Episode Transcript
Simon Floss (Host):
Hello and welcome. You’re listening to the Health and Wellness podcast, brought to you by the experts at Sanford Health. I’m your host Simon Floss with Sanford Health News. Today we are talking about an issue that everybody faces at some point in their lives: sleep, or lack of sleep.
Here to help us drift through dreamland is Dr. Haven Malish, a pulmonologist and sleep medicine specialist at Sanford Health in Bismarck, North Dakota. Thanks for being here today.
Dr. Haven Malish:
My pleasure. Thanks for having me.
Host:
So, first things first, what are a few sleep stats that you can share with us?
Dr. Haven Malish:
Probably the most common sleep issue is insomnia. And I’d say at least half of the population experiences that at some point more common in older age, but it can affect any age of patients. And another common one is obstructive sleep apnea. That’s probably one of the most common organic sleep disorders. About 20% of the population is estimated to have that. So, a lot of patients out there who are still undiagnosed, there’s been quite some headway in terms of getting people diagnosed and treated over the last 20 years. And even 40 years ago, we had hardly ever heard of this condition. So, a lot of progress has been made and a lot more can be done though.
Host:
And what might be some signs of poor sleep?
Dr. Haven Malish:
So, I’d say, sleep deprivation kind of hits on that, and I think it’s kind of rampant that the average person only gets six to seven hours of sleep per night. And what’s recommended is seven to eight. When you have poor sleep or essentially a sleep deprived state, it’s either not enough sleep or the sleep quality is not as good as it should be, even if you’re getting that seven to eight hours of sleep. If you have either of those, you’re going to present with signs of sleep deprivation or of impairment in some way. And so that can be poor cognition difficulty thinking, difficulty even with executive function. It can affect your mood. Your partner might say you’re more irritable, you know, difficulty staying on task. And one of the most common public health issues is like sleepy driving, especially truck drivers not getting enough sleep or with undiagnosed sleep apnea. There’s a safety concern there. And so that all what applies to truck drivers also applies to the general population. You’re going to have difficulty with motor tasks you know, falling asleep during normal daily activities and so forth.
Host:
So, from a health standpoint, and I know you mentioned side effects, people can expect day to day if they’re not getting enough sleep, but what happens health-wise or physically if someone doesn’t get enough sleep? You know, I’ve heard things like weight gain, a lower immune system. So, what are some risk factors physically if someone isn’t getting enough sleep?
Dr. Haven Malish:
And that, that’s a really good question and that’s a really good distinction to make because the, the, the patient’s not going to come present and say, “hi, my immune system’s weak because I’m sleep deprived.” They’re going to come in with the immediate effects of the sleep deprivation type of situation. So, the actual health effects are going to be like you said, poor immune response. They’ve done actually done some basic science studies in rats where they just sleep deprive the rats and they eventually die from overwhelming infection. And so, every time a rat tries to fall asleep, they have them go on a little platform that they end up getting dunked into water <laugh>, which is kind of an interesting experiment.
Host:
Well, that is no fun for the rats by any means <laugh>.
Dr. Haven Malish:
Right. Even when I did my undergraduate at University of Pennsylvania and there were always these studies you could sign up for as a student and it would essentially be staying up for three days or (getting) maybe two or three hours of sleep a night over a three-day period, something like that. And then they would do blood draws and see how robust your immune system was. And I think the results were that you definitely have a weakened immune system with sleep deprivation. You also have a pro-inflammatory response. So, your cytokines go up, your interleukins go up. Things that promote inflammation, the markers that promote inflammation are all elevated. If you’re sleep deprived, you’ve got increased risk of hypertension. So, it’s got cardiovascular effects which can then lead to increased risk of stroke and heart attack.
Dr. Haven Malish:
In regard to the hormone changes you have the hormones that promote weight gain, or the balance of hormones will promote weight gain. So, with sleep deprivation, you have increase in the hormone grail in which makes you more hungry, and then you have a decrease in leptin. Leptins supposed to suppress your appetite. And so, you’ve got the hunger hormone increase in the appetite suppression hormone decrease and so that just makes you want to eat a donut instead of celery <laugh>. So, you’re craving things that aren’t necessarily good for you. That tends to be what you’re predisposed to eat poorly with sleep deprivation. There are various other health risks as well. So, the bottom line is that sleep deprivation or poor quality sleep effects a broad array of systems within the body that can adversely affect your health.
Host:
So, doctor, what should good sleep look like then? And I know you mentioned it earlier, but how much sleep does a person really need? You know, some people say, “oh, I really only need four to five hours and I feel great,” but as we’ve talked about here today, that’s really not the case.
Dr. Haven Malish:
Essentially this breaches on the topic of good sleep hygiene and the framework is going to bed, trying to go to bed at a certain the same time every night. And even more importantly, getting up at the same time every morning because really getting up the same time every morning, really kind of set your clock for the whole day. And so, for example, if you go to bed too late, you’re going to want to wake up later. But if you’re waking up at the same time, then that kind of sets things in a regular pattern to where your body is used to, you know, a certain circadian rhythm. And so for most people, in terms of the actual sleep amount, seven to eight hours, with some rare exceptions, there was a saying when I was learning about sleep that they say scholars get seven, bankers get eight and gluttons get nine or more <laugh>.
Dr. Haven Malish:
And so that’s kind of a good way to remember it. Even if you’re sleep deprived, two nights, 10 hours (of sleep) should be sufficient to catch up in most cases. So, once you get more than that, it can also have adverse health effects. More sedentary, I think it’s related to being more sedentary. And so seven, eight hours is the target. There are some rare exceptions to that. But those are people with genetic where they are just short sleepers and it actually is true that there are some people rarely that can get four to five hours. They just can’t sleep more than that, they don’t have any other sleep conditions or underlying sleep disturbances. They feel refreshed after that. But that’s the rare exception. And there, it’s usually a genetic, there’s genetic markers, they’re genetically predisposed to that, but that’s rare <laugh>.
Host:
So, what are some ways to improve your sleep then?
Dr. Haven Malish:
It depends on what your starting point is. I’d say that if people are struggling with the quality of sleep, first thing to start with is good sleep hygiene. And so that has to do in part with what we’ve already discussed: trying to go to bed at a certain time, getting up at a certain time, minimizing what we call stimulus control, some minimizing things that can distract you. Making it a quiet place maybe with some white background noise, which sometimes can be helpful for people if the dead silence, some people will just go to sleep a little better if there’s a little bit of white back background noise, what we call white noise in the background, if you tend to stress about not being able to fall asleep, then we say turn the clock away from you so you don’t clock watch. Avoiding blue light in in the evening, which can disrupt kind of your melatonin and circadian rhythm and make you want to stay up later, which might be harder to get up at the time you want to get up if you’re going to bed later.
Host:
Ah, so what you’re saying is no mindlessly scrolling tiktoks in bed at night? Yeah. Okay. <Laugh>.
Dr. Haven Malish:
Yeah, so avoid the technology, the blue light feature on a lot of technology. It’s a good thing in general, but if you’re scrolling even with the blue light filter on, it’s the seeing things and saying, “Ooh, I like that,” or “, I don’t like this post.” Social media tends to activate your brain too, even if there’s no blue light. And so some people more than others, people who tend to get really into their social media, I’d say just forget the devices altogether for a good two, three hours prior to bedtime. But the blue light’s another factor. So, watching TV with blue light, for example, it doesn’t have the social media component, but then the blue light from it can be disruptive as well.
Host:
So, if you’re struggling to get good sleep and you’re noticing things just aren’t improving, could it be a sleep disorder? When does that come into play and when might that be a factor?
Dr. Haven Malish:
One of the most common presentations that I’ve seen is when there’s a change where people are used to getting a certain amount of sleep or being refreshed to a certain amount from their sleep, and then they notice things start to kind of go downhill where the sleep isn’t as refreshing or the sleep is good, but they’re just not able to get as much sleep could be from a medical illness that’s developing like thyroid condition, a new medication, they’re on a change in work schedule. So, it can be for a variety of different reasons, but when that’s the case, when the patient perceives a problem, they can always start by asking their primary care provider to guide them through the initial part of that. And then if they deem necessary, get a referral to a sleep specialist.
Dr. Haven Malish:
And so, if it’s not one of those first issues, then we look for a primary sleep disturbance. One of the most common ones is obstructive sleep apnea. Like I said, 20% of the population has it. It can present even in children, but it’s also associated with older age. Because, as we age, we tend to gain weight and weight gains associated with sleep apnea. It’s not the only risk factor, but it’s one of them. So, if there’s a problem with the sleep, I’d say go to your primary care doctor first, make sure you’re doing all the good sleep hygiene techniques that we’ve talked about. And then if it’s still an issue, then you might need to see a sleep specialist.
Host:
I know melatonin and zzquil are very popular for over-the-counter sleep aids. What are the pros and cons of over the counter sleep aids and are there any long-term use effects with those?
Dr. Haven Malish:
Well, that’s another good question. So, I’d say I’ll start with the most common over the counter sleep aid, and that’s going to be diphenhydramine, which is an antihistamine and its primarily antihistamines are not intended to make people sleepy. It’s one of the side effects <laugh>. And so oftentimes when you see like a PM in a sleep aid like acetaminophen with a PM or ibuprofen with a PM oftentimes the PM is really diphenhydramine or the common name is Benadryl, and Unisom is another antihistamine that’s pretty common. But they all are in these over the counter sleep aids. And so there can be some benefit short term, like if you’re going on a long plane ride and you just need something to help you sleep on the plane, just one time use, there’s not going to be a whole lot of harm in doing that.
Dr. Haven Malish:
In general, when you do use these types of over-the-counter antihistamines in this fashion, you get more light sleep earlier on, but it’s usually at the expense of deeper sleep later. And so, it’s a tradeoff. Everyone’s a little different. So, some people know that as long as they’re able to get to sleep initially, if they tend to be sleepy people in general, then maybe just getting the sleep, getting to sleep initially is their goal. But by and large, most of the people in the population, you have that trade off where you do get more lighter sleep earlier in the night, but then later you’re going to toss and turn a little bit more and not get that deep REM sleep that you’re supposed to be getting later in the night. Now in terms of long-term use, Benadryl or diphenhydramine has been linked to dementia, and initially we thought this was reversible, but studies have shown that it’s not necessarily the case. So, I would not recommend any long-term use of diphenhydramine to help people sleep.
Host:
Specifically for over-the-counter medicines and sleep aids that contain diphenhydramine, what would some name brands be that contain that?
Dr. Haven Malish:
It’d be Tylenol PM, Motrin PM those, those are probably the most common. One Unisom does (contain diphenhydramine). It’s not Benadryl, it’s another antihistamine. And so, those are the most common ones, I would say. There are somewhat, what I’d say reasonable alternatives and you asked about melatonin, that’s something our body kind of creates anyway. And that can be a good aid to help people kind of readjust their clock or as what we call a hypnotic to help them fall asleep at the beginning of the night. What I’ve seen is that for those, in those patients where it works, it usually works for an initial time period, then a lot of times it’ll lose its effect over time. But it can be very helpful, especially if you’ve got jet lag and, but you got to time it appropriately. Melatonin is a tricky one.
Dr. Haven Malish:
It’s one of those where more’s not necessarily better, and if you take it too late, it could have the opposite effect. And so, I’m going to circle back to Benadryl and the antihistamines is that some people, when they take the Benadryl or things like it, they’ll say that it makes them wired. And usually what I’ve seen in that situation is if those are people with restless leg syndrome. And so, it’s that the antihistamine, if you have restless legs, can make the restless legs a lot worse. And so they’re just moving their legs the whole night. And so, it’s not that it makes you wired, it just makes the restless legs worse and that’s why the Benadryl doesn’t work. If anyone’s out there listening, say(ing), “well, when I take Benadryl, I’m, I’m just crawling off the walls,” then you probably have restless legs and there is treatment for that <laugh>. The first one being avoid medicines that make it worse. <Laugh>.
Host:
So, just a couple more questions here before we let you get on your way. What type of care or programs does Sanford offer for sleep challenges or sleep disorders?
Dr. Haven Malish:
We, there are sleep specialists at most of the major locations. We do offer sleep study testing. This usually involves an overnight study where they hook a bunch of electrodes to your head around your nose. There’s an EKG, it’s got some limb leads on there. And so we get a lot of good information from a sleep study. And so that’s usually going to be the, the initial first step. I know here in Bismarck we go down to age three. We are accredited down to age three with the American Academy of Sleep Medicine, we’ve got a fully accredited lab. And then we also do some other, like daytime testing to look for things like narcolepsy and other, what we call conditions of hypersomnolence. And so we do have a pretty comprehensive sleep evaluation service here and clinicians that can follow up on those results.
Dr. Haven Malish:
And I think that holds through for most of the major Sanford locations. One of the new programs that we’ve developed recently is one of the alternative treatments for sleep apnea. Let’s start by just saying with obstructive sleep apnea, the primary treatment of it is something involving positive airway pressure or continuous positive airway pressure, which is CPAP, which a lot of people have heard of. And so about two thirds of the time patients can tolerate it and within that two thirds, a third of them love it initially, and the second third get used to it eventually. And then the final third just can’t do it <laugh>. And so there’s an alternative that kind of moves the tongue forward in your sleep and clears the airway. And so that’s a newer program. It’s called the Inspire device. And so an ear nose throat specialist puts that in.
Dr. Haven Malish:
Here it’s Dr. Sharon. We’ve done over a hundred of these here and really kind of pioneered the way here in Bismarck in terms of that therapy. I don’t think anyone else is offering that within the vicinity. And so patients are struggling with CPAP. That’s one of the newer programs is to get evaluated to see if the inspire device can help. We also treat the whole gamut of sleep disorders though restless legs, narcolepsy, even if you have insomnia, usually your primary care provider can try to help initially, but insomnia may also be indicator of an underlying sleep disturbance. So, if the initial approach with the primary care provider isn’t getting the patient where they need to be, then a sleep specialist referral may be very helpful.
Host:
Well, this really has been so great doctor, and you’ve shared just a plethora of information that I think is really going to help a lot of people, including me. I’m a rather light sleeper, so I was really excited to do this podcast with you because I was like, “well, I’m going to talk to a pro and I’m going to learn.” And you know what, I did learn a lot today. So, before I let you go here, what would be a good take home message or what’s maybe the most important bit of information that you want people to know who are going to listen and read this?
Dr. Haven Malish:
So, I’d say if, if you’re not happy with where your sleep’s at, be proactive. Start with the sleep hygiene. That’s the regularly going to bed at a certain time using the bed for only sleep. Waking up at the same time, but don’t suffer with it if you don’t have to. Talk to your primary care provider, see if they can help. And if needed, sleep specialty referral, we’re here to help and then we can see what else can be done. The other thing I would say is poor sleep. A lot of people chalk it up to old age and it’s not necessarily the case. I mean, we, just because you’re getting older doesn’t mean your sleep has to be poor. So, be proactive and try to try to get things better. If you’re not happy with where your sleep’s at, we’re here to help.
Host:
Thank you so much for your time and knowledge and for joining us today.
Dr. Haven Malish:
My pleasure. Thanks for having me.
Host:
This episode is part of the Health and Wellness series by Sanford Health for additional podcast series by Sanford Health. You can find us on Apple, Spotify, and news.sanfordhealth.org. Thanks again for listening. I’m Simon Floss.
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