Scientists Search for the Best Sleepers

Working to unravel the secrets of sleep, gene by gene.

Less than 1% of Americans need less than six hours of sleep. Researchers are trying to unlock the secrets of the early-to-bed, early-to-rise sleeper. WSJ health reporter Sumathi Reddy discusses on Lunch Break with Tanya Rivero. Photo: Getty

In a lab at the University of California, San Francisco, a husband-and-wife team is working to unravel the secrets of sleep, gene by gene.

Louis Ptáček is studying why some people are genetically wired to be morning larks—an estimated 3% of the population who go to bed unusually early and rise early—while others are night owls.

His wife, Ying-Hui Fu, is researching another phenomenon: why some people require unusually short amounts of sleep, a group that is estimated to be less than 1% of the population. These hardy few, called short-sleepers, can biologically get by with less than six hours of sleep a night and feel fully refreshed.

Dr. Ptáček hopes soon to begin testing for drugs that could alter the body's circadian rhythms—the internal clocks that influence virtually all our biological workings, from sleeping and eating to cardiovascular function. Such a drug might be useful to treat jet lag, for instance, or to enhance the curative powers of cancer treatments.

And Dr. Fu's goal is to someday develop a drug therapy that can reduce how much sleep we need. "The natural, short-sleeper—these people are very optimistic, very energetic, they are go-getters," said Dr. Fu, "If we can identify the pathways that can regulate our sleep duration then maybe someday we can come up with something better than caffeine."Drs. Fu and Ptáček, both in their 50s, are neurology professors at UCSF and share a lab there. Dr. Fu was trained in molecular biology and human genetics and worked in the biochemical industry before turning to academia. Dr. Ptáček is a neurologist who became interested in human genetics and molecular neuroscience. The couple met at an American Society of Human Genetics conference.

Their interest in circadian rhythm came about by chance in 1996 when the two were professors at the University of Utah. A 69-year-old woman came to the sleep clinic complaining that she had to go to sleep very early at night and woke up very early. The woman and her family are still subjects of the research, as are about 100 other families who fall into the lark group of sleepers.

In the process of studying early risers, Drs. Fu and Ptáček stumbled into the phenomenon of the short-sleeper, which spurred a separate research project.

The researchers enlist subjects for the studies nationwide. The participants submit a questionnaire and send in a blood sample or sometimes a saliva swab.

Lab technicians extract DNA from the samples and sequence the participants' entire genome to look for genetic mutations. It is time-consuming, needle-in-a-haystack kind of work. The researchers also conduct animal studies to test their work.

"These families are an important way to learn about the genetics of sleep and of clock function in humans. Understanding that is going to help understand the implications of sleep deprivation on our health," said Dr. Ptáček.

Our internal circadian clocks are located in every cell in our body. They are controlled by a part of the brain called the suprachiasmatic nucleus, which ensures that every cell is in sync with the others.

All our biological functions oscillate daily with our circadian rhythm.Studies have shown that disrupting the body's clocks, by working night shifts, for instance, can increase risk for developing chronic diseases such as cancer, obesity and metabolic syndrome.

Light helps our roughly 24-hour internal clocks reset themselves every day, as do our genes. Researchers are trying to identify the specific genes, as well as learn more about how the clock ticking in our brain coordinates the daily oscillation of all our physiological processes.

Dr. Fu is studying the genetics of a database that currently includes more than 50 families of short-sleepers. Many in the group seem to share characteristics in addition to sleep patterns, the research team has observed. They are generally optimistic and appear to have a high pain threshold, Dr. Fu says. One participant doesn't need Novocaine for dental work. Another said she had little pain during childbirth even without a painkiller.There are many genes involved in regulating sleep. So far Dr. Fu has discovered one mutation common to short sleepers in the gene Dec2, and is zeroing in on two more mutations in other genes.

She says the next step is to determine what pathways each of the three genes they've identified are involved in and if they intersect. She says any effort to begin developing a drug that mimics short-sleepers' behavior is at least 10 years in the future.So-called morning larks, the focus of Dr. Ptáček's research, generally sleep on average seven to eight hours, like a normal adult. But larks' chronotype, or preferred sleep pattern, is earlier than others. (Those who prefer a later-than-normal sleep time are often called owls. Most people fall somewhere between the two types.)

Dr. Ptáček focuses on the most extreme larks—those that tend to fall asleep at 8:30 p.m. and wake up before 5:30 a.m. His research team has found multiple gene mutations in their group of larks, including in the gene Per2, which plays a central role in regulating circadian rhythms.

The group has already identified a possible therapeutic target—a protein that regulates the Per2 gene—and is currently preparing a lab screening to test the effect of various drugs.Dr. Ptáček says a drug that manipulates people's circadian rhythms could be used to help jet-lagged travelers and night-shift workers stay more alert. He says a more important use would be to enhance the effects of existing treatments for diseases, such as chemotherapy for cancer.

Because of people's circadian rhythms, there is usually an optimal time of day when chemotherapy will be more effective. But scheduling cancer treatment usually doesn't take this into consideration. With a circadian-rhythm drug, cancer patients would be able to adjust their body clock when they get chemotherapy so their body gets the optimal benefit from it, Dr. Ptáček says.

"Being able to shift the clock, I think, will have profound implications for many different things, from night-shift work to driving at night to conducting chemotherapy," he said.

For Sleep Apnea Patients, a Possible Alternative to Masks

Notes from Dr. Norman Blumenstock:

Long-term impact of stimulation of the nerve in the jaw, called the hypoglossal nerve, is not known.

By CATHERINE SAINT LOUIS

Stephen Maturen for The New York TimesJackie Kopplin of Coon Rapids, Minn., had an upper airway stimulator implanted to help treat obstructive sleep apnea.

The standard treatment for people with moderate to severe obstructive sleep apnea is a mask worn at night that helps them breathe without interruption. The mask is unwieldy and uncomfortable, however; one study found that46 percent to 83 percent of patients with obstructive sleep apneado not wear it diligently.

Now scientists may have found an alternative, at least for some patients: a pacemaker-like device implanted in the chest that stimulates a nerve in the jaw, helping to keep part of the upper airway open. The device, called a neurostimulator, helped reduce breathing interruptions and raise blood oxygen levels in about two-thirds of sleep apnea patients participating in a trial, researchers reported on Wednesday in The New England Journal of Medicine.

“This is a new paradigm of surgical treatment that seems to effectively control obstructive sleep apnea in selected patients,” said Dr. Sean M. Caples, a sleep specialist in the division of pulmonary and critical care medicine at Mayo Clinic in Rochester, Minn. “It’s very exciting.”

Still, Dr. Caples, who was not involved in the new study, noted that “a third of patients were not improved when all was said and done,” even though they were chosen because they were seen as likely to benefit.

The new trial was funded by the maker of the device, Inspire Medical Systems.

At 22 sites internationally, in 126 patients, doctors surgically implanted a remote-controlled neurostimulator that, activated at night, sends regular electric impulses to a nerve inside the jaw. The impulses cause the tongue to move forward during inhalation, opening the airway.

Patients experienced a decline in breathing pauses after using the device for a year, to 9 per hour on average, from 29.3 episodes per hour. The number of dangerous drops in blood oxygen levels also declined, to 7.4 per hour on average, from 25.4 per hour.

There was no control group during this phase of the study, however, and other experts said that  diet, exercise or other factors may have contributed to the reductions.

At a year, only two of 126 patients stopped using their upper airway stimulator at night, and 86 percent reported daily use. But sleep apnea worsened in about 20 patients using the device, though it is unclear why.

In the second phase of the study, 46 patients doing well with the stimulators after one year were randomly assigned to either continue with the therapy or have it withdrawn for a week. The therapy-continuation group had little change in the number of breathing pauses per hour or drops in blood oxygen levels. But in the patients from whom the stimulation therapy was withdrawn, the number of such breathing pauses increased sharply, to 25.8 per hour on average from 7.6 per hour. The episodes of blood oxygen level drops rose to 23 per hour on average, from 6 per hour.

“That rebound was compelling evidence that this device did something for their sleep apnea,” said Dr. Christine H. Won, the medical director of the Yale Sleep Center.

Stephen Maturen for The New York TimesMs. Kopplin has two scars where the implant was placed.

An alternative therapy for patients who cannot or will not use the standard continuous positive airway pressure, or CPAP, masks diligently would be “very valuable,” Dr. Won said.

The neurostimulator is not yet approved by the Food and Drug Administration and may only benefit a subset of sleep apnea patients, including those with a body mass index of less than 32 and people whose obstructions stem from airway collapse behind their tongues. Only patients who could not or would not use mask therapy participated.

Experts disagreed on how widely beneficial this kind of stimulation might be.

“Many people have a problem with upper airway dilator muscles, so my hunch is this would work in a decent number of them,” said Dr. Atul Malhotra, chief of pulmonary and critical care medicine at the University of California, San Diego, who wrote an editorial accompanying the new study. 

Dr. Lawrence J. Epstein, a co-director of the sleep medicine clinic at Brigham and Women’s Hospital in Boston, said the study showed “the success of a relatively novel alternative for a disease that has major health implications.”

But he warned the technology would not be a universal option, especially for obese patients.

When patients stop using the masks, they sometimes get surgery to advance their jaw or to trim part of the soft palate. But “those surgeries, which are associated with substantially more pain at least initially, have not been as effective as we would like,” said Dr. Patrick J. Strollo, the lead author of the new study.

The new device “doesn’t require surgery that reconfigures the airway,” said Dr. Strollo, the medical director of the sleep center at the University of Pittsburgh Medical Center.

Less than 2 percent of study participants experienced serious adverse events. Still, more than half reported discomfort from stimulation, tongue abrasion, incision discomfort and other issues.

After her chin incision became inflamed after implantation of the neurostimulator in 2011, Jackie Kopplin, 45, who runs a housecleaning business in Coon Rapids, Minn., was “blown up like a basketball” and in pain for six weeks. “I was regretting it at first,” she said.

But she now sleeps eight to nine hours at night, is not bothered by the tongue thrusting, and no longer dozes off while driving.

As long as she remembers to turn on the stimulator nightly, Ms. Kopplin said, “I wake up and I have energy to make it through the whole day.”

Long-term impact of stimulation of the nerve in the jaw, called the hypoglossal nerve, is not known, Dr. Malhotra said. “This is a lifelong disease. A year in the grand scheme of things is not very long.”

Originally posted: http://well.blogs.nytimes.com/2014/01/08/for-sleep-apnea-patients-a-possible-alternative-to-masks/?action=click&contentCollection=Booming&module=MostEmailed&version=Full%C2%AEion=Marginalia&src=me&pgtype=article&_r=1

Is it just Snoring or is it Sleep Apnea?

From Dr. Norman Blumenstock:

Not everyone who snores has sleep apnea, and not everyone who has sleep apnea snores.

Posted on December 25, 2013

Not everyone who snores has sleep apnea, and not everyone who has sleep apnea snores. So

how do you tell the difference between normal snoring and a more serious case of sleep apnea?

The biggest telltale sign is how you feel during the day. Normal snoring doesn’t interfere with

the quality of your sleep as much as sleep apnea does, so you’re less likely to suffer from

extreme fatigue and sleepiness during the day.

Even if you don’t have sleep apnea, a snoring problem can get in the way of your bed partner’s

rest and affect your own sleep quality and health. But there are plenty of tips and treatments

that can help.

The following strategies can help you decipher the symptoms:

Keep a sleep diary – Record how many hours you’re spending in bed, any nighttime awakenings,

and whether you feel refreshed in the morning. Ask your sleep partner to keep track of your

snoring, including how loud and frequent it is. Also ask him or her to note any gasping, choking, or

other unusual sounds.

Record yourself sleeping – Taking a video or audio recording of yourself while you sleep can

be very informative and revealing. You can use a sound-activated audio recorder, a video camera,

or software that turns your computer into a recorder.

http://www.kaltura.com/index.php/kwidget/wid/0_vszpoipq/uiconf_id/8700151

Originally Published at:  http://www.mdadvice.com/blog/2013/12/25/is-it-just-snoring-or-is-it-sleep-apnea/

Experts Reshape Treatment Guide for Cholesterol

Notes from Dr. Norman Blumenstock:

The intermittent hypoxia created by obstructive sleep apnea appears to alter the surface of blood vessels, allowing the cholesterol to adversely affect those blood vessels. Statins drugs alone may not be enough if the obstructive sleep apnea is not treated in my opinion.

By GINA KOLATA

Published: November 12, 2013 

The nation’s leading heart organizations released new guidelines on Tuesday that will fundamentally reshape the use of cholesterol-lowering statin medicines, which are now prescribed for a quarter of Americans over 40. Patients on statins will no longer need to lower their cholesterol levels to specific numerical targets monitored by regular blood tests, as has been recommended for decades. Simply taking the right dose of a statin will be sufficient, the guidelines say.

Enlarge This Image

Dr. Neil J. Stone, chairman of a committee on cholesterol.

Related

Well: 3 Things to Know About the New Cholesterol Guidelines(November 12, 2013)

Readers’ Comments

The new approach divides people needing treatment into two broad risk categories. Those at high risk because, for example, they have diabetes or have had a heart attack should take a statin except in rare cases. People with extremely high levels of the harmful cholesterol known as LDL — 190 or higher — should also be prescribed statins. In the past, people in these categories would also have been told to get their LDL down to 70, something no longer required.

Everyone else should be considered for a statin if his or her risk of a heart attack or stroke in the next 10 years is at least 7.5 percent. Doctors are advised to use a new risk calculator that factors in blood pressure, age and total cholesterol levels, among other things.

“Now one in four Americans over 40 will be saying, ‘Should I be taking this anymore?' ” said Dr. Harlan M. Krumholz, a cardiologist and professor of medicine at Yale who was not on the guidelines committee.

The new guidelines, formulated by the American Heart Association and the American College of Cardiology and based on a four-year review of the evidence, simplify the current complex, five-step process for evaluating who needs to take statins. In a significant departure, the new method also counts strokes as well as heart attacks in its risk calculations, a step that will probably make some additional people candidates for the drugs.

It is not clear whether more or fewer people will end up taking the drugs under the new guidelines, experts said. Many women and African-Americans, who have a higher-than-average risk of stroke, may find themselves candidates for treatment, but others taking statins only to lower LDL cholesterol to target levels may no longer need them.

The previous guidelines put such a strong emphasis on lowering cholesterol levels by specific amounts that patients who did not hit their target levels just by taking statins often were prescribed additional drugs like Zetia, made by Merck. But the new guidelines say doctors should no longer prescribe those extra medicines because they have never been shown to prevent heart attacks or strokes.

Zetia has been viewed with increasing skepticism in recent years since studies showed it lowered LDL cholesterol but did not reduce the risk of cardiovascular disease or death. Still, it is among Merck’s top-selling drugs, earning $2.6 billion last year. Another drug, Vytorin, which combines Zetia with a statin, brought in $1.8 billion in 2012, according to company filings. And in May, Merck won approval for another drug, Liptruzet, which also contains the active ingredient in Zetia and a statin, a development that surprised many cardiologists because of questions about its effectiveness.

The new guidelines are part of a package of recommendations to reduce the risk of heart attack and stroke that includes moderate exercise and a healthy diet. But its advice on cholesterol is the flash point, arousing the ire of critics who say the authors ignored evidence that did not come from gold-standard clinical trials and should also have counted less rigorous, but compelling, data.

For example, Dr. Daniel J. Rader, the director of the preventive cardiovascular medicine and lipid clinic at the University of Pennsylvania, points to studies of people with genes giving them low LDL levels over a lifetime. Their heart attack rate is greatly reduced, he said, suggesting the benefits of long-term cholesterol reduction.

Committee members counter his view, saying that cholesterol lowered by drugs may not have the same effect.

Critics also question the use of a 10-year risk of heart attack or stroke as the measure for determining who should be treated. Many people will have a lower risk simply because they are younger, yet could benefit from taking statins for decades to keep their cholesterol levels low, they say.

Dr. Rader and other experts also worry that without the goad of target numbers, patients and their doctors will lose motivation to control cholesterol levels.

Experts say it is still unclear how much the new guidelines will change clinical practice. Dr. Rader suspects many cardiologists will still strive for the old LDL targets, at least for patients with heart disease who are at high risk. “They are used to it and believe in it,” he said.

Dr. Steven E. Nissen, a cardiologist at the Cleveland Clinic, said he thought it would take years for doctors to change their practices.

The process of developing the guidelines was rocky, taking at least twice as long as in the past. The National Heart, Lung and Blood Institute dropped out, saying that drafting guidelines was no longer part of its mission. Several committee members, including Dr. Rader, also dropped out, unhappy with the direction the committee was going.

The architects of the guidelines say their recommendations are based on the best available evidence. Large clinical trials have consistently shown that statins reduce the risk of heart attacks and strokes, but the committee concluded that there is no evidence that hitting specific cholesterol targets makes a difference. No one has ever asked in a rigorous study if a person’s risk is lower with an LDL of 70 than 90 or 100, for example.

Dr. Neil J. Stone, the chairman of the committee and a professor of preventive cardiology at Northwestern University’s Feinberg School of Medicine, said he was surprised by what the group discovered as it delved into the evidence. “We deliberated for several years,” he said, “and could not come up with solid evidence for targets.”

Dr. Nissen, who was not a member of the committee, agreed. “The science was never there” for the LDL targets, he said. Past committees “made them up out of thin air,” he added.

The Department of Veterans Affairs conducted its own independent review and came to the same conclusion. About a year ago, the department, the nation’s largest integrated health care system, dropped its LDL targets, said Dr. John Rumsfeld, the V.A.'s national director of cardiology.

“It is a shift,” he acknowledged, “but I would argue that it is not a radical change but is a course correction.”

Dr. Paul M. Ridker, the director of the center for cardiovascular disease prevention at Brigham and Women’s Hospital, in Boston, said he worried the new guidelines could easily lead to overtreatment. An older man with a low LDL level who smokes and has moderately elevated blood pressure would qualify for a statin under the new guidelines. But what he really needs is to stop smoking and get his blood pressure under control.

Dr. Stone said he hoped doctors would not reflexively prescribe a statin to such a patient. Doctors are supposed to talk to their patients and realize that, with a man like the one Dr. Ridker described, the real problem was not cholesterol.

“We are taking people out of their comfort zone,” Dr. Stone said. “Instead of being reassured that reaching this number means they will be fine, we are asking, ‘What is the best therapy to do the job?' ”

Originally Posted:  http://www.nytimes.com/2013/11/13/health/new-guidelines-redefine-use-of-statins.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20131113

Getting the Most Out of Sleep

By C. CLAIBORNE RAY

Published: September 23, 2013

Q. To get the health benefits of a good night’s sleep, is it just the number of hours that counts? What if sleep is induced by a sleeping pill or is stressful because of a nightmare?

A. While duration is important, “the quality and timing of sleep are also critical to a good night’s rest,” said Dr. Ana C. Krieger, medical director of the Weill Cornell Center for Sleep Medicine at NewYork-Presbyterian Hospital.

Optimal sleep duration varies widely, depending on a person’s genetic makeup, underlying health conditions and daytime activities, among other factors, Dr. Krieger said. An individual’s natural sleep rhythm and actual schedule may be poorly aligned, leading to inadequate sleep. Sleep specialists often suggest that a born early riser or night owl adjust schedules accordingly.

As for quality, Dr. Krieger said, sleep disorders can fragment sleep in ways that may not be obvious — except that the sufferer may not feel well rested.

“Nightmares or other sleep disturbances that interfere with sleep consolidation or the sleep/wake cycle may lead to unrefreshing sleep,” Dr. Krieger said. “Medications may also interfere with sleep.”

Because of chemical processes, medication-induced sleep may not be as refreshing as natural sleep, so sleeping pills should be used only under medical supervision. question@nytimes.com

What you should know about sleep apnea from The Doctors

Three myths about a common disorder that can rob you of rest and good health

Myths About Obstructive Sleep Apnea: E.R. physician Dr. Travis Stork explains how The Doctors' latest article in USA Weekend Magazine focuses on common myths about obstructive sleep apnea.

Snoring means you have sleep apnea: That’s one commonly held belief about the condition that’s just not true. Lots of people snore — some estimates say up to half of Americans do it at one point or another. But there’s the harmless “sawing of logs,” and then there’s the snoring associated with obstructive sleep apnea, which is often characterized as loud and chronic, gets worse when you’re sleeping on your back, and — most telling — is peppered with silent pauses, sometimes followed by snorting or choking sounds. These pauses are the midsleep breathing interruptions that define apnea: They last anywhere from a few seconds to minutes and can occur 30 times or more an hour. Here are three more myths about sleep apnea, and the facts behind the fiction:

MYTH: It's not that serious.

The combination of not-restful sleep and reduced blood oxygen levels from disrupted breathing can be tough on the body. It can strain your heart and cardiovascular system, which may increase your risk of hypertension and heart disease, as well as congestive heart failure, cardiac arrhythmia or stroke. Findings from new research published in theJournal of the American College of Cardiology suggest sleep apnea may also boost the risk of sudden cardiac arrest. The disorder can also mess with your mood and memory and leave you feeling exceptionally drowsy during the day, which puts you at a higher risk for work-related accidents and automobile accidents.

MYTH: Only older adults develop sleep apnea.

Though it’s true that risk increases with age, anyone can develop sleep apnea — even children. Men are more likely than women to have apnea; so are people who are overweight or have small airways in their noses, throats, or mouths. Family history, smoking and ethnicity may play a role as well. Recent, preliminary research also suggests a link between asthma and obstructive sleep apnea: According to scientists who worked on the study, people with asthma were about 70 more likely to develop apnea eight years later.

MYTH: I'll have to sleep with a breathing mask.

Continuous positive airway pressure (CPAP) machines — which gently blow air through a mask to help keep airways open while you sleep — are a common and effective treatment for moderate to severe apnea, but if you can’t tolerate the devices, there are other options. Your doctor may suggest different types of airway pressure devices; researchers also are exploring a promising new treatment for more serious cases that involves implanting an electrode to help stimulate the upper airway. For mild cases, wearing a mouthpiece designed to keep airways open may help, and so could changes in living habits, such as losing weight, sleeping on your side or avoiding alcohol and medicines that make you sleepy.

Advice About Sleep Deficiency in Midlife, Part 1

By THE NEW YORK TIMES

Published: September 25, 2013 

Nearly 200 people sent questions about sleep to Orfeu Marcello Buxton, a neuroscientist who studies chronic sleep deficiency in the workplace and home and how it contributes to disorders like obesity, diabetes and cardiovascular disease.

Dr. Buxton is an associate neuroscientist in the Division of Sleep Medicine in the Department of Medicine at Brigham and Women’s Hospital in Boston, as well as anassistant professor at Harvard Medical School and the Harvard School of Public Health. He received his doctorate from Northwestern University in Evanston, Ill. (Note: Dr. Buxton is a researcher, not a physician, and he emphasizes that his responses should not take the place of recommendations from your health care provider.)

More responses will be posted next week. Because of the volume of questions, not all may be answered.

Disclosure statement: Dr. Buxton’s current research is financed by several branches of the National Institutes of Health. He is a consultant to the Harvard School of Public Health Center for Work, Health and Well-being and is on the scientific advisory board for Matsutani America (a dietary fiber supplement manufacturer). He has served as an expert witness for Dinsmore L.L.C., received speaking/consulting fees from Takeda Inc., and was the principal investigator on investigator-initiated research financed by Cephalon Inc. (now Teva) and Sepracor Inc. (now Sunovion).

Introduction

Thank you to all readers who commented and submitted questions. The breadth of the questions speaks to the many different ways that we sleep, and how our expectation about sleep, and our sleep patterns and habits can vary with circumstances and our environment, and across the course of life.

Healthy Sleep in Midlife

Q. I go to sleep fairly early (8:30 p.m.) because I am exhausted, yet I wake up around 2:30 or 3 a.m. and cannot get back to sleep. I used to sleep much longer and arise more rested. Is this probably just age? Are there things I can do to help myself sleep longer? — CM, Placitas, N.M.

A. Many readers addressed directly or indirectly the question, “What is ‘normal sleep’ in midlife?” Setting aside the possibility of a sleep disorder (some of which are addressed below), normal sleep has a physiological basis, but also a cultural basis (see below on the relatively modern emergence of an expectation of a single consolidated night’s sleep). What we might consider normal sleep in midlife varies depending on individuals and their circumstances.

Typical advice has been to get a full eight hours of sleep, but this is the “tyranny of the mean.” Our individual sleep need is roughly the same across adulthood, though as discussed below (“Sleep and Aging”), the amount of sleep we need may decline slightly as we age. For most adults, routinely sleeping seven to nine hours per night regularly is appropriate for optimal functioning and health. That said, there will be some people who need less, and some who may need more sleep; it’s just that there are far more of us getting less than we probably need (the United States average is just above seven hours a night, and the proportion of short sleepers is increasing). Information is available from the Harvard Division of Sleep Medicine on the benefits of healthy sleep and getting enough sleep, including a “sleep makeover,” and 12 simple steps to improving your sleep.

So how can you tell if you are getting enough sleep at this time in your life? I have a nonclinical litmus test. First, pay off your sleep debt by getting plenty of extra sleep for a few weeks. Vacations outside of our normal pressures can work well for this. Then, begin going to sleep and waking up at about the same times each day, and you will find that your individual number may emerge — the number of hours of sleep after which you wake up and generally feel refreshed, without stimulants. The test is: can you sleep this amount, get up without an alarm clock (except for backup to avoid worrying about missing a morning obligation), and feel good? Bonus: someone else may also report you are (even more) pleasant?

As you can imagine, maintaining healthy sleep is a lifestyle and is not achieved through a quick fix. We don’t go to the gym once and expect immediate fitness, or eat salads for one day and expect leanness. Getting enough sleep gives more energy for vigorous exercise and improves healthy food choices. But where is the time for all this, you might say? To achieve healthy sleep, prioritize your health and recognize that being your best, rested self is more important than something else like watching television or mobile-device screens, especially in their most ad-infused forms, or social media indulgences that don’t bring real joy. The three pillars of health (diet, sleep and exercise) can help everything else go better in our lives, especially the most important things like our relationships and true passions.

Sleep Apnea

Q. How we can differentiate between normal snoring and sleep apnea? — Jnanawala, Surat, India

A. Some readers asked directly about the symptoms of sleep apnea and snoring, or described extremes of daytime sleepiness that might suggest sleep-disordered breathing or other sleep disorders that would be good to rule out. Sleep-disordered breathing results in a lack of sufficient oxygen being taken into the lungs and throughout the body, usually because of a constriction of the airway, but possibly also related to structural issues or sometimes breathing centers in the brain not working ideally. Sleep-disordered breathing also causes frequent interruptions and awakenings during sleep.

Symptoms of sleep-disordered breathing include excessive daytime sleepiness, choking or gasping during sleep and sometimes morning headaches because of low oxygen during sleep. In response to falling oxygen levels in the blood (and or rising carbon dioxide levels), a brain “arousal” lightens sleep and a gasp or deeper breathing takes in more air. Risk factors include having a greater than 17-inch neck size, obesity, being male and a family history of apnea. But it is possible to have none of these factors and have sleep-disordered breathing. Snoring is much more common than sleep-disordered breathing, and snoring doesn’t necessarily mean one has sleep-disordered breathing. But the cessation of breathing for more than 20 seconds during sleep is an indicator of sleep apnea. A diagnosis of sleep apnea involves a sleep test at a sleep clinic or in the home.

There are a variety of treatment options, but the most common is an air pump and a mask that is worn during sleep to provide enough extra air pressure to overcome the obstruction. These work best if worn the entire night.

The Harvard Division of Sleep medicine has accessible and engaging content on sleep apnea here. Detailed patient information about sleep-related breathing disorders and treatment options is available from the American Academy of Sleep Medicine.

Insomnia

Q. What can be done about middle-of-night insomnia? I go to bed at 9:30 or so, exhausted and fall asleep in 2 seconds. Then I wake up anywhere from 1:30 to 4 a.m., and cannot fall back asleep for hours if at all. It turns the days into endurance events. Once in a great while, I get a full seven to nine hours and feel magnificent. There is no pattern to it and I cannot make it happen. I cannot take my 1:30 a.m. start of the day. Don’t want to take pills to sleep. — xojoyox, Brooklyn

A. Difficulty getting to sleep or staying asleep on a regular basis (three or more times per week for at least a month), and a complaint about this sleeplessness causing other problems, is chronic insomnia. Acute insomnia usually has a clear precipitating cause, like stress, anxiety, conflict, grief or a medical condition or medication with side effects. In contrast, chronic insomnia can have less obvious or long-past precipitating factors. Chronic insomnia is thought to be perpetuated by established habits and expectations about sleep, as well as potential brain neurotransmitter or brain system changes that cause the brain to be hyperaroused during sleep, or in other words, cause the wake centers of the brain to be stuck in the “on” position. Chronic conflict at work, harassment at work, or stress at work in general can contribute to insomnia.

The inability to sleep in the middle of the night is an especially difficult form of insomnia on the minds of many of us in midlife. Sleep maintenance difficulty is, for example, more strongly related to diabetes risk than short-sleep duration or difficulty getting to sleep. But it’s important not to overly worry about this because this rumination can worsen insomnia.

There are several active steps to take.

Try to understand what might be causing the awakening: is there a regular interruption like noise that is contributing to this? Snow days are so peaceful and restful when airplane flights are canceled and snow dampens traffic and other sounds, but only until the snow plows grind down the street. Pets and bed partners can be a source of potential interruptions.

If it seems that the awakenings are internally generated, start with an assessment of sleep disruptors, like excess caffeine; or a sleep environment that is too bright, hot, cold or noisy.

If these things don’t work, it may be time to talk to your physician about potential medical causes of insomnia, like medications, sleep disorders (sleep apnea, restless-legs syndrome) and medical and psychiatric causes.

Additionally, consulting a sleep specialist may help. New formulations of F.D.A.-approved medications with short half-lives may be useful in treating middle-of-the-night insomnia — in the short term. In the long term, behavioral treatments to improve sleep, including cognitive behavioral therapies or mindfulness practice can improve sleep, and have a sustained impact after the cessation of active treatment. A lot of work remains to be done to determine the effectiveness of these various pharmacological and behavioral treatments, especially head-to-head comparisons, but promising ones are available now.

For useful patient information on all manners of sleep disorders, include information from the American Academy of Sleep Medicine, which includes a Find a Sleep Center tool.

Sleep and Aging

Q. What can a 65-year-old woman, who ever since menopause wakes up 10 times a night, do to get a good night’s sleep? — Bonnie Rozanski, Lawrenceville, N.J.

A. Many of us are concerned about sleep changes with age. In general, sleep is much deeper when we are very young — thus the expression “sleeping like a baby.”

Insomnia reports are thought to be more common in women than men in midlife, and further increase in peri-menopause and post-menopause.

There are several aspects of sleep changing with age, including our response to the sleep environment.

External stimuli are less likely to awaken us during this deep, non-R.E.M. or slow-wave sleep. The amount of deep, slow-wave sleep declines over the first several decades of life. In the third decade of life the amount of this deep sleep decreases rapidly, and thus we become more likely to be awakened by external stimuli like sounds. Also, even in healthy sleepers, as we grow older it can take a bit longer to fall back to sleep once we are awake. This causes us to be awake for longer periods of time, increasing our chances of remembering awakenings during the night that might otherwise be so brief as not to be recalled the next day. We also exhibit more awakenings during the night. It also appears that as we age we have a reduced capacity for sleep, or potentially, even a reduced “need” for sleep.

It is important to remember that frequent and longer awakenings in midlife are fairly common. Bonnie and other readers with similar questions about generally sleeping better did not express a concern with some aspect of daytime functioning, like excessive sleepiness. A sleep-related complaint might warrant a closer look, but adjusting expectations and not worrying about sleep unnecessarily is also part of sleeping better. If you think that your daytime function is not optimal because of a sleep problem, and the 12 simple steps to improving your sleep, which you can read here, don’t seem to help, you may want to consult your physician and then a sleep specialist.

More answers from Dr. Buxton will be posted on Booming on Oct. 2.

'More than half' of pilots have slept while flying

More than half of pilots have fallen asleep while in charge of a plane, a survey by a pilots' union suggests.

Of the 56% who admitted sleeping, 29% told Balpa that they had woken up to find the other pilot asleep as well.

The survey comes after it emerged that two pilots on an Airbus passenger plane were asleep at the same time, with the aircraft being flown on autopilot.

Balpa is campaigning against changes to flight-time regulations, which are to be voted on by the European Parliament.

On Monday, new rules which include allowing pilots to land an aircraft after being awake 22 hours, as well as being able to work seven early starts in a row rather than the current three, will be put to a vote.

'Biggest threat'

The Civil Aviation Authority (CAA) supports the proposals and said the incident on 13 August where both pilots were asleep was an isolated one.

In that case, a report found the pair fell asleep after both had only five hours sleep in the previous two nights.

But of the 500 commercial pilots surveyed by Balpa, 43% said they believed their abilities had been compromised at least once a month in the last six months by tiredness, with 84% saying it had been compromised at some stage during the past six months.

And 49% said pilot tiredness was the biggest threat to flight safety - three times more than any other threat.

The plane was at 35,000ft when the pilots fell asleep

The union said its members, who were the pilots that were surveyed, overwhelmingly worked for British-based airlines.

Balpa wants MEPs to back a motion which would require the European Commission (EC) to withdraw the proposed changes and to have them scrutinised by scientific and medical experts.

Its general secretary Jim McAuslan told BBC Radio 4's Today programme that the EC was trying to get a level playing field across Europe but it had instead diluted UK standards.

"This is deeply worrying for everyone concerned.

"The CAA has been completely complacent about these rules (for pilots to report sleeping incidents).

"It suggests to us that they are ignoring this problem. This is the second time in two years that the survey has run that has shown consistent figures with pilots falling asleep."

'Increase safety'

House of Commons Transport Committee chairwoman Louise Ellman said: "I agree with Balpa's concerns that the proposed changes to EU rules could endanger air passenger safety."

She added: "We have called for scientific evidence to be used to judge just how long pilots should be awake. There is still time for the UK government and Europe to think again."

In a statement, the CAA said: "We think the new European flight time limitation regulations maintain the UK's current high safety levels, and will actually increase safety for UK passengers travelling on some other European airlines.

"This view is informed by expert opinion, based on scientific principles, operational knowledge, regulatory oversight information and research.

‪"The changes will give the CAA far greater access to airline data to help us oversee fatigue risk management."