Introduction

Dr. Bob: And welcome to The Dr. Bob Show. Thank you so much for taking your time to learn a little bit about being happier and healthier. We've got a show that's loaded with helpful hints on how to keep you healthier. We'll be spending most of the time talking about getting a good night's sleep. You know, can you remember back in your youthful days when you could just lie down anywhere you wanted and you could just go right to sleep? Now it may be just a little bit harder. Maybe you're not sleeping as well and maybe after you get to sleep you wake up in the middle of the night and can't go back to sleep. Maybe you have trouble getting to sleep. Maybe there're some medical problems that are keeping you from sleeping.

We'll be talking about how to get a good night's sleep and about some sleep disorders on this show. I have an outstanding guest. My guest is Dr. Rosanne Barker, board -certified neurologist, who deals with sleep medicine and she's got lots of great information. She's one of my favorite teachers. Later on in the show we'll be talking about trigger finger. Is there any such thing as mild asthma? Could it be more dangerous than you think? What are some of the causes of blood in the urine? "Hematuria" we call it. And is aspirin a simple medicine and what are some of the side effects that we can have from aspirin that you may not know about? We've got a lot of good information. You'll want to stay tuned and keep watching The Dr. Bob Show.

Dr. Bob: We're talking with Dr. Rosanne Barker, board-certified neurologist who deals with sleep medicine and Rosanne, thank you for coming to The Dr. Bob Show.

Dr. Barker: It's a pleasure, thank you.

Dr. Bob: How long have you been doing sleep medicine?

Dr. Barker: I've been doing it 16 years now.

Dr. Bob: 16 years! I'll bet you've got a million stories to tell about sleep.

Dr. Barker: I've seen quite a few sleep patients, yes.

Dr. Bob: Let's talk about, what happens in the brain when people are going to sleep. Are there certain activities that go on?

Dr. Barker: Well, we think that sleep is very, very important for learning, for memory, for concentration. In fact, recently a lot of the brain chemicals have been identified that have to do with all of our different sleep patterns. There's nothing between awake and asleep. We're either awake or we've gone into the first stage of sleep.

Dr. Bob: Now, what's the first stage of sleep called?

Dr. Barker: It is called "Stage 1" and we think of it as drowsiness. A lot of people think that's still awake but it's not-it's drowsiness. And the next stage of sleep is light sleep and it's called "Stage 2." Deep sleep is "Stage 3" and "Stage 4" and then everybody's heard about REM sleep which is when we dream.

Dr. Bob: So, that's when dreaming happens-REM sleep. Which stage is that or is that not a stage? What is REM sleep?

Dr. Barker: Well, it is the fifth stage of sleep, you could say, but it really doesn't have a number attached to it, but it is when we dream. It's actually a very light stage of sleep. We cycle into it about four times over the course of the night. That's partly why we seem to need eight hours sleep because there are about four different cycles, an hour and a half to two hours each, with the dreaming at the end of each cycle and we dream more and more toward morning. So, we'll remember more dreams as we start to wake up closer to the morning,.

Dr. Bob: Do people always remember their dreams or sometimes not? I don't remember mine too often but occasionally I'll get a good dream that I'll remember.

Dr. Barker: Well, dreams really are not for our entertainment so, we don't necessarily remember them. We dream in real time, just like we were watching a movie or something with a story line, and we dream about 20-25% of the night. We think it has a lot to do with our memory and our emotional health. So, it's important but not any more important than the other stages of sleep. We need a balance.

Dr. Bob: And which stage of sleep is the one that we get most rest in?

Dr. Barker: Well, that's really what I was referring to because we need all the different stages of sleep in the right proportions during the night. I like to think of quality of sleep as having to deal with both getting the different stages of sleep and also the smoothness with which we sleep. We should stay in the different stages of sleep for a period of time and then we should smoothly transition into the other stages. With many of the different sleep disorders which we'll talk about later we've lost the smoothness, too.

Dr. Bob: So, when somebody goes to sleep, is it different for each different age group? People sleep better, don't they, when they're younger than they do when they're older? You always hear, the older you get, the less good sleep you get.

Dr. Barker: It really is unfortunately true. Even as healthy adults, the older we get, the less well we sleep. We wake up more during the night and we have a harder time maintaining deep sleep. In fact, we get less and less deep sleep the older we get. We have about the same amount of dreaming, that light stage of sleep we were talking about, REM, but less and less deep sleep. Kids get a third more a night of very, very deep sleep. By the time we're in our 80's, deep sleep may only be 1 to 3% of the night. So, unfortunately the quality does deteriorate.

Dr. Bob: Are we learning more about how to get people to have that good sleep, that deep sleep?

Dr. Barker: We can't really change that as we get older. I mean, there are certainly medications that will sometimes deepen the sleep but we really don't think that's appropriate to do, necessarily. You know, a healthy lifestyle and maintaining the best sleep that we can through more natural means would be the best idea.

Dr. Bob: Now, I want to get some helpful hints on two different problems that people commonly have. Number one would be just getting to sleep. Another one is if you wake up in the middle of the night, how do you get back to sleep? Let's talk about the first one. How do you recommend people have a good night's sleep?

Dr. Barker: Well, it starts with what you always talk about, healthy lifestyle. Everybody should be trying to exercise several days out of the week because the cooling off process after we exercise or taking a warm bath helps us get to sleep, too. And also, healthy eating. Avoid too much alcohol or caffeine, particularly late in the day. Alcohol actually makes us drowsy but during the night it causes more disturbed sleep and nicotine also is a stimulant that helps wake up us. We need a regular schedule of going to bed and getting up about the same time every day and trying to get that eight hours sleep that you always like to talk about (and I appreciate that very much). And a healthy environment to sleep in is important-usually a cool, quiet dark room to sleep in with whatever type of bed or pillows or bed covers the person is most comfortable in, too.

Dr. Bob: You're making me all relaxed. I'm almost ready to go to sleep just thinking about the eight hours sleep that I'm going to try and get tonight. So, we've got a very comfortable place. Anything else? You've gone through the major things-exercise, lifestyle, avoiding stimulants, have dark room….

Dr. Barker: And having a pre-bedtime ritual is very important. We wouldn't expect our children to play up right into bedtime and then be able to relax and go to sleep. So, we need that last hour or so before we go to bed to be a little relaxing time doing whatever we like to do. We should go through a ritual of a bath or brushing our teeth or reading a book for a while and getting ourselves really prepared and ready to go to bed. And then go to bed at a regular time, not waiting until we're terribly sleepy, but staying on a schedule so that when we go to bed, we will go to sleep.

Dr. Bob: Regularity is really a very, very important thing, isn't it?

Dr. Barker: It really is. It really is.

Dr. Bob: Now, how about reading at bedtime? Does that stimulate some people? I get a really heavy book and if I'm reading, it goes boom, it just falls on my chest. Does reading stimulate some people's minds?

Dr. Barker: Some people have to be careful with either television, reading, or it can be different things for different people. But many people find quiet reading for a few minutes in bed part of that ritual helps the brain realize it's time to go to sleep, but you wouldn't want to get involved with something like an action novel or an action TV program that could stimulate you because then it would actually waken you and give you insomnia.

Dr. Bob: What about the other person who wakes up at 2:30 or 3:00 and just can't go back to sleep?

Dr. Barker: Well, then that person should get up and really go out to another room and take a break and do something boring, whether that's reading or a puzzle or needle work or something, quiet. Don't get up and do housework or any type of computer work, things you might normally do in the daytime that your brain associates with being awake and staying awake. I love to tell people that if they're not getting anxious and they're resting in bed, sometimes they really are in stage 1 and 2 sleep and they may want to just stay there and relax and enjoy that quiet time, too.

Dr. Bob: Those are great great tips. Sleep disorders. How many are there?

Dr. Barker: Almost 100 now that are actually very clearly defined and coded.

Dr. Bob: And that's what we're going to be talking about. Not a 100 sleep disorders, but we're going to be talking about the ones that I think are the most common that will help you. Right now, let's talk with somebody who had a sleep disorder and see what they did.

A Patient's Experience with a Sleep Apnea:

Patient: I was diagnosed with sleep apnea which is a sleeping disorder where you stop breathing at night.

Dr. Bob: And what did your doctor tell you to do?

Patient: She put me on a C-Pap machine for that.

Dr. Bob: And what was it like and when she put you on the C-Pap how were you when you woke up in the morning? How did you feel? What was the difference you felt?

Patient: I felt more refreshed. I mean I did feel more refreshed.

Dr. Bob: Did your dreams go away?

Patient: The dreams are still there. I still have the dreams. Those haven't totally subsided yet.

Dr. Bob: Now, she diagnosed you with sleep apnea and some other things too. What were they?

Patient: Restless, restless leg syndrome.

Dr. Bob: Restless leg syndrome. Now, tell me about how you would know you had restless leg syndrome.

Patient: I would never have known it until she told me about it. But I guess my legs moved about 359 times and so they put me on Requip, which is a drug used for Parkinson's.

Dr. Bob: Did that make you feel more rested?

Patient: Yes, still there was the trouble of not staying asleep and not being able to go to sleep at times and having that struggle of daytime drowsiness, forgetfulness, and dreams. My dreams, now that's the scariest part about this illness. Your dreams are so real!

Dr. Bob: Now, that's not due to sleep apnea. That's not due to restless leg. That's another thing she found...

Patient: Which was narcolepsy.

Dr. Bob: Narcolepsy. So, you've got three things all in one person. How did you get so lucky?

Patient: I have no idea.

Dr. Bob: Aren't you glad you saw Dr. Barker?

Patient: I am.

Dr. Bob: If you've got a sleep problem, it can be fixed. We've been talking about routine sleep, about the stages of sleep, about how to start off getting a good night's sleep, and now we're going to talk about sleep disorders. Let's go right to people that have problems with their legs jerking. What do you call those problems and what do we do for them?

Dr. Barker: There's "restless legs" which is the waking part of this phenomenon, the person feels disagreeably uncomfortable sensations in the legs. That the sensations occur while you are at rest is key to this type of problem-it is usually worse when you get into bed at night. But some people will have these sensations in the evening or earlier in the day, too. The sleeping part of this disorder is called "periodic leg or limb movements," where about every 30-40 seconds (when this starts up in the night) they'll get a little bicycling movement usually in the legs, sometimes in the arms. They don't know they are doing it but a bed partner may because it disturbs their sleep.

Dr. Bob: I would imagine their bed partner would say, "What in the world are you doing?"

Dr. Barker: It can become very annoying. Occasionally a bed partner isn't aware of it because it can be fairly small in some people.

Dr. Bob: Are these common problems-periodic leg movement or restless leg?

Dr. Barker: It's very common. You'll see it in up to 40% of people by the time a person reaches their 70's or 80's. We don't have to treat all those people. Sometimes it does bother their sleep so we treat it if it's interfering with sleep, either their own, or their bed partner's.

Dr. Bob: And, tell me, how do you treat it? What's the medicine?

Dr. Barker: Yes. We know that it's due to low dopamine in the brain in most cases and so there are medications to replace that. Requip and Mirapex are two of the most frequently used and we know it's also associated with low iron levels so we are often checking that and using iron replacement.

Dr. Bob: Low iron level. Now, why would low iron level have anything to do with it?

Dr. Barker: Well, I just mentioned dopamine being low in this condition and iron is very important in the production of dopamine in the brain. So, if your iron is low, you can't make as much dopamine which can result in restless legs or leg movement.

Dr. Bob: And those two medicines again?

Dr. Barker: Requip and Mirapex.

Dr. Bob: Requip and Mirapex. Now, let's go to obstructive sleep apnea. First let's start with snoring. Is snoring a sleep problem?

Dr. Barker: Well, snoring itself is often more of a problem for the bed partners than the patients themselves. But snoring is never normal. I think that's the key point. It's not OK to snore. Lots of things will cause snoring but one of the most serious problems that cause snoring is, of course, sleep apnea.

Dr. Bob: Now, what really is sleep apnea? You hear it, but-really, what is it?

Dr. Barker: We're talking really about obstructive sleep apnea where there is a narrowing or a collapsing in the upper airway, the throat, or the upper neck area. So, it blocks the flow of breathing while the person is asleep.

Dr. Bob: Is there blockage where snoring occurs? Where does snoring occur?

Dr. Barker: Yes. We think it comes from the area where the tissues come together and while they are together, it creates the noise.

Dr. Bob: Now, how do you know if you've got obstructive sleep apnea? What if somebody doesn't snore-can you have it without snoring?

Dr. Barker: Yes and that's a very good point because 10-20% of people with obstructive sleep apnea don't snore. Not breathing can be very quiet too.

Dr. Bob: Oh yes, it can be very quiet. With snoring, if somebody has obstructive sleep apnea, what do you listen for? How do you tell if it's sleep apnea if somebody is a snorer? What's it like?

Dr. Barker: Yes, well, if somebody is simply a regular, loud snorer, right there's a sign that they may have sleep apnea. So, sometimes you need to go on into the testing. Or, if the person has been observed to have their breathing stop at home, that's actually when apnea is occurring. Then there's an extremely high chance, of course, we're going to also diagnose it on the testing. But you have to be careful because sometimes people have apnea at home but no one actually sees the apnea happening.

Dr. Bob: How long are the apnea periods where somebody's not breathing? Does it last a minute and a half or ten seconds or two seconds?

Dr. Barker: Usually we'll see it between 10 and 30 seconds.

Dr. Bob: 30 seconds?

Dr. Barker: Yes. 10 seconds is kind of a minimum for it to really to be an apnea, it really takes about that long before we start to see the oxygen drop so that's really the important aspect of this.

Dr. Bob: What triggers the patient to start breathing again if they stop for 30 seconds?

Dr. Barker: Yes, the brain starts to notice the drop in the oxygen level and will cause an arousing or a brief awakening that rejuvenates the breathing again.

Dr. Bob: Now, I'd love to spend another 30 minutes on this right here. When you do a sleep apnea test or when you do a sleep study, how many times will people have apnea per hour?

Dr. Barker: Yes. Well, if it's mild apnea it can be between maybe 5 and 15 times per hour. Moderate sleep apnea may be 15-30 per hour, and over 30 per hour is severe. And that criteria has tightened up over the last few years. We're realizing more and more that even mild obstructive sleep apnea needs to be treated, even down in that 5 per hour range in some cases. It's like treating diabetes or hypertension or anything else…the earlier we catch it and treat it, the more we prevent long-term complications.

Dr. Bob: What are the long-term complications? Why do we need to treat this?

Dr. Barker: Well, this is a type of smothering. The oxygen fluctuates at night and it greatly increases the chances over the years of developing hypertension, heart disease, strokes and diabetes.

Dr. Bob: Actually that's one of the causes of high blood pressure, isn't it?

Dr. Barker: Yes it is.

Dr. Bob: I would like to talk more about the illnesses like heart arrhythmias that you can have as a result of sleep apnea. Can heart attacks be caused because of sleep apnea?

Dr. Barker: They actually can. You can, of course, get a heart attack or a stroke from a blocked artery causing low oxygen to a part of the body but you can also get low oxygen from obstructive sleep apnea and it can result in a stroke or heart attack.

Dr. Bob: How do people know if have sleep apnea? What are their symptoms that they have during the day. I think this is very important.

Dr. Barker: Yes, yes, because most patients with apnea don't know they're necessarily having trouble at night. They often say, "I sleep great," you know, but they are often tired and not rested when they wake up; more tired or sleepy through the day with a loss of energy level; often more moody; have more difficulty concentrating; poor short-term memory. These are the major signs.

Dr. Bob: And the treatment that we have for obstructive sleep apnea-is there good treatment?

Dr. Barker: There really is now and it's ever expanding and improving for us.

Dr. Bob: When we come back, we're going to take a little bit more time talking about those treatments for obstructive sleep apnea. Is it a C-PAP? Is it something like a prosthesis for the mouth? Are there new medications that we can use? We're going to be talking about that. Stay tuned.

Dr. Bob: I'm having such a good time. We're talking with Dr. Rosanne Barker, board-certified Neurologist. We're talking about sleep problems and now we're on sleep apnea which can be a cause of headaches in the morning, can be the cause of high blood pressure, can be the cause of heart rhythm disturbances, and even maybe heart attacks. We've got to talk about the treatment. Rosanne, let's go into the treatment. What are the treatments of obstructive sleep apnea?

Dr. Barker: Well, basically the treatments are either to widen the airway or add support-these are surgical options. There is using an oral appliance, a mouth piece, or there is C-PAP, Continuous Positive Airway Pressure. Weight loss may be helpful but it is not one of the main treatments.

Dr. Bob: "Continuous…." -- what was that called, C-PAP?

Dr. Barker: Continuous Positive Airway Pressure.

Dr. Bob: Now what is that, the C-PAP? Tell me about C-PAP.

Dr. Barker: The C-PAP device itself is basically a very small, fancy little fan or air compressor that pulls in room air and pressurizes it. It hooks up through a tube to a mask that's worn over the face at night and delivers that air pressure into the nose, goes down into the upper airway and acts like an air pressure splint in this region to add just enough support to keep the airway from collapsing through the night.

Dr. Bob: When you tell people that you're going to put them on a mask that blows air down into their throat, what do they say?

Dr. Barker: Well, I think more and more people are hearing about it but, luckily, as a result of a lot of research and development all of this has gotten easier to wear. We have a very high success rate. We have a 90% long-term usage rate in our sleep center with the support that we can give to people.

Dr. Bob: Does everybody have to have a different shaped mask?

Dr. Barker: There are different styles. There are different shapes. There are different fittings that we can use and even, I didn't bring them, but things that go right in the nose instead of around the nose. So, we have a lot of options now.

Dr. Bob: I've got to tell you a story. I have talked with patients that are on C-PAP for obstructive sleep apnea and I ask them, "How did you ever go to sleep?" And they say, "I didn't think I could, and then all of a sudden I woke up the most rested I have ever been in my life." Do you hear that frequently?

Dr. Barker: Yes, because we're only giving this to people that really need it and so therefore it does the job for them and they feel great. I like to say people start out using it because we discuss it with them, and they understand why they are using it for this dangerous condition. They keep using it because they don't want to go back to feeling like they used to.

Dr. Bob: And you mentioned one other thing. You mentioned about an oral prosthesis. What are you talking about?

Dr. Barker: An oral appliance. Starting about 10-15 years ago lots of people were inventing devices, mouth pieces that would go into the mouth and would hold the tongue or the lower jaw more forward and keep a wider breathing space open behind here. And one that we like very much now is called the "Klearway," spelled with a K, Klearway, one word. We like this because it has been heavily researched and used in thousands of patients and we have hundreds of patients using it and doing research with it. But it holds the lower jaw more forward and is highly adjustable, with 44 different positions. We can actually get 88 positions using an extender a quarter of a millimeter at a time. It's very durable. We don't see tempomandibular joint problems with it, or tooth and gum problems. It does the job well without any side effects for people and it's really popular because it can fit into just a little box and they can take it with them if they travel or go places.

Dr. Bob: I think that I would choose to have you pull my jaw forward rather than stick a mask on my face while I'm sleeping.

Dr. Barker: And many people do. The more the severity of the apnea, the more collapsing o the airway, and the more people need the full support that the C-PAP may give. But for many people with mild to moderate cases of apnea, this has been very effective and and a popular way to go.

Dr. Bob: Rosanne Barker, you are amazing. You are a wonderful teacher and I thank you so much for taking the time to come to The Dr. Bob Show. This has just been great information and I can't tell you how much I appreciate your coming.

Dr. Barker: You are very welcome. Thank you.

Dr. Bob: We took extra time and I've just got a couple of minutes and we will be talking about some medical problems that I think are important to your health. What a great show!

Supplemental Commentary

Announcer: Coming up next on The Dr. Bob Show, reporter Jane Nowiski gives some tips for leading a healthy life. And later Dr. Bob answers his mail.

Jane Nowiski: When people have so much trouble sleeping that it affects the rest of their life, oftentimes they end up in a sleep study center like this one. A sleep study center can help to determine all types of sleep disorders including the very common sleep apnea. Sleep apnea occurs when a person stops breathing for several seconds at a time. This causes the blood oxygen levels to drop and the carbon dioxide levels in the blood to rise. Aside from low oxygen levels and sleepiness, people with sleep apnea often wake up feeling as though they are suffocating. This causes a jolt of adrenalin through the body causing the heart to race and the blood pressure to rise. Sleep apnea not only causes people to be fatigued during the day but it has also been linked to high blood pressure, irregular heart rate, early morning headaches and is a common cause of automobile accidents. If you have trouble sleeping, be sure and talk to your doctor about trying to find a way to help you get a peaceful night's rest. Reporting for The Dr. Bob Show, I'm Jane Nowiski.

Closing

Dr. Bob: I want to thank Dr. Rosanne Barker for a wonderful discussion on sleep disorders. Wow, what a teacher! And now for a couple of questions. Dr. Bob, what's "trigger finger?" Well, trigger finger… The tendons that bend your fingers run through a tunnel or sheath. Trigger finger is caused by a thickening on the tendon. As you bend your finger it catches as it runs in and out of the sheath, it clicks and eventually locks and surgery is usually needed.

Letter 1

Dr. Bob, is mild asthma dangerous? You better bettcha it is. If you're using a metered dose inhaler more than once a week, then you could be causing damage to your lungs later on by not treating the inflammation that goes on in asthma.

Letter 2

Dr. Bob, what are some of the harmful side effects of aspirin? G.I. bleeding, upset stomach, neurologic problems, and aspirin use in children has been associated with Reye syndrome, a rare but serious condition that can cause death so we don't use aspirin in children. And there are some people who are very allergic to aspirin.

Dr. Bob: That's all the time we have. I hope you are getting your exercise 20 minutes a day, seven days a week. Eight hours of sleep is terribly important and a good breakfast. And most of all, you need laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com