Snoring could be an early warning sign for memory loss.

CBS NEWS     April 16, 2015, 12:43 PM

There's new evidence suggesting just how important sleep is for the brain.

A study, published Wednesday in the journal Neurology, finds that people who snore heavily and have breathing problems during sleep may develop memory loss and cognitive decline at a much younger age than average.

"This study might be keeping some people up at night," Dr. Carol Ash, director of sleep medicine at Meridian Health, told "CBS This Morning."

http://www.cbsnews.com/pictures/sleep-hacking-tips-7-ways-to-maximize-your-zzzzzs/

Snoring and sleep apnea -- a condition where breathing is repeatedly interrupted during sleep -- are common among older people, affecting about half of men and a quarter of women, according to the researchers from NYU Langone Medical Center.

They studied the medical histories of nearly 2,500 people ages 55 to 90. Participants were categorized as having either normal brain function, mild cognitive impairment (MCI), or early stages of Alzheimer's disease.

The study found that people with sleep apnea were diagnosed with mild cognitive impairment an average of nearly 10 years earlier than people without sleep apnea.

"That's significant," Ash said. Even though the study did not prove cause and effect, she said it adds to a growing body of evidence that links sleep to brain health.

• How to protect your aging brain
• New clue about what causes Alzheimer's disease

Fortunately, she said, there are things you can do to lower the risk. "When you have symptoms of snoring or symptoms that suggest you have sleep-disordered breathing, you really want to take it seriously. There's simple screening that can be done to identify somebody that has a problem. There's a home sleep test to make the diagnosis. Then there's treatment options."

For people with sleep apnea, a device called a CPAP mask, worn over the nose and mouth, can help keep the airways open at night. It may look uncomfortable, but Ash said, "When you have a patient who truly has this problem, it can change and save their life. You have to coax them through and get them comfortable, but once they're using it, they won't go back."

Losing a few pounds can also be effective, since excess weight often contributes to snoring and breathing problems. In other cases, dental work or surgery can make a difference.

The NYU researchers found that patients whose sleep issues were treated were able to ward off cognitive decline. "The age of onset of MCI for people whose breathing problems were treated was almost identical to that of people who did not have any breathing problems at all," study author Ricardo Osorio, MD, said in a press statement. "Given that so many older adults have sleep breathing problems, these results are exciting --we need to examine whether using CPAP could possibly help prevent or delay memory and thinking problems."

Ash stressed the importance of getting diagnosed and dealing with sleep problems, since in addition to memory decline, snoring and sleep apnea have also been linked to an increased risk of stroke, heart attack, and other life-threatening conditions.

"Sometimes you can't undo all of the damage, but I've seen significant improvements," she said. "It's worth looking into."

Your Brain May Get Smaller if You Don't Sleep Enough

Notes from Dr. Norman Blumenstock

EmpowerHER reports that a portion of the brain may shrink when individuals do not get an adequate amount of sleep.

The cerebral cortex is the site of complex functions of the brain, and controls how we think and interact with the world. According to the study, lack of sleep may shrink part of the frontal cortex, which deals with problem-solving, self-control, planning and logic. Lack of sleep also accelerates the rate of brain loss in regions that process sound, language and spatial orientation.

Monkey Business Images/PhotoSpin

Getting a good night’s sleep has all sorts of health benefits, while a bad night’s sleep can lead to health issues, from aging skin to weight gain. But these effects seem less drastic in light of a study published last month in the journal Neurology. It showed that poor quality sleep is actually linked with wasting away of the brain, especially in those over 60 years old.

Researchers from University of Oxford and University of Oslo sampled 147 adults. The subjects ranged from 20-84 years old and encompassed a variety of physical activity levels, body mass index (BMI) and blood pressure levels.

Each subject completed a questionnaire that measured sleep quality. The questionnaire assessed three main things: sleep latency (how long it takes to fall asleep), sleep duration (how many hours of sleep per night) and sleep efficiency (the percentage of time spent actually sleeping).

Two MRI scans were done for each subject, an average of 3.5 years apart, to see how different sleep habits affected the brain. After comparing brain volumes from the two scans, the researchers found that physical activity, BMI and blood pressure were not related to brain volume.

However, poor sleep quality was related to reduced brain volume, specifically in the cerebral cortex.

The cerebral cortex is the site of complex functions of the brain, and controls how we think and interact with the world. According to the study, lack of sleep may shrink part of the frontal cortex, which deals with problem-solving, self-control, planning and logic. Lack of sleep also accelerates the rate of brain loss in regions that process sound, language and spatial orientation.

The correlation between lack of sleep and reduced brain size was strongest for subjects over 60 years old, a period in life that is often characterized by poorer sleep. Generally, people older than 60 sleep less, take longer to fall asleep and wake up more often in the middle of the night, according to a New York Times article.

The researchers of the Neurology study emphasized that they didn’t know for sure whether poor sleep causes brain shrinkage or whether it's the other way around. Perhaps brains naturally decay somewhat as we age, which leads to worse quality of sleep, the study said.

Other people have suggested that poorer quality of sleep in older people doesn’t come from their age, but rather their illnesses or medications. “The more disorders older adults have, the worse they sleep,” Sonia Ancoli-Israel, a sleep researcher at the University of California, San Diego, told New York Times.

It turns out that sleeping well is just as important for the over-60 crowd as for 20 year olds, although what defines sleeping well could be different for the two age groups.

Regardless, there seems to be a consensus that getting a good night’s sleep is important, no matter the age. And for those over 60 years old, good sleep may be essential to slowing down brain loss.

Sources:

The Elderly Always Sleep Worse, and Other Myths of Aging. New York Times.com. Retrieved October 5, 2014.
http://www.nytimes.com/2007/10/23/health/23age.html?_r=0

Human Brain: Facts, Anatomy & Mapping Project. LiveScience.com. Retrieved October 5, 2014.
http://www.livescience.com/29365-human-brain.html

Lack of sleep may shrink your brain. CNN.com. Retrieved October 3, 2014.
http://www.cnn.com/2014/09/04/health/no-sleep-brain-size/index.html?hpt=...

Poor sleep quality is associated with increased cortical atrophy in community-dwelling adults. Neurology. Retrieved September 28, 2014.
http://www.neurology.org/content/early/2014/09/03/WNL.0000000000000774

Reviewed October 8, 2014
by Michele Blacksberg RN

Sleep sensors: waking up to the need to study our night's rest

Notes from Dr. Norman Blumenstock

Many people are turning to fitness trackers to help boost the health benefits of better sleep

Sales of sleep tracking devices are booming as more people become mindful of their health. Big manufacturers are piling in, but do the gadgets work, and, if so – how? Photograph: Vincent Besnault/Getty Images

Every night Jack Hammond straps a small gadget to his wrist. The sensor claims to track his sleep, monitoring every toss and turn so that when he wakes it can tell him how long he slept, how much of it was deep sleep – and how often he was woken up by his unsociable neighbor.

"I can see that I need about four hours' deep sleep to feel refreshed, and I need to be asleep for about eight hours for that to happen," says Hammond, a 36-year-old plumber from Northhampton. "I can also see that when I've had caffeine too late I get less deep sleep."

Hammond's gadget is a fitness tracker – a small bracelet device that by day can measure his activity and calorie burn, the distance he has walked and altitude climbed, and reveal how long he spends at his desk. Part of the "quantified self" movement, more than 3.8m fitness trackers like Hammond's were sold worldwide in 2013, predicted to rise to 14.6m by the end of 2014, according to the analysts CCS Insight.

"Several devices have supported sleep measurement for some time, from smaller companies such as Jawbone, Fitbit and Basis," said Ben Wood, the head of research at CCS Insight. "The big players are now getting in on the action and Sony and Samsung devices support sleep tracking too."

But do the devices work? Does using them do you any good?

Sleep has always been considered scientifically important to all-round physical health. But efficacy of fitness trackers to measure and improve sleep is less established.

Studies have found that people who sleep for less than six hours a night have a risk of high blood pressure three times greater than those who get more than six hours, and that women who sleep less than four hours a night are twice as likely to die from heart disease as those who sleep longer. Other research suggests that a lack of quality sleep is linked to the onset of diabetes, obesity and cancer, not to mention deterioration of mental health and memory. Conversely, sleeping too long has also been shown to cause issues. The recommended amount is between seven and nine hours.

"There's physical restoration component to sleep, including healing, as well as mental restoration component," explains Dr Michael Breus, a US "sleep doctor", based in Scottsdale, Arizona. "During REM [rapid eye movement] sleep in particular there's a cleaning process to get the trash out of there, and a strengthening process that occurs for the more important memories," said Breus.

"Anything that allows you to wake up feeling refreshed in the morning is what you should be aiming for, which is generally between six and nine hours," explained Dr Irshaad Ebrahim from the London Sleep Centre. "But it's not all about time, it's about the quality of the sleep, whether you complete sleep cycles."

As to using motion trackers to measure sleep, he said: "They're not measuring sleep, simply motion – not muscle tone, brain waves, heart rate or eye movement. You cannot infer quality of sleep from motion and tell what is crucial REM [rapid eye movement] sleep and what is not. People can become obsessed about their sleep through these gadgets doing them a disservice, worrying about it and in turn getting less decent sleep and having a negative impact."

Breus is less concerned. "They pique people's curiosity, and it gets them to ask 'how is my sleep'? That's the best thing about them. I wouldn't say they are dangerous, but it's a garbage-in, garbage-out situation, and it's impossible to make recommendations without good data."

For some users, that curiosity can lead them to understand how to sleep better. "My Fitbit told me I slept for more hours than I thought I did," said James Stockton, 29 from Southampton. "It was quite encouraging, and I could see patterns in my sleep when I exercised more or drank alcohol."

If, however, inspired by a sleep gadget, you want to find out general tips for better sleep, you will discover the advice doesn't fit so well with a modern lifestyle. Screens on smartphones, tablets and TVs emit blue light that disrupts the natural process of falling asleep – and is best avoided for an hour before going to bed. Avoiding alcohol and caffeine raises the quality of sleep, as does getting regular exercise.

Motion trackers aren't the only gadgets claiming to track sleep. Products such as the SleepRate, which comes with a chest strap, will track heart rate, which can be used to infer sleep. Although more accurate than motion trackers, they still cannot conclusively monitor all stages of sleep and reveal the crucial quality of a period of sleep.

"I get patients showing me their sleep data on smartphones," said Breus. "But I can't tell them what I don't know. The data isn't good enough to give them a diagnosis. They could be useful for tracking sleep trends over a longer period of time, to see when something changes, though."

Most of the devices currently available to consumers simply track motion to infer sleep. Sleep therapists use much more sophisticated machines that monitor brain waves, muscle tone and eye movement to directly detect the different phases of light and deep sleep.

The next wave of sleep gadgets, expected to hit the market within six months, is likely to include more sophisticated sleep-trackers that can monitor brain wave activity and eventually other biometric indicators, such as heart rate, muscle tone, eye movement and breathing rate.

Brain wave patterns are thought to be the best indicator at present. "We expect this to become a standard feature in most wearable devices , both fitness bands and smart watches, from now on," said Wood.

In the meantime, many sleep-tracking devices are built into tools for tracking more general fitness – and there is evidence that consumers are losing enthusiasm. A third of owners abandon their fitness tracker within six months, according to research from Endeavour Partners.

"I used to track my sleep with my Flex, but I gave up in the end," said Jessica Ross, 22, from Liverpool. "It was boring and didn't really tell me anything to keep me wearing it either at night or through the day. It lasted four months and then went in a drawer."

Top trackers

There are many devices on the market that claim to track your sleep, some better than others.

Here are six of the best available at the moment.

Misfit Shine – £80 A small metal waterproof disc, the Misfit Shine is one of the smallest and most comfortable to wear. It automatically detects deep and light sleep and awake moments via movement. It has a four-month battery life and outputs the data via Bluetooth to an Android or iPhone app.

SleepRate – £60 Combining a chest heart rate monitor with a smartphone app, SleepRate, which uses a heart rate strap, monitors sleep and can craft a bespoke sleep improvement plan. SleepRate claims to be more accurate than motion-based sleep monitors and if serious problems are detected SleepRate will suggest a visit to a sleep doctor.

Jawbone UP24 – £125 This fitness band can monitor light and deep sleep and waking periods using movement while automatically connecting to an iPhone or Android smartphone via Bluetooth. It will also wake up the wearer with a small vibrating alarm at the optimum time for a maximum refreshed feel.

Fitbit One – £80 Fitbit's pedometer-style fitness tracker can also monitor sleep, slipped into a small soft band worn around the wrist. Like the others it detects movement and can wake the user through a small vibrating alarm.

Fitbit Flex – £80 The Flex is essentially the Fitbit One formed into a bracelet, detecting sleep through moment and connecting to the Fitbit iPhone, Android and Windows Phone app via Bluetooth.

Withings Pulse O2 – £100 The Pulse will track sleep via movement, giving readings on total sleep and sleep cycles, slipping into a bracelet worn around the wrist. It connects via Bluetooth to an iPhone or Android app to display the data.

Notes from Dr. Norman Blumenstock

Excessive snoring might seem like a relatively harmless issue, but more evidence shows that sleep apnea can cause serious health issues to your brain.

Kathleen Lees k.lees@scienceworldreport.com

First Posted: Sep 10, 2014 06:16 PM EDT

More than 18 million Americans are estimated to have sleep apnea, a breathing disorder that disrupts air flow and can result in a poor night's rest. (Photo : Reuters)

Excessive snoring might seem like a relatively harmless issue, but more evidence shows that sleep apnea can cause serious health issues to your brain.

Recent findings published in the journal PLOS ONE show that blood flow in the brain can actually damage related tissues presented by this health issue.

"We know there is injury to the brain from sleep apnea, and we also know that the heart has problems pumping blood to the body, and potentially also to the brain," said lead study author Paul Macey, associate dean for Information Technology andInnovations at the UCLA School of Nursing, in a news release. "By using this method, we were able to show changes in the amount of oxygenated blood across the whole brain, which could be one cause of the damage we see in people with sleep apnea."

For the study, researchers measured blood flow in the brain by using a non-invasive MRI procedure: the global blood volume and oxygen dependent (BOLD) signal. This method is usually used to observe brain activity. Because previous research showed that poor regulation of blood in the brain might be a problem for people with sleep apnea, the researchers used the whole-brain BOLD signal to look at blood flow in individuals with and without obstructive sleep apnea (OSA).

In the study, researchers measured men and women both with and without the issue that had their BOLD signals measured during three physical tasks while they were awake, according to the release: 

• The Valsalva maneuver: participants forcefully breathe out through a very small tube, which raises the pressure in the chest.
• A hand-grip challenge: participants squeeze hard with their hand.
• A cold pressor challenge: A participants's right foot is put in icy water for a minute.

"When we looked at the results, we didn't see much difference between the participants with and without OSA in the Valsalva maneuver," said Macey. "But for the hand-grip and cold-pressor challenges, people with OSA saw a much weaker brain blood flow response."

"This study brings us closer to understanding what causes the problems in the brain of people with sleep apnea," concluded Macey.

With future studies, researchers hope to determine better treatments for certain types of obstructive sleep apnea and how to reverse related health issues. 

Can Sleep Loss Affect Your Brain Size?

Published on September 4, 2014

Sleep difficulties may be linked to faster rates of decline in brain volume, according to a study published in the September 3, 2014, online issue of Neurology, the medical journal of the American Academy of Neurology.

Sleep has been proposed to be “the brain’s housekeeper,” serving to repair and restore the brain.

The study included 147 adults between 20 and 84 years old. Researchers examined the link between sleep difficulties, such as having trouble falling asleep or staying asleep at night, and brain volume.

All participants underwent two MRI brain scans, an average of 3.5 years apart, before completing a questionnaire about their sleep habits.

A total of 35% of the participants met the criteria for poor sleep quality, scoring an average of 8.5 out of 21 points on the sleep assessment. The assessment looked at how long people slept, how long it took them to fall asleep at night, use of sleeping medications, and other factors.

The study found that sleep difficulties were linked with a more rapid decline in brain volume over the course of the study in widespread brain regions, including within frontal, temporal, and parietal areas.

The results were more pronounced in people over 60 years old.

“It is not yet known whether poor sleep quality is a cause or consequence of changes in brain structure,” says study author Claire E. Sexton, DPhil, with the University of Oxford in the United Kingdom, in a release. “There are effective treatments for sleep problems, so future research needs to test whether improving people’s quality of sleep could slow the rate of brain volume loss. If that is the case, improving people’s sleep habits could be an important way to improve brain health.”

Sleep study shows dangers of driving drowsy

Notes from Dr. Norman Blumenstock

In a sleep deprivation study, a hand full of participants stayed up for 24 hours straight and was then monitored in a sleep study room. Dr Chris Hammond from the Ogden Clinic monitored their brain waves to show how sleep deprivation affects how people function.

http://www.good4utah.com/story/d/story/sleep-study-shows-dangers-of-driving-drowsy/20327/E9GIgqGZaU-4_GLJJUPhoA

OGDEN, UTAH (GOOD 4 UTAH) - The Utah Department of Transportation, the Utah Highway Patrol and the Department of Public Safety wants the public to know the dangers of driving drowsy. They say it's one of the top five behaviors killing people on Utah roads.

It’s all part of Utah's first Drowsy Driving Awareness week put together by the Utah Department of Transportation's Zero Fatalities program and participating agencies.

UDOT tells Good 4 Utah already this year there have been 636 drowsy driving related crashes in Utah and they hope by bringing light to drowsy driving it will prevent the problem from growing.

In a sleep deprivation study, a hand full of participants stayed up for 24 hours straight and was then monitored in a sleep study room. Dr Chris Hammond from the Ogden Clinic monitored their brain waves to show how sleep deprivation affects how people function.

“Not only does it affect attention, but it affects memory and executive function, which entails good judgment and good insight. Without those two we don't appreciate how sleepy we may be or how capable we are to safely driving on the road,” said Dr. Chris Hammond.

Right now Utah's has three deaths related to drowsy driving, but still UDOT says it's three too many and encourages drivers to avoid getting behind the wheel without enough sleep.

How a Lack of Sleep Can Hurt Your Finances

Notes from Dr. Norman Blumenstock

“The fact is that man-made disasters ranging from the explosion of the Space Shuttle Challenger to the spilling of Exxon Valdez, and the chemical disaster in Bhopal, India, all have sleepiness as a primary contributing factor,” Wickwire says.

Proud that you’re awake at all hours and still functioning normally? It may be costing you.

The arguments for a good night’s sleep are well-documented, with studies showing that people who get more sleep get fewer colds, tend to maintain a healthier weight and have a smaller chance of coming down with heart disease and diabetes.

But if you’re uninterested in the health benefits of sleep, you may want to consider what your sketchy sleep patterns are doing to your wallet.

You’re probably sleepwalking through your sleep problem.There are many reasons we don’t get enough sleep. Some people are workaholics or night owls. Others are kept up by chronic stress or insomnia, and still others have a disorder like sleep apnea. According to the National Sleep Foundation, more than 18 million Americans have sleep apnea, a condition that causes troubled breathing during sleep, and 75 percent of people with sleep apnea don’t know they have it.

Related: How Financial Stress Dramatically Lowers Your IQ

What’s unsettling is that the average person may not realize they’re sleep deprived due to the way the body works. ”We habituate to adenosine, a brain chemical that induces sleep. So even though judgment and performance are impaired, we think we’re performing just fine. The reality is, they are depriving their brains of a nutrient just as vital as food or water,” says Emerson Wickwire, sleep medicine program director at Howard County Center for Lung and Sleep Medicine in Columbia, Maryland. He also teaches non-drug treatment approaches to sleep disorders at The Johns Hopkins University School of Medicine and Walter Reed National Military Medical Center.

Wickwire continues: “The effects of sleep loss on cognitive processing, concentration and memory are striking and acute. Processing speed deteriorates dramatically with shortened sleep duration, and you can’t simply ‘catch up’ on the weekends.”

If you aren’t sleeping, you’re putting your career at risk.Nitun Verma, medical director for the Washington Township Center for Sleep Disorders in Fremont, California, sees this a lot. He works with many professionals in Silicon Valley and says there are two typical groups of patients who tend to come into his office.

"The first group is the professional at a larger, more established company, usually in their 40s to 50s," Verma says, adding that these people often feel sleepy at work, which worsens as the afternoon progresses. "They have a fear that some younger, more energetic person is going to take their job or their promotion."

People in their 20s and 30s suffer from sleepless nights, too, Verma says. They have a more active social and professional night life, advancing their lives and careers, and often only sleep four to five hours a night, he says.

"Adrenaline is carrying them during exciting times, but the sleepiness finds them during brainstorming and creative times," Verma says.

Of course, it’s easy to dismiss the problems. Occasionally falling asleep during a meeting, aside from the embarrassment, may not be so bad. But do it enough, and it can destroy your career.

In Large Study, Sleep Quality and Duration Improve Cognition in Aging Populations

Notes from Dr. Norman Blumenstock
Better sleep has a positive connection to better memory.

Published on June 17, 2014

A new University of Oregon-led study of middle-aged or older people who get 6 to 9 hours of sleep a night shows that they think better than those sleeping fewer or more hours.

The study, published in the June issue of the Journal of Clinical Sleep Medicine, reaffirms numerous small-scale studies in the United States, Western Europe, and Japan, but it does so using data compiled across six middle-income nations and involving more than 30,000 subjects for a long-term project that began in 2007.

“We wanted to look at aging, particularly dementia and cognitive decline as people get older, and the importance of sleep. Our results provide compelling evidence that sleep matters a lot,” says lead author Theresa E. Gildner, a doctoral student in the University of Oregon (UO) anthropology department, in a release. “In all six countries, which are very different culturally, economically, and environmentally—despite all these differences—you see similar patterns emerging.”

The study, based on the first wave of data from the project, focuses on people 50 years old and older in China, Ghana, India, Mexico, the Russian Federation, and South Africa.

Among the key findings:

• Men reported higher sleep quality than women in all six nations, with men and women in Mexico reporting the highest.

• Women reported longer sleep durations than men in all countries except Russia and Mexico. Men and women in South Africa slept longer than in any other country. The least sleep hours for both sexes occurred in India.

• Individuals sleeping less than 6 hours and more than 9 hours had significantly lower cognitive scores compared to those in the intermediate group. 

Trained native speakers in each country interviewed the participants, who rated their sleep quality on a five-point scale and the number of hours they’d slept over the two previous nights. That information was averaged. Participants then went through five standard cognitive tests involving immediate recall of a list of presented words, delayed recall of those words later, forward and backward recall of long lists of numbers, and a verbal fluency test in which they listed as many animals as possible without repetition, the use of proper nouns, or descriptors.

The study concludes that the findings have important implications for future intervention strategies for dementia. The consistent associations between intermediate sleep durations, high sleep quality, and enhanced cognitive performance in these diverse populations suggest that improving sleep patterns may help reduce the level of cognitive decline as seen in older adults.

Another important finding, Gildner says, is the gender difference in all sleep and cognition variables. Citing previous studies, the authors had hypothesized that women’s sleep patterns reflect postmenopausal changes, increased bladder instability, and feelings of isolation after the loss of a spouse or lack of social support. Cognition scores of women may result from their sleep difficulties and/or lower educational levels.

The growing database in the long-term study, known as the Study on global AGEing and adult health (SAGE), is allowing researchers to mine many combinations of variables connected to health and lifestyle, says J. Josh Snodgrass, professor of anthropology at the UO. “It also will allow anthropologists to explore cultural factors that may contribute to sleeping and health patterns.”

Snodgrass is a key investigator on SAGE, which is funded by a joint agreement of the National Institutes of Health and the World Health Organization.

“This study is hugely powerful and so different from what’s been done in the past, simply because of the consistency of how the data was collected—multi-national, random samples of people,” he says. “Sleep is something that is important but often undervalued in our society.

“From doing this research and being familiar with the literature,” he adds, “an emphasis on sleep issues by the media in recent years is warranted. Every single piece of evidence that people look at now as they are investigating sleep and different health associations is all showing that sleep really, really, really matters. We’re just now scratching the surface on what patterns of sleep normally are, and also what are these associations between sleep and health issues.”

Co-authors with Gildner and Snodgrass were: UO doctoral student Melissa A. Liebert, anthropology; Paul Kowal of the World Health Organization in Geneva, Switzerland, and University of Newcastle Research Centre on Gender, Health, and Aging in Australia; and Dr Somnath Chatterji of the World Health Organization.

Crystalline Obstructive Sleep Apnea and the Eye

Notes from Dr. Norman Blumenstock

A recent  study by the University of North Carolina, adds ocular diseases to the long list of obstructive sleep apnea associations.

By Matheson A. Harris, MD, Syndee J. Givre, MD, PHD, and Amy M. Fowler, MD
Edited by Ingrid U. Scott, MD, MPH, and Sharon Fekrat, MD

Sleep is something we all need and, especially as physicians, often cherish. While eyelids that are tired and droopy may be one of the first signs to herald sleepiness, sleep disorders such as obstructive sleep apnea (OSA) actually have many ocular sequelae, some of which are vision-threatening. It is important for ophthalmologists to understand and identify sleep disorders—especially OSA—and their ocular associations, as these can occasionally be the source of unusual and often perplexing conditions.

About OSA

The increasing prevalence of obesity in our society has been associated with an upsurge in OSA, a disease that results in the cessation of breathing during sleep for 10 seconds or longer due to partial or complete obstruction of the upper airway. It is estimated that as many as 24 percent of Caucasian men and 9 percent of Caucasian women in the United States have OSA, though many of these cases remain undiagnosed.¹

Taking a good sleep history is the key to diagnosis and includes questions about day- and nighttime symptoms, specific obstructive breathing symptoms, and medical history of conditions associated with increased risk of OSA. Common daytime symptoms include sleepiness, difficulties with concentration and memory, and depression. Patients may also experience decreased productivity, anxiety, gastroesophageal reflux and sexual dysfunction. Nighttime symptoms include insomnia, frequent awakenings, and nocturia. Obstructive symptoms include loud snoring, choking and gasping, and witnessed apneas, which may be reported only by the patient’s bed partner. As patients age, the classic history of obesity, snoring and witnessed apneas is less common, and a careful history of sleep disturbances may be more revealing. Additional examination findings include increased neck circumference, tonsillar hypertrophy, enlarged soft palate, retrognathia and lower extremity edema.

Conditions associated with increased risk of OSA include positive family history of the disease, hypertension, diabetes, pulmonary hypertension, menopause and increased alcohol use. OSA patients also have an increased risk of automobile accidents as well as a higher risk of heart failure, stroke and death. Numerous ocular disorders have been found to be more prevalent in patients with OSA, including floppy eyelid syndrome, glaucoma, nonarteritic anterior ischemic optic neuropathy and papilledema with raised intracranial pressure.

Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES) is probably the most common ocular disorder that has been associated with OSA. It is characterized by rubbery, redundant upper eyelid tissue and papillary conjunctivitis, and is seen most commonly in obese middle-aged men.²

The affected eyelid may correspond to the side on which the patient prefers to sleep. The etiology is uncertain, but current theories include an upregulation of elastin-degrading matrix metalloproteinases possibly caused by direct eyelid trauma, ischemia-reperfusion injury due to pressure placed on the eyelid, or low arterial oxygen tension during sleep.

When FES is severe, the eyelid may spontaneously evert during sleep and rub on the patient’s pillow, causing an acute exacerbation of mechanically induced conjunctivitis.

When a thumb is placed on the lateral upper eyelid and traction is applied, a striking laxity will be found and the eyelid will easily evert. These patients typically present with eye irritation, tearing and blurred vision, all of which are worse upon awakening. Examination findings may include beefy, red, palpebral conjunctiva with velvety papillary changes, diffuse punctate keratopathy, eyelid and eyelash ptosis, and loss of eyelash parallelism. As many as 10 percent of patients may have associated keratoconus.³

While the prevalence of OSA in patients with FES has been reported to be as high as 90 percent, only 2 to 5 percent of patients with OSA may have FES.⁴ Thus, it is impractical to screen all patients with OSA for FES. However, all patients with FES who do not have an established diagnosis of OSA should have a thorough sleep history taken and, when appropriate, should be referred for sleep evaluation including polysomnography.

Treatment of FES initially involves the use of lubricating eye drops and ointment, in addition to preventing mechanical injury during sleep by taping of the eyelid or use of an eye shield. Patients with FES and OSA who are already being treated with continuous positive airway pressure (CPAP) need to have their masks properly fitted to avoid additional eye injury due to misdirected air further drying out the eyes. Surgical treatment includes a full-thickness tarsal wedge resection, usually pentagonal in shape, or horizontal eyelid tightening with a traditional lateral tarsal strip procedure.

Common OSA Signs and Symptoms

Daytime Symptoms Excessive sleepiness Morning headache Difficulty with concentration/memory Depression Nighttime Symptoms Loud snoring/gasping Witnessed apneas Insomnia Frequent awakenings Nocturia Signs Obesity Increased neck circumference Enlarged soft palate/tonsils Retrognathia Lower extremity edema

Glaucoma

The link between glaucoma and OSA is controversial. Most studies have shown a higher prevalence of both primary open-angle glaucoma and normal- tension glaucoma among patients with OSA, with one study showing a prevalence as high as 27 percent.⁵ Several small studies have identified OSA in patients with glaucomatous optic disc cupping and associated visual field defects who do not respond to medical or surgical IOP-lowering treatments, but whose visual fields stabilize when treated with CPAP. One Chinese study showed that patients with OSA were four times more likely to have glaucomatous optic disc changes and visual field defects than age-matched controls.⁶ The higher rate of normal-tension glaucoma among patients with OSA strongly indicates the two are correlated.

Several theories have been used to link OSA to glaucoma, one of which is that optic nerve head (ONH) damage is caused by apnea-induced ischemia. This would explain the lack of IOP elevation and family history of glaucoma in most persons affected with OSA. In addition, the vascular endothelium of the ONH vessels has been shown to function poorly in those with sleep- disordered breathing, which can lead to poor autoregulation of ONH blood flow and further ischemic damage. This is especially important at night when nocturnal fluctuations in systolic blood pressure are poorly compensated.

Current evidence suggests that at the very least a sleep history should be elicited from any patient diagnosed with normal-tension glaucoma who either has none of the classic risk factors for glaucoma or who has failed medical and surgical therapy. Also, it is important to confirm that persons with OSA and suspected or documented glaucoma are being treated adequately for OSA.

Other Optic Nerve Pathology

Nonarteritic anterior ischemic optic neuropathy. Multiple studies have shown that the incidence of OSA is higher in patients with NAION than in the general, age-matched population. In fact, NAION is more commonly associated with OSA than it is with diabetes or hypertension. It has been suggested that patients with NAION be questioned about their sleep habits. One research group that did this elicited a history of OSA 2.5 times more often in patients with NAION than in controls.⁷

Papilledema. Also associated with OSA, papilledema is thought to be caused by nocturnal increases in intracranial pressure. Potential mechanisms include raised venous pressure due to forced inspiration against a closed airway or hypercapnia-induced cerebral venous dilation.

When neuroimaging is normal, a careful sleep history in a patient with papilledema is critical in order to determine whether OSA is a causative factor. In such patients, treatment of the OSA has been shown to improve or resolve the papilledema.

Conclusion

Because OSA is associated with sight-threatening disorders in addition to systemic conditions with significant associated morbidity and mortality, we as ophthalmologists cannot afford to miss the diagnosis of a sleep disorder. Asking a few simple questions about your patient’s sleep habits may be the difference between making a sight-saving diagnosis or just looking like you’re asleep on the job.

Sleep Loss May Cause Brain Damage and Accelerate Onset of Alzheimer’s, Two New Studies Show

Notes from Dr. Norman Blumenstock:

Two more studies on the dangers of sleep deprivation and obstructive sleep apnea.

April 03, 2014 

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By Dr. Mercola

Could poor sleeping habits cause brain damage and even accelerate onset of Alzheimer's disease? According to recent research, the answer is yes on both accounts.

According to neuroscientist Dr. Sigrid Veasey, associate professor of Medicine and a member of the Center for Sleep and Circadian Neurobiology at the Perelman School of Medicine, this is the first time they've been able to show that sleep loss actually results in the loss of neurons.

A second study also suggests that if you sleep poorly, you're at increased risk for earlier onset of severe dementia.

Sleep Loss Linked to 'Massive Brain Damage'

 The first study in question, published in the Journal of Neuroscience,1, 2, 3 found that sleep is necessary for maintaining metabolic homeostasis in your brain. Wakefulness is associated with mitochondrial stress, and without sufficient sleep, neuron degeneration sets in.

The research also showed that catching up on "sleep debt" on the weekend will not prevent this damage. To reach their conclusion, the researchers submitted mice to an irregular sleep schedule similar to that of shift workers.

Inconsistent, intermittent sleep resulted in a remarkably considerable, and irreversible, brain damage—the mice actually lost 25 percent of the neurons located in their locus coeruleus,4 a nucleus in the brainstem associated with arousal, wakefulness, and certain cognitive processes. As reported by Time Magazine:5

"The scientists believe that when the mice slept inconsistently, their newer cells would create more sirtuin type 3, a protein meant to energize and protect the mice. But after several days of missing sleep, as a shift worker might, the protein creation fell off and cells began to die off at a faster pace."

Chronic Sleep Disruption May Trigger Alzheimer's Onset

In a similar vein, research published in the journal Neurobiology of Aging6suggests that people with chronic sleep problems may develop Alzheimer's disease sooner than those who sleep well. According to lead author Domenico Praticò, professor of pharmacology and microbiology/immunology in the university's School of Medicine:7

"The big biological question that we tried to address in this study is whether sleep disturbance is a risk factor to develop Alzheimer's or is it something that manifests with the disease."

Using mice bred to develop Alzheimer's, the researchers exposed one group of mice to 12 hours of light and 12 hours of darkness, while another group was exposed to 20 hours of light and only four hours of darkness. This lack of darkness significantly reduced the amount of time the mice slept.

At the end of the eight-week long study, the mice that slept less were found to have significantly poorer memory. Their ability to learn new things was also impaired—despite the fact that the two groups of mice had about the same amount of amyloid plaque (a hallmark of Alzheimer's) in their brains. According to Dr. Praticò:

"We did observe that the sleep disturbance group had a significant increase in the amount of tau protein that became phosphorylated and formed the tangles inside the brain's neuronal cells...

Because of the tau's abnormal phosphorylation, the sleep-deprived mice had a huge disruption of this synaptic connection. This disruption will eventually impair the brain's ability for learning, forming new memory and other cognitive functions, and contributes to Alzheimer's disease."

Since both groups of mice were bred to develop Alzheimer's but the sleep deprived group developed these dementia-related problems sooner than the others, the researchers believe that poor sleep acts as a trigger of pathological processes that accelerate the disease. The researchers concluded that "chronic sleep disturbance is an environmental risk factor for Alzheimer's disease."

Previous research, published in the journal Science,8 has also revealed your brain removes toxic waste during sleep through what has been dubbed "the glymphatic system."9, 10, 11, 12, 13 This system ramps up its activity during sleep, thereby allowing your brain to clear out toxins, including harmful proteins linked to brain disorders such as Alzheimer's.

By pumping cerebral spinal fluid through your brain's tissues, the glymphatic system flushes the waste, from your brain, back into your body's circulatory system. From there, the waste eventually reaches your liver, where it's ultimately eliminated. So it's quite likely that sleep affects your brain function and your risk of degenerative diseases such as Alzheimer's in more ways than one.

Elderly Women Are Twice as Likely to Develop Alzheimer's Than Breast Cancer

Being aware of the links between sleep and Alzheimer's onset may be particularly important for women, as they are at greatest risk for the disease.14According to the 2014 Facts and Figures report issued by the Alzheimer's Association,15 women over the age or 60 have a one-in-six chance of developing Alzheimer's—nearly double the risk of men, who have a one-in-11 chance. Even more disturbing, a woman's chance of developing Alzheimer's is twice as great as her risk of developing breast cancer!

Since there's no cure, and no truly effective treatments, taking steps to prevent Alzheimer's becomes paramount. And it seems clear that sleeping properly is one important factor to take into consideration. For more information about Alzheimer's prevention, please see my previous article "How to Prevent Alzheimer's Disease—A Neurologist Speaks Out."

How Light and Dark Affects Your Sleep

Fortunately, there are many ways to improve your sleep, thereby helping to reduce any risks to your brain health. Maintaining a natural rhythm of exposure to sunlight during the day and darkness at night is one crucial foundational component of sleeping well. This was addressed in a recent interview with Dan Pardi (@dansplanhealth), a researcher who works with the Behavioral Sciences Department at Stanford University and the Departments of Neurology and Endocrinology at Leiden University in the Netherlands.

The reason why light is important is because it serves as the major synchronizer of your master clock. This master clock is a group of cells in your brain called the suprachiasmatic nuclei (SCN). As a group, these nuclei synchronize to the light-dark cycle of your environment when light enters your eye. You also have other biological clocks throughout your body, and those clocks subsequently synchronize to your master clock.

Most people in Western societies spend the larger portion of each day indoors, which essentially puts you in a state of “light deficiency” as outdoor light is far more intense than any indoor light fixture. Meanwhile, most people are exposed to too muchlight in the evening, at a time when the natural light has faded.

To maintain healthy master clock timing, aim to adjust your light exposure to a more natural light rhythm, where you get bright light exposure during the day and limited blue light and bright light exposure once the sun sets. Pardi recommends getting at least 30-60 minutes of outdoor light exposure during daylight hours, in order to “anchor” your master clock rhythm. The ideal time to go outdoors is right around solar noon but any time during daylight hours is useful.

Research also shows that exposure to bright room light before bedtime suppresses melatonin production in 99 percent of individuals. This can effectively rob you of sleep by masking sleepiness, as this hormone influences what time of day or night your body thinks it is - regardless of what time the clock on the wall displays - and because it’s one of several key biochemical signals that stimulate sleep onset and maintenance.

Shift Workers Are Particularly Vulnerable to Accidents and Disease

One of the worst things you can do to disrupt your body clock is engage in regular night shift work. I realize many people may not be able to avoid night shifts once they've chosen certain professions, but it is vital to understand that when you regularly shift your sleep patterns, you are in fact seriously compromising your health and longevity—in more ways than one. For example, in a study16 of nurses, researchers from the Harvard School of Public Health revealed that a woman's risk of type 2 diabetes rises according to how many years of night-shift work she has completed. Even working a night shift periodically for three years increased diabetes risk by 20 percent, and this increased with time.

The lack of sleep, or poor sleep that comes with shift work and jobs where you're working double shifts or other erratic schedules also makes you far more vulnerable to accidents. The recent subway train accident at Chicago's O'Hare airport17 is a perfect example In this case, more than 30 people were injured, and the accident caused an estimated $6 million in property damage. . I was born and grew up in Chicago and this is the airport I regularly use.  According to the Associated Press18:

"The operator of a Chicago commuter train that crashed at O'Hare International Airport acknowledged she dozed off before the accident and had also done so last month when she overshot a station platform, a federal investigator said Wednesday. Before the crash, the operator had been running trains on the nation's second-largest public transportation system for just two months.

In Monday's accident, which injured more than 30 people, she woke up only as the eight-car train jolted onto the platform and barreled up an escalator leading into the airport. The accident occurred around 3 a.m., as the driver was nearing the end of her shift. The woman had an erratic work schedule and investigators were looking to see if that played a role in her evident fatigue... [T]he operator was an extra-board employee, meaning she filled in to cover shifts for regular employees and her hours varied from one day to the next."

If you currently work nights, I would strongly suggest trying to switch your hours, or at the very least restrict your night shift duty to a couple months at a time. This will at least give your body a chance to readjust in between. If it is not possible for you to avoid working the night shift, you can somewhat counter the health effects by keeping to a schedule. By being consistent, your body's clock will eventually adjust to your sleep/wake cycle, and this is LESS damaging than if you constantly change shifts and expect your body clock to adjust.

Next, although day sleeping makes it much more challenging to create a dark environment, it is essential that you make your bedroom pitch-black, even if you're sleeping at noon, as exposure to light squelches the production of melatonin. Even the dim glow from your clock radio could be interfering with your ability to sleep -- and more importantly, your long-term health.

Other Helpful Tips to Improve Your Sleep

Besides maintaining a natural circadian rhythm, there are a number of additional ways to help improve your sleep if you're still having trouble. Below are half a dozen of my top guidelines for promoting good sleep. For a comprehensive sleep guide, please see my article "33 Secrets to a Good Night's Sleep."

1. Avoid watching TV or using your computer at night—or at least about an hour or so before going to bed—as these technologies can have a significantly detrimental impact on your sleep. TV and computer screens emit blue light, similar to daylight. This tricks your brain into thinking it's still daytime, thereby shutting down melatonin secretion. Under normal circumstances, your brain starts secreting melatonin during something called dim light melatonin onset. If the light in your environment doesn't dim, because of multiple artificial light sources, melatonin won't be released and this affects sleep timing, quantity, and quality.
2. Sleep in darkness. Remember, light can disrupt your internal clock and your pineal gland's production of melatonin. Refrain from using night-lights, cover up your clock radio, cover your windows — I recommend using blackout shades or drapes, or use an eye mask—and don't turn on a light if you have to go to the bathroom at night. You don't need to sleep in complete darkness. The intensity of light needs to be at a certain level (different levels depending on the spectrum) to suppress melatonin production. Complete darkness is probably best however.
3. Keep the temperature in your bedroom no higher than 70 degrees F. Many people keep their bedrooms too warm. A reduction in core body temperature is a part of the sleep-initiation and sleep maintenance process. A room temperature that is too warm or too cool can prevent your core temperature from lowering to its ideal place for good sleep. Aim to keep your bedroom temperature between 60 to 68 degrees, and identify the best room temperature for you through trial and error.
4. Take a hot bath or shower 30 min before bedtime. The hot bath increases your core body temperature, opening up the blood vessels in your limbs. When you get out of the bath, heat can leave your body easily (if the room temperature is cool), abruptly dropping your core body temperature, making you drowsy and ready for great sleep.
5. Check your bedroom for electro-magnetic fields (EMFs). These can disrupt your pineal gland and the production of melatonin and serotonin, and may have other negative effects as well. To do this, you need a gauss meter. You can find various models online, starting around $50 to $200. Some experts even recommend pulling your circuit breaker before bed to shut down all power in your house.
6. Move alarm clocks and other electrical devices away from your bed. If these devices must be used, keep them as far away from your bed as possible, preferably at least three feet. This serves at least two functions. First, it can be stressful to see the time when you can't fall asleep, or wake up in the middle of the night. Secondly, the glow from a clock radio can be enough to suppress melatonin production and interfere with your sleep. Cell phones, cordless phones and their charging stations should ideally be kept three rooms away from your bedroom to prevent harmful EMF's.

Sleeping Well Is Part of a Healthy Lifestyle Plan

In summary, if you want to get good sleep, you have to have properly aligned circadian rhythms. If you don’t, aspects of your waking/sleeping system will be working at the wrong time. The ramifications of this go far beyond daytime sleepiness, as the research discussed above can attest to.

So first and foremost, make sure to get daylight exposure, ideally around solar noon, for at least half an hour or more each day. A gadget that can be helpful in instances when you, for some reason, cannot get outside during the day is a blue-light emitter. Philips makes one called goLITE BLU. (You can find it on Amazon19 for less than $150.) It's a small light therapy device you can keep on your desk. Use it twice a day for about 15 minutes to help you anchor your circadian rhythm if you cannot get outdoors.

Then, in the evening, dim environmental lights and avoid the blue light wavelength. Use blue-blocking light bulbs, dim your lights with dimmer switches and turn off unneeded lights, and if using a computer, install blue light-blocking software like f.lux.20 Also keep in mind that digital alarm clocks with blue light displays could have a detrimental effect. Last but not least, when it's time to go to sleep, make sure your bedroom is very dark. I recommend installing blackout shades for this purpose. A far less expensive alternative is to use a sleep mask to avoid disrupting your melatonin production and circadian rhythm.