice guidelines for the
treatment of insomnia. The scientific conclusions of research studies and
systematic reviews have been inconsistent as far as determining whether
acupuncture is a reliable clinical approach. My belief—and one that I
frequently share with patients—is that if a treatment doesn’t hurt and it may
help, it might be worth a shot.

Acute insomnia is something we have all experienced. The night before a

big test or a presentation, we may not be able to get to sleep or stay asleep.
Typically, once the stressful event has passed, sleep returns to normal. It is
only a serious problem when it becomes chronic (see “Insomnia”).

ADHD (attention deficit hyperactivity disorder) is a chronic condition

leading to inattention, hyperactivity and impulsivity, difficulty regulating
emotions, or problems with cognition. It is an important diagnosis in the
sleep world for three reasons: (1) because it can sometimes be the “wrong”
diagnosis in a case of narcolepsy or sleep apnea insofar as sleepiness is
actually the cause of the inattention, not ADHD itself; (2) it can often co-
occur in other sleep disorders such as insomnia; and (3) the medications
used to treat ADHD (see “Stimulant medications”) can make insomnia
worse.

Adenosine is a naturally occurring chemical that relaxes and dilates blood

vessels. It has many effects in the human body, and it is used as a treatment
in certain heart rhythm disorders. For our purposes here, adenosine builds
up over the course of a day and signals the brain that the person is sleepy.
Caffeine, a stimulant, stops the adenosine signal from acting. Interestingly,
the use of cannabis in rats causes adenosine levels to rise and makes them
sleepy.

Advanced sleep phase disorder is a problem stemming from a faulty

“internal clock” (see “Circadian rhythm”) in which the clock is set too
early; patients prefer to get to sleep early and wake early. It is unlike its
cousin, delayed sleep phase disorder, in which patients prefer to go to bed
late and wake up late. Advanced sleep phase disorder is generally seen in
older people, who as an example, would go to bed at eight o’clock in the
evening and wake at four o’clock in the morning. We treat this by
introducing bright light in the early evening to “trick” the brain to keep
melatonin from being released too early, keeping the person awake until a
more appropriate time.

Alarm clocks are similar to naps in that they both can be very helpful if
used the right way. This may sound a bit strange, but I mean that alarm
clocks can help us to stick to a good sleep-and-wake routine, keeping our
internal clocks set right. They can also be detrimental to sleep. One thing I
find is that many times, people will set the alarm ten to thirty minutes
before they want to wake up, so that they can hit the snooze and go back to
sleep. This feeling of going back to sleep releases serotonin in the brain, but
the brain is not an on-off switch. The process of waking up, then going back
to sleep, and then waking up again can leave us feeling “hungover” and
suffering from sleep inertia (see “Sleep inertia”). It’s better to just set the
time you need and get up then. Also, watching an alarm clock throughout
the night can worsen insomnia, so I tell my patients to use an alarm clock
but to keep it covered or facing away from the bed.

Alcohol and sleep. We’ve all heard that a nightcap—an alcoholic drink
before bed—is good for sleep. But it’s more likely that glass of wine or shot
of something stronger has a downside we tend to ignore. According to
“Why You Should Limit Alcohol Before Bed for Better Sleep,” which
appeared in the June 17, 2020 issue of the Cleveland Clinic’s Health
Essentials, a drink of alcohol before bed can cause you to fall asleep more
quickly, but the result can be an increase in NREM sleep and a decrease in
REM (rapid eye movement) sleep—a combination that can lead to not only
intense dreams and nightmares but also an increase in sleep apnea and
sleepwalking. Another study by the Sleep Foundation
(www.sleepfoundation.org/nutrition/alcohol-and-sleep) concludes that low
amounts of alcohol decrease sleep quality by roughly 9 percent, while high
amounts tend to decrease the quality of sleep by more than 39 percent.
Typically, it takes about two hours for the body to metabolize a drink—
whether that be a glass of wine, a shot, or a beer—and I urge people to take
that into account. A glass of wine with dinner is fine, but several drinks
right before bed can disrupt your sleep that night.

Alpha waves refer to brainwaves seen during a sleep test; we see them
most often during the relaxed mental state with eyes closed. Researchers
traditionally believed that alpha waves indicate a wakeful period during
sleep, which is known as alpha wave intrusion, but this is controversial. The
theory is that people who have alpha waves in NREM (non-rapid eye
movement) sleep have lower quality sleep, which is associated with
conditions like fibromyalgia. This is a phenomenon that is not well
understood, and alpha waves themselves may be an essentially normal
finding.

Anatomy of sleep. Any discussion of sleep must mention the component

parts of our brain, so we can have a better understanding of how the process
unfolds. The brain is composed of billions of cells; some are the “brains” of
the operation (pun intended) and some do the “supporting” work. Neurons
are the cells that process and formulate information, but they are not the
only cells that make up the brain’s structure. Another type of cell, called
astrocytes, carries the burden of housekeeping and yardwork of the brain.
These cells help the neurons get the nutrients they need while keeping the
bad elements away.
The brain is broken up into four lobes and the cerebellum. The four—
frontal, temporal, parietal, and occipital lobes—form the cerebrum, and the
cerebellum (it is weird that the names are so similar) is the funny-looking
structure located just beneath the occipital lobe. The frontal lobe is the area
of the brain located right above the eyes. Its main area of concern is
executive function, a fancy term for what we do when we plan our day,
decide what we are going to do and say, and even what we shouldn’t say.
This illustrates the important point that the frontal lobes are like a filter for
the rest of what the brain wants to do. The left and right frontal lobes
control decision making and personality, but there are three other lobes: the
temporal lobe, the parietal lobe, and the occipital lobe.