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Today I'm going to talk about
how to sleep better and feel
better and how sleep affects
our mental and our physical health.
My work has been supported, in part,
by grants from the National Institute of Mental Health
and the Brain & Behavior Research Foundation,
and I am a co-investigator in
the UCSD-IBM Center for
Artificial Intelligence for Healthy Aging.
Today I'm going to talk to you
about what happens when you sleep,
a little bit about insomnia and health,
changes in sleep during the COVID-19 pandemic,
and review some basic sleep treatments,
both for insomnia, as well as things we can do on our own.
There has been a lot of attention in the media,
especially lately, about
how important sleep is for health.
This New York Times article from a few years ago,
stated that sleeping more is
the simplest way to drastically improve your life.
Sleep deprivation, which affects about 1/3 of all people,
has negative effects on health and well-being,
and yet it's hard to know
exactly how much sleep is enough sleep.
This CNN article, again,
from a couple of years back,
shows that even too much sleep
can be linked to poor health.
Ultimately sleep is really heterogeneous
among individuals, and sleep is related to health,
but it's not clear for each person
what is the optimal amount,
or type of sleep, or how it
impacts health for each individual.
This is part of why I'm so interested in sleep is that it
is so personal, and it's so heterogeneous,
and we need to learn more about how
to improve things for each person.
First of all, what happens when you sleep?
Let's start with how sleep changes as we age.
From infancy,
we spend about 70 percent of our day sleeping.
We often wake to start our days,
and our parents' days, around 5:00 AM.
Then we grow into becoming
teenagers who have phase-delayed sleep.
We end up going to sleep late,
often spending a lot of time on sleep and waking up late.
Given that schools tend to start on the early side,
we're often quite sleep-deprived and tired during the day.
Then as we age into being adults,
our sleep phases shift earlier again.
We go to bed earlier. We wake earlier.
However, most adults,
especially Americans, do not actually sleep well,
but 35 percent of Americans are sleep-deprived,
which means sleeping about less than seven hours a night.
About 50-70 million US adults have a sleep disorder,
the most common being insomnia,
about 30 percent with short-term issues and
about 10 percent with chronic issues.
Unfortunately, those types of issues worsen as we age.
Older adults have higher rates of
insomnia as well as other sleep disorders.
They have more frequent overnight awakenings
and shorter overall sleep time,
and about half of older adults report
having some type of sleep problem.
So why is sleep so important?
Sleep is clearly a biological process
that's key to development and health.
It's been shown to be important for promoting growth,
regulating metabolism, heart and lung function.
The purpose of dreams, it's not exactly clear,
but that's an important function
that happens while asleep.
Sleep is important to solidifying memories
as well as to clearing toxins from the brain.
That's been an area of
increasing interest over the last few years.
Clearing toxins such as amyloid and tau proteins,
which are key in the pathogenesis
of Alzheimer's dementia,
has been shown to happen as we sleep.
Insomnia, obstructive sleep apnea,
short sleep duration, or
poor sleep quality have all been identified as
independent risk factors for cognitive impairment in
the development of Alzheimer's dementia
and vascular dementia.
We know that poor sleep is linked to issues with memory,
attention, mood problems, as well as falls.
So sleep really has a mechanistic impact on cognition,
which we are still learning a lot about.
In terms of insomnia,
insomnia itself has a strong impact
on health. What is insomnia?
Some of the major signs of insomnia
include difficulty of falling asleep,
staying asleep, or waking
too early and not being able to fall back asleep again.
It causes clinically significant impairment
or distress in at least one of
these key areas including
fatigue or low energy, daytime sleepiness,
mood disturbances, behavioral difficulties,
cognitive problems that can impair
concentration, attention, or memory,
impaired abilities to complete
occupational or academic functions,
impaired interpersonal or social functioning,
and it can also affect your
caregiver family functions.
Diagnosing sleep apnea usually
starts with a clinical evaluation
with your doctor to rule out
other medical problems that can interfere with sleep.
Many times it can be helpful to get
referred to as sleep specialist.
Sometimes it can be helpful to track
your nightly patterns of sleep with a sleep diary,
looking at bedtimes,
awakenings, your overall sleep quality,
and the use of interfering substances
like caffeine, alcohol, and medications.
There can be a number of questionnaires that
can help to understand about
these sleep symptoms as well as
the potential precipitating factors,
lab test to rule out other medical issues,
and then even sleep studies.
The health consequences of insomnia are pretty broad.
Poor sleep has been linked to
metabolic issues such as obesity, heart problems,
cardiovascular disease,
hypertension, even immune dysfunction,
as well as depression and anxiety.
Some of this may be a little bit
bidirectional in that sleep can cause
these problems, as well as some of
these issues can worsen sleep as well.
Now with COVID-19, we've actually seen many
of these issues magnified in certain populations.
During COVID-19, about 41-70 percent of
older adults in certain studies
have reported sleep problems.
The sleep problems have been associated with female sex,
having increased anxiety or depression,
complaints of loneliness, either not
working or being confined to the home,
and social distancing measures have been
shown to be associated worse on sleep.
Again, however though,
the sleep quality during COVID-19 has been variable.
Certain populations are reporting
worse sleep quality, while others
have actually reported better sleep quality.
Again it seems to
affect different populations differently.
Another interesting point is that good quality sleep is
really important for optimal immune function.
Even a single night of poor sleep can
actually affect inflammatory biomarker levels,
lymphocyte counts, which are
a key immune cell in the body,
as well as your vaccine
antibody response the following day.
One of the notes I remember
seeing when the COVID-19 vaccine came out was
that having a good night's sleep before can
actually make the vaccine more effective.
Chronic poor sleep can actually upregulate
innate immune system activity and affect how
leukocytes are trafficked or
brought to different sites of
the body to help with fighting off infections.
Our work in schizophrenia, bipolar,
as well as healthy adults have shown
that a lot of the night-to-night changes or
variability of sleep patterns can
actually be strongly associated with inflammation.
We've seen that people with more labile sleep patterns
when they sleep very short amounts
one night and maybe much larger amounts the next night,
so the changes from night-to-night
are larger for those folks,
actually, may have increased levels
of inflammation or oxidative stress.
Another important impact of
sleep in addition to the effects in immunity,
the stressors of COVID-19 can also affect sleep in turn.
COVID-19 has created what was coined
by a group of authors, including Smith and colleagues,
as a connectivity paradox.
While the risk of social isolation
and loneliness may be increased by taking
further social distancing or isolation measures,
you're really balancing the COVID-19 infection risk
against the risk of social isolation and loneliness.
This is important to us because
we've seen that there's been
an increased prevalence of loneliness
during the COVID-19 pandemic,
and other studies have actually shown, pre-COVID,
that loneliness is strongly
associated with sleep problems.
We've seen a number
of studies that have shown loneliness,
associated with decreased sleep efficiency,
which is less percent time sleeping overnight,
increased overnight awakenings, also
called WASO or wake after sleep onset,
longer sleep latency, which
means it takes longer
to actually fall asleep when you go to bed,
worse sleep quality, and even having
insomnia associated with loneliness.
Again this may be bidirectional in that loneliness
is associated with poor sleep, and
poor sleep is associated with loneliness.
In one of our studies of
older adults in collaboration with IBM,
we've actually seen that loneliness is
linked with psychosocial functioning and other behaviors.
We found that when we looked at
reported sleep quality and loneliness here on the x-axis,
so higher levels of loneliness were associated with
higher scores on the sleep quality,
which actually indicates worse sleep quality.
We are seeing that lonely older adults
had worse self-reported sleep quality.
When we put fitness trackers on them
to actually assess objectively how their sleep was,
this density plot here shows data from
362 nights from about 39 older adults.
As opposed to showing the actual mean sleep,
it actually plots the overall curve
of how they sleep over time.
Each individual here is shown by a line.
The red lines indicate
people who reported higher levels of loneliness,
and the blues are the individuals
with lower levels of loneliness.
The flatter curves are the individuals with
more variability in their total sleep time.
We found that, while mean
sleep duration was similar between
lonely and non-lonely individuals
with the average amount that they sleep at night,
the actual intra-individual variability
was higher in lonely individuals.
It seems that this variability of sleep,
which we've shown in
other studies we associated with inflammation and
other negative health outcomes,
may actually be worse in lonely people.
The reason why we're so interested in that is
because sleep may actually
be a mediator of how loneliness affects health.
Just to close, I'm going to talk a little bit
about some common sleep treatments for insomnia,
as well as some general recommendations
on how to improve your sleep.
Focusing on insomnia, there are
a number of medications that
people have been prescribed for sleep.
One common group is called the Z-drugs,
which are specific medications
that hit the benzodiazepine receptors
but are usually marketed specifically for sleep.
You might have heard of Ambien or
zolpidem and other medications like that.
These medications, on the bright side, are best suited for
acute issues and are often
available through primary care doctors.
However it does come with a number of
side effects, as well
as, it may not be useful for chronic long-term use.
There's also a number of over-the-counter options that
are marketed for sleep issues.
You might have heard of Seroquel
or using Benadryl or Unisom.
There tends to be less dependence from
those medications, but unfortunately, similar,
the efficacy often wanes when they're being
used for chronic treatment.
There's also therapies that can be helpful.
One in particular I'm going to talk about is
cognitive behavioral therapy for insomnia.
This treatment has been shown to be safe and effective.
It has lasting effects on improving insomnia.
However, it does require a bit of
motivation on behalf of the patient.
It does take time, often six weeks or more,
and then it tends to be less successful in
terms of finding therapists who are
skilled in CBTI for different patients.
The other thing that many people
will talk about is sleep hygiene.
When you don't have a diagnosed sleep disorder,
there's a number of different things you
can do to try to improve your sleep.
One key point is to avoid caffeine, alcohol, nicotine,
or exercise around bedtime, for the most part
stimulating things, that may
make it difficult to fall asleep, but also alcohol.
If you're thinking about it as a sleep aid,
it may make you drowsy in the short term,
but it may wear off before you're ready to wake up.
However, on the other hand, exercising regularly is
important for maintaining and
improving sleep quality overall,
as long as it's not right before you go to bed.
Having regular meals can be
an important way to reregulate your body
to be more aligned with
regular circadian activities or circadian rhythms.
Having regular bedtimes even on weekends.
There's been some studies that show that catch-up sleep
on the weekends is actually not associated
with better cardiovascular health, and having that
regular bedtime and wake time
everyday can be better for your body.
Trying to schedule enough sleep,
so at least seven hours of sleep, can be very important.
Having calming bedtime routines,
so avoiding stimulating TV or stressful task right before
sleep, can help to
avoid having anxiety or trouble falling asleep at night.
Maintaining a dark, quiet, cool environment,
trying to avoid having a lot of clocks in the bedroom,
and then, of course,
using your bed only for sleep and sex.
No eating, studying, TV.
Try to avoid all these other associations
of active things you might be doing in bed.
During COVID-19, there's a number of
other things that have been shown
to be helpful for sleep.
Going outdoors everyday,
getting the natural sunlight,
managing the stress related to COVID-19,
so practicing mindfulness, self-compassion and gratitude,
maintaining a daily routine,
even at a time when things may be blending
together, and we may be feeling
like we're in groundhog state, and
everyday is the same,
this can be a real key part to actually provide
definition and creating structure to our day.
Another one is cultivating
meaningful daily social interactions.
That's been one area that a lot of
patients have told me is a real challenge.
They miss almost the regular minor social interactions
you might have at a coffee shop,
or on the bus, on the way to work, things like that,
and finding ways to cultivate
meaning through social activities is important.
Another one is, again, providing structure,
but it may be more along the lines of a longer-term scale,
is looking at how to celebrate
milestones and actually plan for the future.
Then the last of course is,
if symptoms are getting worse in terms of sleep or
even mood and stress contributing to sleep problems,
the key thing is to seek help from
your doctors and getting
evaluated to see if
there are other things that can be done.
One of the most important things I find about sleep is
that is so modifiable and treatable,
that it's important to consider that as
a key integral part of your health.
So just to summarize,
sleep is a key biological process for the growth,
maintenance, and for aging successfully,
sleep disorders are treatable,
COVID-19 has affected sleep in many populations,
including older adults, and that we can improve
our own sleep through changing habits, and
rituals, and other enriching activities.
It's important to emphasize that.
Last of all, I just want to thank you all, my audience,
my sources of funding,
as well as our wonderful team at UCSC.
Thank you so much for your attention.
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