Why Can't I Sleep?

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Transcript

Chrissy Billau:

Welcome to Prescribed Listening from the University of Toledo Medical Center. On this podcast, we interview our experts to get the answers you need and can trust. I'm your host, Chrissy Billau and today we're diving into some of the top Googled health questions from 2020 and 2021 with Dr. Andre Aguillon who works in sleep medicine. Dr. Aguillon, thank you so much for joining us to talk about the power of a good night's sleep. Do you lay awake at night, staring at the ceiling and then find yourself simply exhausted during the day wondering why can't I get good quality sleep? What in the world is sabotaging my shut eye? Let's ask our expert. Dr. Aguillon, one of the top Googled health questions is why can't I sleep?

Dr. Andre Aguillon:

The reasons are numerous. All right. So the first thing I look at are medications because there are a number of medications that can have side effects on sleep and sleep quality and the ability of patients to fall asleep. So that's the first thing that I look at. Sometimes I look at patients may have certain medical conditions that prevent them from falling asleep. For example, people have chronic pain due to bone diseases, for example, that prevent them from falling asleep. For women, for example, there's something called primary menopausal insomnia where, especially in postmenopausal women, where they have hot flashes and sweats, which can prevent them from falling asleep. There are sleep disorders, for example, restless legs that primarily happen around bedtime that can be challenging in patients falling asleep. So I look at that too.

Dr. Andre Aguillon:

Sometimes patients have trouble falling asleep because they have a lot of ruminating thoughts. So they have a lot of preoccupying thoughts that they can't get their mind to stop running a million miles per minute, or they can't get their mind to shut off. So there are multiple reasons why people have a hard time falling asleep. Sometimes there are certain sleep disorders, for example, like sleep apnea, which prevents patients from falling into a deeper sleep. We see that even though that patients feel like they're not falling asleep, they are falling asleep, but they're toggling back and forth between wake and the light stages of sleep. So again, a lot of factors, a variety of causes and a lot of things to nail down.

Chrissy Billau:

Why is sleep critically important for our overall health and wellbeing? Most people think it's just a time when our body rests, but it's not time wasted.

Dr. Andre Aguillon:

First I have to answer the question, well, how much sleep do you actually need?

Chrissy Billau:

Yes, well how much does an adult need for sleep every night? And how many hours of sleep should children be getting every night?

Dr. Andre Aguillon:

Adults ages 18 to 60 should have at least seven hours of sleep on a consistent basis for healthy sleep. In the pediatric population, it varies. In the baby population. It's usually half of the day is sleep. Half of the day is awake. Adolescents would require about eight to 10 hours of sleep.

Chrissy Billau:

For an adult, if I'm in bed at night, staring at the ceiling and processing the day in my head or going over my to-do list for tomorrow, what can help me fall asleep in that moment?

Dr. Andre Aguillon:

The key to good sleep is regularity. So make sure that you have a consistent bedtime and a consistent wake time. Also avoid any substances that can impair sleep. So for example, avoid drinking caffeine before you go to sleep. Also avoid drinking alcohol before you go to sleep. I have some patients that they use alcohol to help them fall asleep, which yes it can. But the problem is that when the alcohol wears off during the night, people will have this withdrawal effect. Avoid large meals before you go to bed. If you're hungry, you can eat a light healthy snack. Allow one hour for yourself to unwind before you go to bed. The problem is that we take our work to bed.

Dr. Andre Aguillon:

Try to make a to-do list and then complete it one hour before you go to bed and then put it away. Because that one hour should be that time where you should unwind your mind and unwind yourself. So try to avoid, or turn off your smartphone, your tablet, your computer, or try to avoid watching TV, playing video games, watching Netflix, watching YouTube 30 minutes before you go to bed. Because a lot of these flat screen that are in these devices emit a blue light which can fool your brain into thinking it's still daytime. So your brain is not going to manufacture its old melatonin, which is known as our dark hormone, which helps us fall asleep and help regulate our biological clock.

Dr. Andre Aguillon:

Some people wear these blue light blocking glasses around the evening. I'm all for it. I know some smartphones have some function or an app that can decrease that blue light. I encourage that too.

Chrissy Billau:

Is there an amount of time it should take you to fall asleep?

Dr. Andre Aguillon:

Normally it should take you about 15 to 30 minutes to fall asleep.

Chrissy Billau:

Are sleep medications are over the counter sleep helpers like Benadryl okay?

Dr. Andre Aguillon:

The current recommendation is that over the counter medications like Benadryl or any antihistamine, melatonin, valerian root, things like that are not recommended to help fall asleep because there's not enough data to support that those over the counter can improve sleep quality or help fall asleep.

Chrissy Billau:

Melatonin. I know you brought it up a little bit before, but I'd like to unpack it a little more. What is it? Is it safe? Can kids use it? Would it be effective if you took a pill of it every night?

Dr. Andre Aguillon:

Well, melatonin, as I said, it is naturally made in our body and is in a part of our brain called the pineal gland. And it is released around nighttime or close to night fall to help us fall asleep and help regulate our biological clock. That being said, when we take the exogenous melatonin, like you get at your local Rite-Aid or CVS, in our practice we don't use melatonin for the purposes of insomnia or to help fall asleep. We use melatonin specifically for the purpose of regulating our biological clock because we have patients that present with circadian rhythm disorders, whether it's delayed phase where their habitual bedtime and wake time is later than what should be. And we have our advanced phase where their natural bedtime and wake time is early than what should be. Then we have people who have jet lag disorder and we use melatonin for those purposes to help regulate our biological clock.

Dr. Andre Aguillon:

Is it safe? The thing with melatonin is that it's not entirely regulated on how it's made because it's over the counter so there's going to be impurities that are in these melatonin pills. So the effectiveness may differ from one manufacturer to another. I would also be hesitant to use it on kids because it can affect a reproductive hormone process. There is also a concern if you take too much melatonin. What do I mean by too much melatonin? I mean more than 10 milligrams. Because the problem that if you take too much melatonin, it's going to inhibit your brain from producing its own melatonin. So you have to be careful on and how you use melatonin.

Chrissy Billau:

Should you take it every night?

Dr. Andre Aguillon:

No.

Chrissy Billau:

No. Okay. For adults, do you recommend a nap during the day, or can that help or hurt the rest of your day or prevent you from having a good night's sleep later?

Dr. Andre Aguillon:

That's a good question. I'm not against napping. It depends on the length of the nap and the timing of the nap. If we're going to talk about napping to combat fatigue at work or studying, a nap is actually good to improve alertness. So there's two things to consider. One is timing of the nap. The second is the duration of the nap. The timing of the nap, you have to understand your own circadian rhythm of alertness and sleepiness. So normally when we wake up, we're the most alert. Then we have a dip around the early mid-afternoon. A lot of people call that 2:30 feeling. A lot of people like to blame their fatigue due to lunch, which may be true, but it is also because that's our normal body's circadian rhythm. And then we have a little bit of a second wind around early evening, around dinner time. And then we get the most sleepy in the evening hours. That's when we're supposed to go to sleep.

Dr. Andre Aguillon:

So if you're going to take that nap, you have to be aware of when your body feels the most sleepy during the day. So if you're the most sleepy between two and three o'clock, then that's when you should take your nap. I would not take a nap in the late afternoon because the problem that you're brought into is that if you nap in the late afternoon, early evening, you're not going to have enough sleep pressure to help you fall asleep at your normal bedtime. So that's one, that's the timing of the nap.

Dr. Andre Aguillon:

Second is the duration of the nap. Now there are studies that show that if you nap for 20, 30 minutes, that it can prove alertness for 155 minutes, as opposed to, if you take a nap for 10 minutes, then the effects of improve alertness will only be like 95 minutes. So 20, 30 minutes of a nap, that's good.

Chrissy Billau:

An it's a luxury to be able to take a nap in the middle of a work day. I mean the only time I take an nap is on a weekend when you know you're at home and you can. But if you do you have the time, so 30 minutes is probably the most or is there something that's too long?

Dr. Andre Aguillon:

You have to be careful if it's too long, because if it's too long, you run the risk of having sleep inertia, which is that grogginess that you feel when you wake up from your nap. So I would not take too long of a nap, like one to two hours. I would say 20, 30 nap, that's solid.

Chrissy Billau:

Set an alarm on your watch or your phone, you'll be good. When should you see a doctor about not being able to sleep?

Dr. Andre Aguillon:

If it has effect on your health and of your everyday life. I mean, I have patients that don't get enough sleep, but they're able to function fine. They don't have any excessive daytime sleepiness. They're able to do the normal things they do at work fine. But if they feel like it has an impact on their quality sleep and the quality of life, and if it affects any of their medical comorbidities, Like high blood pressure or diabetes or any cardiovascular problems. And that's when you should see a health professional.

Chrissy Billau:

Can sleeping problems, be a sign of a more serious condition, like a red flag for something else? And I feel as if we all know someone who's experienced sleep apnea or needs to sleep in a recliner or has restless leg syndrome, can it be a sign of something else?

Dr. Andre Aguillon:

Yes. Particularly the patients that I see is if they have any major medical comorbidities, like cardiovascular disease, high blood pressure, diabetes, high cholesterol, kidney disease, those are red flags that could have a possible sleep problem. Because bad sleep, whether it's not enough sleep or bad sleep quality, can contribute to those medical disorders. And we see that when we treat their sleep, when we help people improve their sleep, that those other medical conditions fall in place. For example, I had a patient who had severe sleep apnea and when retrieve their sleep apnea, we noticed that their blood pressure improved and their physician was able to wean off on some of the medications.

Chrissy Billau:

Snoring, what is a remedy for people who snore? Is it surgery or sleeping on a certain side? I've been told, but I don't always believe it, that I snore when I sleep on my back. So for people who have that issue, what is a remedy for it?

Dr. Andre Aguillon:

Well, snoring does have a positional component and yes, snoring tends to be worse when you're lying on your back just because of the effects of gravity on the tongue, which makes it fall backwards and the pallet, which makes it fall backwards, which narrows the upper airway. One simple method is try to sleep on your side because of less effects of the gravity on that area of the upper airway. Some people have stuck like a tennis ball in their back or they would take a shirt that has a front pocket, they turned a shirt the other way around so they can put the tennis ball over there. So it'll force them to sleep on their side. So they turn on their back, that'll force them to go back to their side. But snoring could be a sign of sleep apnea, which is defined as a collapse or a closure of the upper airway, which can have deleterious effects because of decreased oxygen delivery to your tissues, to organs and to your brain and increase in fragmentation of sleep, which can lead to a whole host of cardiovascular and metabolic consequences.

Chrissy Billau:

What is a normal level of the number of times someone wakes up to use the bathroom? How many times should you go to the bathroom?

Dr. Andre Aguillon:

Well, none. I mean, I would say that if you go to the bathroom more than twice a night to urinate, that's significant. What we call nocturia, or frequent urination at night, that can also be a sign of sleep apnea. Because what happens is that when your throat closes up, you're trying to gasp for air. What's happening is that when you're gasping for air, when that upper airway closes up, you're creating an increase in negative pressure inside your chest cavity. When you have an increase in negative pressure in your chest cavity, there's more blood that returns to your heart. And when there's more blood that returns to your heart, your heart falsely thinks it's in heart failure. So it will secrete a hormone which makes us urinate. So there's evidence, that's shown that if you treat sleep apnea, for example, with CPAP therapy, it can decrease urine production by 50%. So at least for males, yes, you may think of prostate, but also think that maybe sleep apnea can cause that. And of course it can be seen in women who have frequent urination at night.

Chrissy Billau:

And one thing is if you're having a drink too close to bed. What is the cutoff time for when you should eat and or drink before bed? Imagine you're going to bed at 10:00, what would the cutoff time be?

Dr. Andre Aguillon:

I would say 30 to 60 minutes.

Chrissy Billau:

Okay. Let's talk about our kids and their sleep. What do they need to be doing to get the most rest possible?

Dr. Andre Aguillon:

The most important thing is parents have to be strict and take away all those devices before they go to bed because children need more sleep than adults, at least eight to 10 in the children, adolescent population. And so that's the biggest thing that parents can do, in addition to having a regular bedtime and awake time. Now the problem with children adolescents is that they're circadian rhythm is offset compared to adults, meaning that they naturally tend to fall asleep later and wake up later compared to adults. Problem they run into are these early school start times, which forces the kids to wake up early when they really shouldn't be falling asleep. And most of our REM sleep usually is in the last one third of the night. And one of the purposes of REM sleep or dream sleep is memory formation or consolidating memory.

Dr. Andre Aguillon:

So if a kid is trying to, when they're studying or when they're preparing for an exam and then you force them to wake up when they're probably in the middle of their dream sleep, they're going to have a hard time retaining that information when they go for their exam. For student athletes, high school, let's say because some of these schools in competitive events they make them wake up early for practice. And they're actually doing a detriment because they need to sleep for recovery. And so there was a recommendation by the American Academy of Sleep Medicine and the American Academy of Pediatrics that classes should not start earlier than 8:30 AM. But the problem is that there some school systems that have an earlier school start time. I don't think it's very healthy for kids.

Chrissy Billau:

Well, I know in California local schools are not allowed to start school until 8:30 AM or later. So you think the school start times are too early for children?

Dr. Andre Aguillon:

8:30 is recommended. I don't know what it is in the Toledo area schools. I know one school, I'm not going to name them because I don't want to hurt their feelings, I think their first bell is like 7:30. I'm like what? That is way too early.

Chrissy Billau:

Yeah. And even for some though, it's complicated because you have to go along with what's the bus transportation system like.

Dr. Andre Aguillon:

Exactly.

Chrissy Billau:

Because you may be getting picked up at 7:30, but your class classes may not start until 8:30. I mean, there's so much at play there, but it's interesting to think about that that if you push back the start time, it could help children do better in school and on their tests.

Dr. Andre Aguillon:

Yes. Tests and athletic performance. And yeah, I understand there are logistical challenges with the bus transportation. Of course, with parents drop off their kids when they pick them up. But ultimately who's the biggest victim here? It's the kids. So we should focus our priority on the kids, to make sure that they have good sleep which will help with their academic performance as well as their athletic performance, if they're involved in those activities

Chrissy Billau:

For those nights when you put your kid to bed, they had the bath, you sing to them you read them a book, but 10 minutes later, they're wide awake and yelling questions or they're constantly getting out of bed and coming to find you, there's a popular book for parents that's funny, but a little bit agonizingly true. I think you've heard of it probably. And I'll bleep myself. It's called Go The Bleep to Sleep. So in those moments when you're nearly pulling your hair out, do you have any tips for helping children go the bleep to sleep?

Dr. Andre Aguillon:

It depends on the age group.

Chrissy Billau:

What about like the sweet monsters who can get out of bed themselves at this point?

Dr. Andre Aguillon:

I don't think I have a clear answer for that. As long as they have a regular curfew and just curtail any stimulating activities or devices before they go to bed. That's that's good enough if they wake up the middle of the night because they need some attention, that's okay.

Chrissy Billau:

Yes. Well, and then nightmares kick in at some point and that's completely different. But I think what I'm hearing is routine is really important. Why does your sleep change as you get older?

Dr. Andre Aguillon:

Just part of the normal aging process, we tend to have less deeper sleep and we tend to have more shallow sleep. I mean, that's just part of the normal aging process and how our brain ages. It's something not to be alarmed about. That's just a normal part of life. But if you just practice adequate sleep hygiene, as I mentioned earlier, then you could still have an ideal quality of sleep at any age.

Chrissy Billau:

Yeah. You always hear people talking about, oh, I can get by on like four hours of sleep a night and my jaw drops. Like how? How are you functioning when it gets to like 4:00 in the afternoon? I have no idea. Are there certain clothes or gadgets that you can buy to get better sleep? Anything from cooling pajamas or weighted blankets or sound machines that really work. I know from mattresses to pillows to masks, there's an entire industry for sleep.

Dr. Andre Aguillon:

I think the biggest thing that I would recommend is having blackout or dark curtains. I think that's the best thing, because there's a concept we call zeitgebers, which is external factors that can regulate our biological clock. Light is the biggest of them especially during the summer months when the sun comes out earlier and people will naturally wake up, but they feel like, no, I need one more hour of sleep, but I can't because it looks bright out. So I think the biggest thing that I would recommend is getting darkened or black and curtains so that your biologic clock won't be easily influenced by the sun. As far as the other stuff, whether it's mattress or pillows or blankets or apps, I don't have any strong recommendation. I don't think there is a strong recommendation, whatever you think feels comfortable to you, then yeah. Go for it.

Chrissy Billau:

For me if it's too warm, I struggle to sleep. So does temperature play a big role in how well we sleep? And if yes, what's the ideal temperature for your bedroom for sleep?

Dr. Andre Aguillon:

I would say normally a cool temperature is recommended as part of a bedroom environment that's conducive to sleep. I don't have a recommended temperature. So that's more relative. I think cooler is better than a warm temperature.

Chrissy Billau:

We live in an accelerated society where we focus on getting things done right away. What do you say to those people who think sleep is a necessary evil or even a sign of weakness?

Dr. Andre Aguillon:

I tell them that sleep is not a luxury. It is a necessity because if you deprive yourself of sleep, you're going to get even less things done. A third of our lives is spent in sleep, if you think about it. So it's really important to respect our body in terms of the need of sleep. Because sleep helps us with recovery. Sleep helps us prevent developing a risk of having further medical complications. Sleep helps us with our mental health. So I would not underestimate the importance of sleep.

Chrissy Billau:

And I always tell the kids that's when you grow exactly. That's when the magic's happening in there.

Dr. Andre Aguillon:

Exactly. Because growth hormone is actually released during sleep. Specifically during the first through the night, it's when we have some of our deepest sleep. So yes, it is important for kids to have enough sleep because that's when our growth hormone is released.

Chrissy Billau:

Can you get too much sleep?

Dr. Andre Aguillon:

There is enough evidence that shows the consequences of too little sleep, but there is not enough evidence to show the consequences of having too much sleep. What I mean by too much sleep, like more than night hours. So of course, if a patient is consistently sleeping too much every day on a consistent basis, then that suggested that they may have an underlying sleep disorder. But if we're just talking about your average person who doesn't have any underlying problems, there's not enough evidence to show that too much sleep is a bad thing. So I'm just commenting on what the evidence is out there.

Chrissy Billau:

Being a sleep doctor, I imagine, can sometimes seem like being a marriage counselor. Do you have advice for couples who are opposites in how they sleep? Whether you're a light sleeper, heavy sleeper, cold or hot, non snoring, snoring, twin beds, king size beds, separate rooms? What's a solution for that?

Dr. Andre Aguillon:

It's funny because when I treat patients for their sleep problems, for example, if a person has a sleep apnea, we had to treat them, their spouse ends up happier because they're saying, oh yeah, my spouse doesn't snore anymore. I don't have to sleep at another room. And so I think we actually saved some relationships. But the bed partner, I would say this, if the bed partner notices anything unusual about their person who they're sleeping next to, whether they're storing, they stop breathing, they're tossing, they're turning, they're acting out their dreams, I mean, that's when they should seek professional evaluation by a sleep specialist. I have no recommendation about that. That's something for them to figure it out, to say how it works best for them, for their family situation. If they have kids, how can they negotiate? And of course how they can spend time together.

Chrissy Billau:

What's the best way to measure the quality of sleep. How do you know if you got a good night's sleep and how do you track as you're trying to improve it?

Dr. Andre Aguillon:

Well, I have patients that come in and they have all these sleep apps and they have questions like, well, I got the sleep app that says, I have light sleep. I have deep sleep. I have dream sleep. With us sleep professionals, we basically put our hands in the air because we don't know how valid they are. You really can't tell quantitatively how their sleep architecture is like unless you do a proper sleep study. For the people with these apps, I would only take it as a grain of salt. The way I would measure sleep quality is basically how well you feel the following morning. Do you feel rested? Do you feel refreshed or do you struggle to wake up in the morning? Do you find yourself having to hit the snooze button several times?

Dr. Andre Aguillon:

Do you wake up with morning headaches and then how able to function during the day? Are you sleepy? Are you fatigued? Do you have issues with work performance? With cognitive performance? Do you fall asleep easily multiple times? Do you take a lot of naps? Do you find yourself drinking excessive amounts of caffeine? Do you fall asleep while you're driving, which is a red flag for us? So these are things that I would look at in terms of if you're getting good quality sleep. I have patients that swear on their sleep app. If their sleep app says they're not getting good quality of sleep, they seem to freak out. I'm like, well, no, don't pay too much attention to your sleep app. I would say that if your symptoms match your sleep app, then okay. Then maybe there's some truth to that. But if you feel like you're functioning okay but your sleep app tells you something different, then don't listen to your sleep app, just listen to your body.

Chrissy Billau:

When we're talking about a morning person or a night owl, and someone who will say, well, I can't do this. I can't physically get up at this time. Does that happen and can it be changed?

Dr. Andre Aguillon:

If their biological clock cannot be changed and it's affecting their everyday life, then it is likely they do have a circadian rhythm disorder. And that should be addressed by a sleep specialist, because we do have techniques and medications to address that. It'll be very difficult to try to solve it on your own. But if you're able to curtail your work around it, for example, if a night owl would feel more comfortable working the night shift and they're able to balance their lifestyles around that successfully then great. So it really depends on how your biological clock affects your everyday life.

Chrissy Billau:

Piggybacking on the Google searches, I want to ask you Dr. Aguillon, what is the most common question you get from your patients? And what is your answer?

Dr. Andre Aguillon:

I would say a general sleep question that I get is how can I get enough sleep? I think are the points that we discussed today covers that question.

Chrissy Billau:

Yeah your eating habits and drinking habits before bed and your technology use, like cut that all off about a half hour before.

Dr. Andre Aguillon:

Yeah. The sleep hygiene. Practicing healthy sleep habits before you go to bed. But if that's still troublesome, it suggests that there's something else going on and that you should talk to your physician about consultation with a sleep specialist.

Chrissy Billau:

And I like your tip about writing down what's on your mind before you go to bed, because you're obviously thinking, oh, I have to remember to send that form in with whichever child to school to make sure they get to go on a field trip or something. Just write it down, go to sleep and you'll see it when you get up.

Dr. Andre Aguillon:

Exactly. Do your to-do list. Then one hour before your bedtime put it away. Don't think about it. Because that can be addressed the next day. That one hour before bedtime, that should be your me time where you're allowing your mind and your body to relax. So that it'll be easier for you to go to bed.

Chrissy Billau:

Let's talk about some elements of your practice. What have you been working on lately?

Dr. Andre Aguillon:

In my position, I service the program director for the sleep medicine fellowship for the University of Toledo College of Medicine. So most of my stuff is on the academic side, in terms of training and education. I've been working on giving lectures to students and residents. So that's, that's been most of my focus. Also at our UTMC clinics, we're switching to a new electronical medical record, Epic, which a lot of you may be aware of. So for me, a lot of focus is try to make sure that we have our templates and workflow. May not be much on the patients, on the general public side, what's more important to us so we can deliver the optimum quality care that comes along with a new medical health record system.

Chrissy Billau:

It's a big change. It's a huge investment. It'll make your life easier, I believe. But also I think maybe the patients will notice too, just with the ease of all the things they have to do as the process of going to the doctor. What is one thing you'd like to tell patients in general, whether it's relevant to your specialty or just about overall health that you have learned and you have found to be successful?

Dr. Andre Aguillon:

I think the biggest thing that I've learned about sleep, when I talk about sleep health is the importance of sleep, the importance of having a good quality sleep and adequate amount of sleep. the former logo of the American Academy of Sleep Medicine is the yin yang symbol. There is a balance and I think not a lot of people are aware of how much sleep is important and how much influences our lives. Personally, I try to approach life in a holistic manner. And I feel like that sleep aligns with my life philosophy of having a balanced life. As an advocate for sleep health, I would tell people do not underestimate the importance of sleep and the relationships of sleep and circadian rhythm to the workplace, to studying, to just mental health or medical wellbeing as a whole.

Chrissy Billau:

For people who are listening to this conversation right now and they're thinking, wow, I think I need his help, how can people schedule an appointment with you?

Dr. Andre Aguillon:

We're over at the University of Toledo Comprehensive Medical Practice located on 2100 West Central Avenue. And you can contact our office at 567-420-1600.

Chrissy Billau:

Thank you, Dr. Aguillon for giving us tips to promote healthy sleep habits and get better quality sleep. And that's all for this episode of Prescribed Listening from the University of Toledo Medical Center. Subscribe to hear more on your favorite podcast platform and join us next week for another episode where we tackle more of the top Googled health questions.