Minimizing impact of COVID 19 pandemic on sleep of healthcare providers / HealthChoice

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good afternoon just barely it's after 12:00 but we'll get started if we could have the next slide please give me information those of you who are logging on and interested in just feel free to take a moment to write down this information on how to claim your scene I'm dr. Mickey trowel

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I'm a psychiatrist with the Department of Psychiatry and with the well MD well PhD Center at Stanford University with me today our sleep medicine experts dr. Rafael Pelayo and dr. Rachel member dr. Palazzo is a clinical professor at Stanford University since 1993 he has been at Stanford he teaches the popular sleep and dreams undergraduate course he helped lead the effort to delay his school start times in California he has

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served on advisory boards and leadership positions for the National Center for Sleep Disorders research at the National Institute the American Academy of Sleep Medicine the National Sleep Foundation and the California sleep Society dr. Rachel member is a professor in the I trained behavioral sciences at Stanford University she is a clinical psychologist specializing in behavioral sleep medicine she directs the Stanford sleep

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health and insomnia program where she and her team provide non pharmacological treatments for insomnia and other [Music] research like her clinical work is also focused on pharmacological treatments for insomnia in general and in specific populations at the next slide please and one more dr. Mann Burke receives royalties from new Harbinger and Guilford press for

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books she has written dr. Pillai ou receives compensation for his work as an advisor for adaptive sound technologies today will first hear from dr. Pillai ou followed by dr. Mann BIR after dr. Manus remarks our sleep medicine experts will take questions from the audience you can start writing questions any time using the Q&A function at the bottom of your screen dr. Pillai oh good afternoon

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next slide please thank you so much for inviting me to be here when the truck was speaking of something cutting it in out a little bit but hopefully it's sounding better now anyway I'm looking at the participation we have 358 people on right now that's amazing thank you for being here the reason we're doing this is it says in the slide we're worried about you both rates on my independently contacted our leadership and other partners said hey what can we do to help we want to

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help out Rachel and I've never done a webinar before together and I'm really glad to do this let's see how this goes maybe we'll take it on the road afterwards but they're real reasons we're doing this and it's because there's so much uncertainty going on around us there would be unusual for you not to be sleeping well I mean to be strange for you to sleep well given the circumstances people don't sleep well in times of uncertainty and this is incredibly uncertain times so we expect you to have trouble sleeping all you do want to know is what can we do to help

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you sleep better so that you can be more effective in what you're doing now the next slide please so why don't you sleep well in times of uncertainty well sleep is a paradox and this is an important concept sleeping animals are prone to being attacked at any point you would think that God Mother Nature evolution we would avoid the need for sleeping for to protect ourselves but it still we're around we actually protect ourselves at all times and animals have to sleep reasons I'm not

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entirely clear I'm talking a little bit about the science behind that but the symbol for sleep medicine was a my diploma my certificates and that the mammary certificates is it yin and yang symbol the black and white symbol that we familiar with and it's because in sleep we don't distinguish the mind from the brain it goes together and a phrase that I use is that your sleep is reflected in your life and your sleepers are in your sleep it goes in both directions clicking so if you think

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about it sleep is the ultimate self-care it's what the body has decided to retain despite the dangers inherent of being asleep the body has decided that this is the best way to take care of itself so sleeping well is ultimately the best way of taking care of yourself and I want to talk to you more about this so the next slide please now when you guys decide to spend your time and invest your time in a webinar like this you're gonna say well what are gonna tell me what's new you know what are they gonna say the same thing I know

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I have to sleep but I'm too busy so I wanted to make a point of providing you with some new information and what could be newer than a paper like this cub published last week this is just from our main journal sleep is our main journal there that we look at and this was a simple study with 40 subjects and it looked at the what the effects of a nap would be now these are people who were not not sleep deprived these are people who are getting enough sleep on a regular basis but still volunteered to take a nap and one good pattern that one other group did not have a nap and what

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they found was they had to have them memorize a set of words and after taking a nap the recall was 21% improve and the people who did the math again these are not sleep-deprived people this is just people who took a nap and then this is a test of their memory and it tells us you know what should value to you to improve your memory by 21% right this is a really good finding so naps are beneficial that beneficial effects on learning alertness memory sustained attention executive function so as we're

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now working through this and you know this incredible crisis that we're going through what's the value to you of having improved to learn you material to be more alert sustained attention and executive function you know there's value and sleep for you next slide please I'll share advances lies myself excuse me so we cannot treat sleep as any convenience it'd be nice if we didn't have to sleep if you could just go sleep later but we have to sleep and the first thing that happens when you don't get enough sleep is that

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people tend to have worse mood and become inattentive and all of you know people who wake up feeling grumpy in the morning and just don't you know or not that pleasant to be around but sleep problems also associated with increase of work accidents car accidents strokes and any kind of neurological say catch a condition that you have will be aggravated if you don't get enough sleep but I went to hone in on this other bullet here about decreased immune function because that's really what's about particularly with this situation that wind right now common wisdom is that what you feel sick you should be in

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bed and in fact we talked about the size of a hospital by how many beds it has and in part what happens is when we have any kind of infection department part of the body's reaction to this is to release of cytokines and satellites will make us sleepy to promote sleep and then the other hand when you're asleep deprived you know for example when you're traveling you know you're more prone to infections so this tells us that sleeping immunity have a bi-directional relationship it goes in both directions and this relationship has my studied for decades among the earliest leap experiments over 100 years

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ago was that if you sleep sleep-deprived an animal it would die interestingly what the animal would die of is sepsis that's what they die of they've done this with lab rats where they have their fur falls out they get skin sores more recently it's been found that lack of sleep interferes with effective of immunizations our hope is to get an immunization against this corona virus well guess what lack of sleep makes the immunizations less efficient less effective and then thinking now this simulator 2 T cell function T cells are

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a part of our immune system help us fight at your cell they're infectious which the viruses and there's not good experimental data in animals that has proven causality causality for the role of sleep and infection outcome people are sleep disordered for example more prone to develop autoimmune diseases lack of sleep is a stressor for the body so it turns out that chronic sleep deprivation to the body's like a low-grade inflammation and if you in this state of low-grade information and you add on top of that in acute

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infection you can see how it's possible to overcome the body's defenses an experiment that's was done this isn't a real experiment I really read about this a few years ago they had volunteers who were sleep deprived and they on purpose received rhinovirus they got rhinovirus in their nose and those who were sleep deprived were more likely to get a cold so that's a simple expire that was done and then another study was done on teenagers and adolescents where they hadn't where actogram I mean how many hours of sleep they actually got and the

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teenagers that got less sleep had a higher number of reported illnesses including symptoms of cold flu and gastritis so you got to think maybe there's some of these partying Spring Breakers you got six wasn't the young kid aren't gonna get sick from this thing see the probation may have made them more prone to get sick so the question is always the same how much deep should I be getting well the fence of the quality via sleep sleep it's not just the hour just like the quality but there is some studies on numbers so the data is that if you have it early sleep five hours or less five hours or less compared to people asleep seven or eight

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hours you're more prone to get all kinds of infectious including Russian air infections so if you're getting five hours or less of sleep you're more prone to this this does not mean however if you've always been a five or six hours sleep and you feel good that you're gonna be more prone to infection this is if you're somebody who routinely gets seven or eight hours and now you go through a period of only getting five hours that's when you're setting yourself up so what does this mean for you it means if you if you get sick do not try to work work your way through this once you have the infection lack of sleep interruption immune system this

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has been conclusively shown didn't lab animals that were experimenting infected and densely deprived they got worse Boris Johnson was in the news he supposedly kept working despite being affected and that ICU so for all of us especially our leaders listening to this please if you think you have an infection you're not going to work your way through this it's not going to happen sleeps effects on the immune system doesn't need a viral functional relative functional relevance it is critical for the optimal performance of our immune system bottom line getting more sleep is not going to hurt you and may actually save your life next

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slide please now for some time now appropriately in sleep medicine we've been focusing on non medication ways of handling sleep problems especially working with insomnia and and there is a role for for medication though so we think of chronic insomnia people sleeping quickly for more than three months people in that situation we want to definitely do a behavioral approach their sleep and it's the right thing to do and it works and dr. Merritt I have shared many patient know how many patient we should over the

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years but we shared many and then get better with the behavioral treatments but also we should not shy away from using medications of in some situations especially for acute insomnia sleep patterns let's see some we were rotating shifts or changing things around you might want to use medication and the way hypnotic some now develop United States in the past they were kind of nonspecific but now we can actually tailor the therapy to specific symptoms of poor sleep so for example people if you're falling asleep only may have something like

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ramelteon and somebody's trouble staying asleep my you something like doxepin and also you can combine medications you could use a medication like doxepin which is help you stay asleep with something like sour plums a short-acting sleep inducing medication of course a lot of caveats a lot of warnings about using hypnotics but for short-term and transient sleep problems that some of you may be having these are these are valid tools to consider next slide please we've dad I'd like to turn it over to

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dr. member rachaelh thank you thank you dr. Pillai oh may I have the next slide please so I wanted to start my talk today by giving you a brief introduction of how normally I think that understanding that would give us a good framework to discuss the rationale for some of the recommendations I will be making and some of the nuances in this recommendation because as you will be

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listening today and already have heard you might spot some apparent contradictions that could lead to fusion and understanding this diagram and how these three factors into play is going to help bridge that apparent contradictions so basically there are three main processes one is the almost static sleep drive also called the sleep pressure the second one is a biological clock with a circadian clock and the

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third one is our rosen awake system so for us to sleep well we need to have all three pieces together be placed in the right place which means when we arrive at sleep we need to have a strong sleep drive we need to place this to get the sleep opportunity in line with a clock and we need to arrive at sleep with a low level of arousal so let me spend a few minutes on each of these so you know more what I'm talking about

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so the homo static sleep drive is something that simply increases as we are the longer time between way the longer time they awake we are building up our sleep pressure our sleep drive and it decreases when we sleep the longer time we sleep the shorter the less sleep pressure we have the less feedback we have so by definition the Skip drive at the beginning of the night is going to be higher than you sleep by with you wake up in the middle of the night and find it more difficult to fall

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asleep you have less of it to help you so other things need to be increased with to be able to sustain sleep the second process is the circadian clock the circadian rhythm this biological clock is responsible to make sure that we stay awake during the day and it permits us to sleep at night it does so by sending alerting signals that increase across the day in a certain time at night they start decreasing and

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at that time if the sleep drive is strong and arousal is low is then ideal time for us to go to sleep because then we'll be able to make me fall asleep relatively quickly but also to sustain over sleep they think about the circadian clock is that there is a large individual probability in in this internal clock that is responsible for the variation in the phenotypes of people who are some people discrepancy strongly night people in other people may describe himself

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strongly morning people and most of us are somewhere in between so it's all a spectrum the third process in the wake system of the arousal system and it is there to protect us in the face of threat so that we will react in the face of threat so even at a time in which we have a stronger more static Drive and it's the time of night that we should be sleeping if there we perceived threat in our environment that's going to drop

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these other two processes which is why it is so critical for the arousal system to really be low at a time that we are trying to go to sleep so let me move on and start describing what kind of behaviors are going to support each of these three factors and I have the next slide please okay so for the homeostatic and sleep drive any behavior that involves sleep

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is going to impact it so if we those off in the evening unintentionally for example that's going to be weakening the sleep drive even though we don't sleep that much because we slept some it will not impact us so much at the beginning of the night so which probably is not likely to impact how fast we fall asleep but it's more likely to impact us if we are waking up in the middle of the night sleeping in late in the morning and then

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trying to sleep at the usual time the next night is also going to reduce the shorter sleep drive because the seat drive simply has less time to get up sleeping during the day is another behavior that such as nothing and I behavior that is going to impact our sleep drive but the the effect is depending on when and how long we ended up skating so an afternoon short like 15-20 minutes a phenomena

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early in the afternoon is probably not going to be the esta tormenta is is usually not detrimental as opposed to something sleeping later and longer next slide please so the behaviors that are impacting the circadian clock if you who needed to have a centerpiece for that I would say it's light exposure I would say the most important thing for our best sleep is to

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anchor the time that we wake up you may hear recommendation always go to sleep and wake at the same time pay attention to the last part getting up always at the same time more or less why is it well if you open your eyes you get light and light is the most strong detriment a determinant of our circadian clock it helps anchor it it makes it be robust it makes us beat strong and support our

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sleep so just because you can sleep later in right now for some of us doesn't mean that's a good idea getting light exposure particularly shortly after waking up helps synchronize our internal clock to the clock that the time of day at the other end of the of the day in the evening it is going to be important to block light and what we know from science is that the most

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important light to block is the blue wavelength of the light and there are some technological solutions for that which are SLS for example a free program that can be installed on computers that's called F no clocks and most devices come come with expecting from night setting and is night setting essentially block the blue light next slide please so - to support low arousal as we arrive

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at sleep I could have and in fact we did have almost a full lecture just on that piece to reduce our arousal but I want to highlight here something that is very unique to sleep and we'll talk about a few more ideas a bit later and that is it is very important to allow some time at least an hour typically to unwind before attempting to sleep even if it means that you'll go to sleep later even if it means that you're interpreting

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less the sleep that you'll get will be more sound and with fewer interruptions it's also important to adopt a mindset in which you're allowing sleep to unfold you don't try to force it if you try to sleep you're likely you have difficulty you're likely to start experiencing performance anxiety and it's going to actually backfire and make it even worse if you worry about sleep similarly it's

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going to make it harder to sleep so this is an interesting concept and principle that easier to state then to actually implement but always to do that may help us mix like this so for the remaining of this talk about I'd like to do is talk about how to deal with the different challenges current challenges in our endemic in shelter-in-place period it we're living in which really impacts all

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three components of the ship regulation that have talked about so I talked about methods additional methods to deal with stress methods to deal with isolation as it pertains to sit behaviors I will talk a little bit about frontline medical providers that might be needing to working some unusual work schedules and I'll talk about things you can do at the moment when you can't sleep

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and more long-term how do you prevent occasional sleep problems from becoming the chronic state problem so let's have the next slide please so when it comes to reducing the minimizing the impact of stress on sleep I would say stress is inevitable it's part of life absent flows and there are many sources for that one one of the things that is unique to this the NIH is the consumption of media in preoccupation

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with the covert 19 but even in general I would say an important piece is to commit to a time like a hard stop after which you stop any activities that are just acting or stimulating with coffered related or be something else the other piece which I already talked about in the arousal slide that I've had is that it is very important to unwind at least an hour before going to bed even if it means going to bed later so some common things that people are doing find

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helpful are engaging in activities that involve self-care reading or listening but then it's important that the content will be non stimulating and that varies from one person to the other cuddling are some examples and you do this until you start feeling sleepy which means if you start feeling sleepy within the hour before sleep your usual bedtime it's okay to go to bed a little bit earlier but if you count your usual bedtime and you're not being very they're not starting to precipitate and

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continue doing the unwinding activity until you do and that's okay any effect beneficial and the other piece about managing the stress is during the daytime you can examine face.you stressor and examine it rather than trying to push it away trying to not think about something it's only something that you've pushed away is only likely to pop its ugly head when you don't have instructions that you have during the day such as when you're trying to sleep so when you sit with

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whatever is stressing you and face it think about what is and isn't in your control this card would see not in your control and think of some small step you can take to address issues that may be in your control and in general just adapt a stance with a viewing you life or restrictive stress with a wide-angle lens it gives you a perspective of the problem in general and it leaves more room for you to find creative solutions to the problem that you're facing next

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slide please now I now let's talk about isolation so being isolated even either if you're even if you're not patient in just a shelter-in-place it really creates a potential impact on the sleep drive the circadian clock and the arousal system because there are many sources of arousal other than just worrying about the complete situation such as now

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you're all of a sudden forced to be 24/7 with everybody in the same house where everybody needs to manage their space and get their privacy and that could potentially create some stressors as well so the recommendations are create a structure to the day when it comes to sleep you want to limit daytime napping and again you've heard from dr. Pillai otech nap is good for consolidating memory but too much not too much of the good things is not good because it would potentially disrupt your sleep as I

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discussed earlier it is also important to make sure to make an effort to get more light exposure during the day particularly in the morning is it sets of biological clocks on object clock it is also important to keep your usual shift and just because you can see the different times doesn't mean again that it's a good idea so be careful be mindful on the timing and the duration obviously to be similar to what you have been doing before unless you were

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sleep-deprived before and I will concede a little more so by all means and the other piece is of course attending to your mental well-being through whatever means that you so that you arrive at sleep with reduced arousal next slide please now to talk a little bit about the two aspects of unusual work schedule that some of you may be facing so those of you who are dealing with at night or long shifts it's very tempting to come

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home and tired and want to go to sleep right away but as I said before it's utterly important particularly important in this situation to allow plenty of time to unwind from there from the shift this way the amount of sleep that you will end up getting who is likely to increase and the quality of the sleep to be better if you have two consecutive nights with shifts supplemented the sleep that you get when you come

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immediately after the shift by a nap and in particular a nap before going to work and if visible during sleep during the shift itself it's a good idea to catch some sleep so here all bets are off from all of the things that I've said before about not being here I'm encouraging that because it it will look at sleep over 24 hours as a protective factor the other piece is for people who who are on

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call and are at home if you do get a call in the middle of the night and you need to attend to us an upsetting situation here again you have to allow yourself time to unwind before working but you see just because you're done dealing with the emergency you are going to still be revved it's okay to sleep a little in because you have had a disruption at night but again not too much and it is a very good idea to take short naps next time please

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so if you cannot sleep at a given moment you did everything possible but you are awake either at the beginning of the night go in the middle of the night perhaps the most important thing is to just take a break from trying to sleep allow sleep to unfold as I say trying to sleep is like the Chinese finger trap picture that you see on the on the right of the screen the harder you pull the harder it is to go to sleep relaxing into it allowing sleep to unfold

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stopping the trying is going to be very helpful and so what do you do instead of trying you just doing something you focus on something else it wasn't resting you listen to or read non-stimulating contents and perhaps you even engage in it let your mind go into a pleasant image and then you allow sleep to come and take you when it is ready next slide please so how do you prevent the progression of

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chronic insomnia phone being from simply a single night or few nights become a chronic insomnia problem here are some things to avoid and then I'll talk about when is it that you will need to seek professional help so the number one thing I would say to avoid is to avoid putting a lot of effort into getting sleep just roll with it your job is not to compromise you sleep opportunity for sleep so give yourself the correct opportunity to still don't work yourself

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too hard and then be sleep-deprived because of that but at the same time stop it that allows that a good ample opportunity for sleep but not too much avoid overcompensating for lost sleep by sleeping in or going to bed too early because it might help you overcome the previous night's deprivation but overall it will prolong the problem because then the next night is more likely then to be problematic and you'll get into what I call a feast or famine situation where

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you'll have alternate nights of sleeping better worse and potentially down the road sleeping holy most nights you also want to alter your can I have the previous track thanks you also want to alter your you do want to avoid altering your daytime activity your plans move on with your day as as you would have otherwise most activities can continue to be done even if you've not gotten enough sleep for a given night

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and also avoid attributing everything that's wrong to your problem would sleep and saying after I get my sleep fixed and I'll fix or like a problem just deal with life and move on so when is it that you would like to seek help I would say if you find also spending a lot of time to get a to sleep that's probably time to to get some help if you worry a lot about how much or how long you sleep or and in particular when you first start finding bed the problem

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with it is beginning to impact you daily and they can activities it's time to get sleep so the next slide I would like to talk about some resources for you and here I put on the left self-help resources so there are some self-help books I put a book that I co-authored in here but below it you will find you will find a online program to help people with insomnia sleep that just last week

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the FDA approval as a treatment it's the first program online program that that get the approval for treatment of insomnia and on the right you will see that you at Stanford we are rich with two programs that provide clinical services our clinical service are on main campus at Stanford and we have five faculty and some postdocs that are helping our patients who want help with

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non-medication approaches for insomnia and in Redwood City we have they started shipped in me that offers students insomnia for other sleep disorders and so we are lacking that way next like this thank you thank you dr. Pillai oh and dr. man burr will now take questions from the audience and we can go to the next slide there is a Q&A button that you can click on to type some questions that you'd like to have answered by our

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sleep medicine experts the first question is for dr. Pillai oh and that is is there a difference between the sleep quality that one will achieve when falling asleep naturally versus sleeping with a medication like zolpidem or ambien myself yes hey guys I've actually typed up the answers to all of these already oh can see them while rachel was speaking so richer you muted by the way you need to unmute

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yourself so you can join in I can answer the question also so 15 questions popped up so I started typing out answers so bottom line is naturally by definition sleeping naturally is the way to go so the real clinical question typically is not where fall asleep naturally versus a medication it's is it better to take a medication or have suffered the consequences I'm not getting a good night's sleep at all so in that situation yeah the medication can be

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better if you look at the with Zobel them the the marketing of it back when it came out was the fact that if you did a sleep study on a person and they took that medication at the dose of 10 milligrams or 12 milligrams you could not spot a difference in their brainwaves so they thought it looks like a more natural thinking those uses a marketing term but nobody really knew that was clinically a significant issue but the point was that if you took a better day as a teen such as oh but the arm valium diazepam excuse me at higher

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dosages you could spot the signal oh those are that medication on the sleep studies but with up with them you couldn't spot it that's one of the reasons they were called atypical I had higher dosages though so but then will behave like like like there's a Pam but at the lower dosages it's it doesn't seem to have the same effect on the brain waves having said that of course naturally is a way to Rachel you couldn't have this question many times muted though I was trying to say out oh and eight so

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anyway we have adequate that answer that's great thank you and we have a question for dr. Mann burr as well and that is dr. Mandurah can you share some ideas for unwinding before bed yes I imagine daph you like taking reading or watching TV is fine watching the program here the importance is to engage in

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content that's not stimulating and not going to be too activating and it differs from person to person some people will start reading and we never stop so for them reading will not be a good idea and other people will start reading they would not be able to pass a page and so there is no universal activity to be engaged in to unwind but as I said cuddling is what I mentioned

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self-care oceans oceans baths just a few sounds good thank you we have another question this one could be perhaps for both of you maybe well here dr. Pillai owes comment and then dr. mandra's and that is is it recommended to sleep with the window blinds open so that daylight helps signal the beginning of the day or another way to look at this is how dark does one's room need to be for optimal sleep the need for sleep is one thing in

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the way we sleep is is learned so we actually learn how to sleep and what I saw this question my first thought was well what does your bed partner want you're sleeping by yourself as one thing but if you're sharing a room with somebody they may have very different feeling about those blinds so assuming that you sleep either alone or you your bed partners and the same sleep schedule as you then waking up naturally to the dawn kind of makes sense and you can't get blackout curtains also if you ever come as at the sleep lab you'll see we have shut our curtains there are our

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alarm clocks that are sold that instead of using sound they use light and they're called dawn simulators you can get one of those if you want that effect the thing with this with natural light coming in is because of the change of seasons the days get long and the days get shorter so if you're not on a regular schedule is kind of nice to wake up that way perhaps or for most people you want to actually hit lock in a wake-up time based on the actual clock and not hundreds on the time of the dawn develops I think it's of interest and

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you know correlation is not cause a lady but it seems like all Bay Area everything went horrible after daylight savings occurred and we lost an hour of sleep and losing sleep is not a good thing for us so I don't really like this this idea so yes you can have light coming through if your bed partners okay with it I would think I would say our individual variability in how sensitive people are to light and how likely light is to be under Qing to them and to them

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ever had patients who could not see clearly almost entirely confined to times of full moon these people will definitely be greatly benefit from having darkening room room darkening shades and having the environment sleep environment that we sleep best in a dark environment light would wake us up the best in between solution is to have shades during the sleep and as soon as

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you wake up to open up the shades and get this much like exposure is possible okay thank you and another question for dr. Mann Burt and that is during this time of pandemic virus then we understand from what we've heard today that it's important to get enough sleep and yet at the same time we understand from what we've heard the day that the more we worry about sleep then the harder it might be to sleep how do you recommend we deal with that that

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is a fantastic question it is really all in the balance it's I think a good way to think about it is with the food and eating analogy our responsibility to our kids is to put food in front of them that is nutritious and then it ends and then they eat or not if we try to pressure them to it because we want to make sure that they get enough nutrition we might develop some problems with their nutrition and the same thing applies to us when it comes to see our

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responsibility to ourselves is to do the kindest thing that I talked about today to set the stage to allow enough opportunity for sleep but not so much that it will actually end up interfering with our sleep and so it is all in the balance it's hard to not worry and I would say a lot of my work day today with patient is to find that balance and find ways for individual people to make

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that balance of choices sounds good thank you dr. Pillai Oh on the question for you and this is from a respect from a participant here indicates that it wakes up to urinate usually five hours after sleep typically falling asleep right afterwards for another three hours is there any issue with this in other words is there a problem with urinating in the middle of the night and specific sure potentially the glomerular filtration

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rate you believe this is a body to make urine actually decreases in sleep you shouldn't be able to go more hours without your needing and sleep than you do when you're awake it's kind of a one of the nice things about it there's certain things if is logically happen we sleep one is our urination changes and also ability to our GI system changes in sleep so you don't get up and go to the bathroom during the night also so five hours and it could be a medication issue it could be sleep apnea does this a lot classically sleep apnea makes people get

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up at night children will have issues along these lines so it could be an issue the good thing though is that the person subscribing being able to go back to sleep quickly so that's kind of sounds more of a physiological issue but it could be the beginning that's often I'll sleep apnea for example begins just getting up to start peeing especially if you ever dry mouth at the same time so I would not ignore that and definitely would pursue this I push through that at some point when things are better around here I think thank you

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so I might from my perspective I would agree with optical i/o that if you have reason to suspect that you have sleep apnea it's definitely good idea to tweety but particularly as we get older waking up and having to go to the bathroom if we can't fall back asleep in the middle tonight it's perfectly normal and non-consequential my perspective and while you have the virtual night dr. Mann burr another question for you and then we can get dr. Pillai owes comments

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on this as well and that is do you have any recommendation recommendations for teenagers during this time of shelter-in-place when school schedules are quite lacked yes definitely I have several teenagers that I'm working with right now the key is to keep the wake time constant in the center in place if the school schedule allows for later time that is okay as long as it's constant so I would say that will be the most important thing for for teenagers

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the other piece for teenagers is to abide by the hard stop of activities that are stimulating the in terms of both light exposure with devices as well as and talking with friends late at night Thank You dr. Pillai Oh the first step with any conversation of the teenager about their behavior is what's their motivation to change their behavior so it's not uncommon for a teenager to spend more time awake in the bedroom than sleeping in the bedroom

44:05

they viewed it's very uh Nadal I think that they did they convert their bedroom to mini studio apartments so you got to give a sense of what's this what does that teenager want to do and then what is expected of them and if those things coincide or they don't or they diverged and have a competition about those things there is we want to keep that wake-up time locked in you want to keep the ability to the wake up time is what's key you don't want people

44:35

sleeping in more than two hours for example sleeping in more than two hours has been associated with bad things happening in teenagers so get a sense of what they want to do what's what's what's happening there is no study that shows if you take away kids electronics they say oh thank you so much taking them away I'm gonna go to sleep now right it because they viewed as resentment so you've got to make sure that they're on board and check with their motivation on this that can't be emphasized enough this all shaquita disorders teenagers a bunch skin disorders begin with the conversation

45:07

but what is your incentive to change your behavior you know the parents want them to change is one thing if the kid wants a change it's a different situation thank you and another question for you while you're speaking and there's this is from a participant who indicates that they take over-the-counter medication specifically a diphenhydramine or benadryl every night and can't tell fall asleep until very late and wants to know is it harmful to take benadryl diphenhydramine every day so the answer is it's probably

45:38

just a waste of time to take it every night the thing with a federal Hydra mean benadryl is the brand name with a lot of different variations of it histamine is made by the mammary nucleus and this one is an alerting you're a transmitter so so that's gonna go up and and our histamine levels increase during the night so it's kind of like you know before you go to the bakery the bakers are there before I had making things ready the body's preparing to be away so histamine is an alerting substance so the antihistamine is more like to

46:09

help you stay asleep not to fall asleep and the brand name the brand name excuse me the the prescription a version of this would be doxepin and medications like trazadone also they have ability to have more antihistamine effects you there more I hope you stay asleep with diphenyl hide you mean these nonspecific all right the histamines what's shown is if you use them every single night after about a week or two they behave like placebo and placebos do work but the reality is it's probably not the right tool the question is why did you end up

46:40

taking a fine argument every night how did that occur to you right because that's the real issue instead of focusing on the medication over-the-counter prescription the real issue is to focus on the insomnia and of itself what's driving people to sleep this way and address that and the nice thing about the work that Rachael and I both do is that most of our patients will get better when I dress correctly there's no reason why somebody has to rely medication every single night to sleep most that's how we can get them better wonderful and we thought some resources from duck commander for both Redwood City and Stanford main campus

47:10

clinics where people can get help if they're wanting help with insomnia specifically and other sleep sleep medicine issues another question this one also we'll start with dr. Mann BER and that is when sleep is not restful when we wake up not feeling adequately rested or not rested enough what can you recommend to us for improving the quality of our sleep so thank you this is also a very good question because there are two common reasons for why you

47:40

wake up feeling not rested one reason you know is that you may have another sleep disorder that makes you sleep very fragmented and most common among them is sleep apnea so if you ever sleep apnea it is a very common reason for why people wake up feeling that refresh that would mean that a good course of action will be to go to the sleep clinic in Redwood City or another sleep clinic in the area and get it tested and treated but there's another reason for why

48:13

people wake up feeling refreshed even if they don't have sleep apnea and that is related to a phenomenon that we call sleep inertia so sleep inertia is basically what you would think that it is like inertia is the propensity of our body to move in the direction it has been moving when it comes to sleep you wake up and you feel like you want to go on sleeping and it takes a while to be fully awake and there's a huge individual variability in how much people have that inertia asleep at an extreme and the people who are

48:44

very strong night people for the sleep inertia is particularly problematic and it takes them a long time before they completely sleep the natural tendency when you wake up and you have sleep inertia and you feeling refreshed is that you conclude that you not sleep well except well enough and the quality of the sleep is the issue where in fact it could be that the quality of sleep is finally just have sleep inertia and a ways to work around it a good way to distinguish between these two course of

49:14

actions be it is it sleep inertia is it sleep apnea is how how what is the course of your alertness as the day progresses if it takes a while to get over the feeling and regression then as the day progresses in feeling better the most likely is related to sleep inertia and potentially to another sleep easily that's called circadian rhythm sleep disorder if on the other hand you sleep is not refreshing in the sense that as

49:46

you go through the day you actually getting worse and worse then probably the best course of action is to consider the possibility of sleep apnea and so circadian rhythms sleep disorders can be treated behaviorally and are treated behaviorally with changes in sleep weight behaviors and light exposure and we can do that both main campus and at the time would clean thank you dr. Pillai or anything to add to that no the main thing is that you should be able to wake up feeling refreshed if you're somebody who says that no matter how

50:16

much sleep I get I'm tired then it's not the amount it's the quality and the quality has to be measured and that's why we would use a sleep study that's the way to think of it if you're tired no matter how much sleep you get then something is wrong and that's when that's we want to focus on measuring the accuracy quality okay thank you and you already mentioned the long term use of Benadryl may not be helpful other than for its placebo effect anything you'd add to that to answer another participants question about long-term use of sleep medicine in general well

50:49

the goal of every patient we see I think reach and I can say we collectively is feasible to fall asleep easily sleep through the night wake up refresh and ideally not use any medication that's what we try to do it everybody and we get there most of the time because for most people who have trouble sleeping there's nothing there's been no neurological impairment to the mecca's in their brain for them not to be able to sleep there exceptions to the rule of course chronic pain patients post-traumatic stress patients have horrible insomnia issues for the most part most people can be able to are able to sleep without medication even just by

51:20

decades of using relying on medication they can still be taught how to sleep again without medication having said that there are gonna be a chunk of patients who no matter what we do they're not gonna sleep well and we might need to use medications with them long term and it's like any other chronic condition you're gonna make a decision about what's the best way handling with individual people there are newer hypnotics being emerging and in reality you know when you think about the patients that we're seeing even though we were before you asleep experts people don't really come to us because

51:51

of their sleep they come to us because how they feel when they're awake which they Achebe to their sleep so are you here because you can't sleep no I'm here because I'm tired and I'm tired because I don't think I'm sleeping well so we always want to focus on the daytime symptoms of this and a lot of probably medications things like over-the-counter things like nyquil for example or any of these other things people take is that the very long act in 15 16 hours of use and you may feel self sleeping but you feel hungover the next day and that's your real focus is how effective do you

52:21

feel the next day yes a patient would take hypnotics for many many years I've had patients that I met when I first was a fellow who I'm still prescribe medication to 26 years later but that's that's a minority fortunately thank you one quick comment I would say that I don't want people listening with the impression that when you have pain or PTSD you need to take medication there are multiple studies that have actually shown that using cognitive

52:51

behavior therapy for insomnia helps people with chronic pain and it does help people with PTSD so just just didn't want to leave the wrong impression and while you are thinking in this way I have another question related to stress not necessarily a pathologic stress but the normal stress that our children are experiencing during this pandemic anything that you might say in a way of advice to speak with children about you know this problem in ways that might help them in this stressful time

53:23

get some sleep sure we had we had a wonderful webinar just on these topics so I would advise to listen to that I would say our children see us as a mirror the way we handle our internal stress our patience with them our way to handle our own stress about the situation and about anything really is going to be reflected in them so I think first and foremost we need to take care

53:54

of ourselves they are I don't think I want to go much beyond that create structure for your kids may give you kids feel safe in any way that you have around them it's really not the stressor around but our reaction to it that that is going to be detrimental for children thank you dr. Pillai or anything you want to add to that no I think that's well said I mean the real issues have

54:27

developed an environment of serenity for that child when this how I was going to sleep right the reason we per fall asleep when we're bored is because boredom is quitter was safety right boredom per se does not make us sleepy it's the perception that well we're safe so our minds will catch up on what I need kids when they're bored don't fall asleep unless you're sleep-deprived so I think the key thing is to develop this as I was trying to do that yes all day long we're dealing with life stretches and certainties but once we're at nighttime the days over tomorrow's another day and we're going to start over so you've earned the chance to go

54:58

to sleep and you've earned this place too and then you're going to be protected you want kids to go to bed feeling safe comfortable and loved at all times that's what we want thank you and we've had a couple more questions on specific substances specifically caffeine melatonin and magnesium caffeine is a stimulant to stay away from magnesium and melatonin being proposed as mechanisms to help us sleep any comments dr. pillai on use of those substances

55:27

caffeine is a most you said like if some the world commodity wise it's I think it's the second most creative thing other than oil so caffeine does play a large role people will use some degree of caffeine in certain ways obviously not everybody but a lot of people do turns out that caffeine has gotten more complicated because we're learning more about the genetics of caffeine metabolism and some people have certain enzymes and ten percent of the people may seem not to be at that affected by it or can but that

56:00

was very quickly in general coffee caffeine takes about six hours to work miss Kazue let's start to work exceed system for about six hours so the rule of thumb for years has been to no caffeine about six hour you plan to go to sleep having said that are some people who don't seem to feel that way about it and some people get really sick from it the other thing was magnesium and melatonin the melatonin is marketed as a as a food supplement so it does not

56:31

have the same degree of strict quality control as a medication would and they've actually analyzed over-the-counter melatonin and what the dosage fluctuates believe it or not by 400% four zero zero 400% what's on what's on the label that was in the bottle about twenty five percent of the samples of serotonin in them so there are issues with with what's happening with melatonin especially if it comes in the gummy formulations and this may explain why sometimes it works and not others for some people magnesium seems to relax people the reality is that

57:03

people who find supplements of any kind or herbal herbal supplements or minerals or things to help them sleep better don't come see wouldn't make it home to come see me nobody they go out of their way to see me same with all good things like chamomile tea and things like that where they you can associate them with soothing environment to help you sleep but usually the real issue is what's driving the insomnia away having trouble sleeping and if you don't address the core reason behind insomnia we should be surprising that eventually things stop working because you know it just inside of itself I think my sleep is that

57:34

everything seems to work in the beginning but eventually over time these things that you think are working stop working but you have to add to them and people who have long-term sleep issues often have a litany of things that they've tried or things they have to add to the sleeper and despite these things that they have through these conditions that they have the still having trouble sleeping because again the Cori reason for the insomnia has never been at really addressed very very quickly very quickly I would say about caffeine caffeine binds to receptors in the brain that are involved in the sleep drive so

58:06

they fooled the brain for a while to think that the sleeper is less and so it can have direct impact but when it was off then you get the rebound but importantly caffeine half-life is impacted by variety of conditions and medications for example pregnant women the half-life of caffeine is much much longer it's like eight nine hours in certain medications also and the other piece I wanted to coning there is good

58:37

research that shows that melatonin seems to be working fairly well in children but the literature their helpfulness of modifying that does is much more sketchy okay thank you and perhaps this may be our last question and that is any thoughts on how exercise and food schedules might affect sleep which schedules food diet I can briefly I can answer it in 20 seconds exercise raises our core body

59:07

temperature so the exercise issue is more matter of timing people to exercise is good method of stress reduction but being too close to bedtime could be detrimental so generally I would say two to three hours before bedtime should not be rigorous exercise stretching walking is fine for dr. Pillai already talked about the fact that the food digestion system shuts down and slows down while we sleep so it's not a good idea to have a heavy

59:38

meal at least four hours before bedtime okay thank you dr. Mann burrow and dr. Pillai oh and those of you wanting to claim CME the information and how to do so is displayed again thank you for joining us thank you everybody

Minimizing impact of COVID 19 pandemic on sleep of healthcare providers

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