In this talk for both clinicians and patients, sleep medicine specialist Kin M. Yuen, MD, MS, DABSM, answers the questions on everyone's yawning lips, including “How much sleep do I need?” and “What constitutes chronic insomnia?” Yuen explains what the various stages of sleep bring us, how much waking up during the night is normal, and why using numerous sleep accessories – such as eye masks and sound machines – might hamper slumber. Learn why some people should try going to bed later and what might be lurking in a melatonin supplement.
So today's topic is about sleep and wellness, and uh that will be something uh that, of course, that we're gonna talk about, um, and first of all, let me let you know that I don't have any conflict of interest to declare. So the question I get asked the most, one of the first questions is, how much sleep do I need, right? And very often that's tough to answer because that depends on the era that we go through as we mature. So, generally for most adults, you can see the transition between young adulthood, which on average could be about 8 hours, there's some exceptions, and as we approach more mature adulthood, we may need a little bit less. And once we become an older adult, definitions 50 and over, um, then it may be closer to 7, 7.5 hours range. But since the 1950s, generally, most of us have been losing an hour's sleep per night, and that's a big loss. There is a survey regarding how much sleep Americans have been getting, Californians in particular, and a third of us. Responded that we are sleep deprived. So if there's an epidemic, sleep deprivation certainly is one of them, and I'll talk about some strategies in terms of how to deal with it. But as we were newborns, we slept most of the day. As I pointed out, in adulthood, perhaps 7 or 8 hours, but teens, what we have found recently, needed a lot more. So on average, 8.5 to 9.25%, so I usually would say about 9 hours. And a lot of you may be familiar with the so-called sleep stages, right? Because your sleep trackers, your, your phones, um, the app may tell you how much sleep you have gotten, how disrupted your sleep might have been. So I want to introduce the sleep stages a little bit and talk about what they do briefly. Usually, this is what's called a hypnogram. So when you see a sleep study, if the doctor or provider, nurse practitioner or physician's assistant show you one of these graphics, this is called hypnogram. It just tells you what your stages were. So this is a typical person who slept well. During the night and the first stage is W, so awake, literally when it dropped down means that we fell asleep. When it comes back up to W level means that we awaken. So hopefully, we shouldn't have too many of these awakenings during the night. About 4 to 6 maybe on par. Um, the dark bars going across are the so-called rapid eye movement sleep. So those are the stages, if you watch someone dreaming, you're going to see beneath the eyelids, eyes rolling around. So literally, that's what they are doing. It's like we're watching a movie right inside our heads. The function I will speak about, uh, in a subsequent slide, stage 1 and 2, the first two dips. Our gateway into sleep. So we typically go through stages 1 and 2, we come back out through stage 1 or 2, or sometimes during REM sleep, some of us can wake up abruptly from what we call stage 3 or deep sleep. So as you can see, the amount of deep sleep that we have generally decrease over time and the amount of REM sleep generally increases over time. So early morning, usually we're waking up from REM sleep. We should not be waking up from deep sleep early morning unless we have been sleep deprived. So this is the schematic in terms of what a good night's sleep may look like. In comparison, I think you can see how this does not look like that, right? The REM sleep is still depicted here, but then the demarcations are down below, so it could be a little bit more confusing. But this person is waking up a bunch compared to the one before, and this person also has 123456 REM cycles, and this person also had a lot of deep sleep right before they're waking up as well. So this probably represented someone who has disruptive sleep during the night, who has been sleep deprived, and that's why they still have some residual deep sleep. Lingering into early morning and they had a lot more REM sleep than the previous graphics I showed you. And so this is what someone who may not be having good quality sleep may look like. And so, does that matter? Yeah, it does because I'm sure we all have felt at one point in our lives, the lack of sleep and their effect, either because we have to catch a plane, we have some important assignment that's due, there's a deadline, whatever it is, but when we sleep well, we feel well because sleep helps us function. We are able to concentrate a little bit better. Now, the stages of sleep have something to do with our memory and retention. When we sleep better, we retain information a heck of a lot better, and so the light stage of sleep stage two kind of is also the gateway to determine, well, what kind of information is relevant to our survival and our experiences. So it determines what gets encoded. So stage 3 sleep is when we are gonna compact some of those memories. It works in conjunction, this is a very simplistic representation, but it works in conjunction with REM sleep to put some of these short-term memories into the longer term storage. So if your storage is full, like your computer is full, We may have to defract the hard drive. We got to make more space, otherwise, we have to perch one item before another item can get in. So we really need that stage to do some of the cleaning, and so what the brain does is dumps all the byproducts that build up the proteins that need to be repaired to kind of, I, I like to term it, take out the trash. So empties out all those repair products into our bloodstream, so it plays a pivotal role in terms of whether we feel refreshed or not. REM sleep further compacts the memory, so things that we're learning for the first time like a skill set, right? If you're learning a new instrument, a new dance step, you have, you learn to operate a very complex machinery. So all those things and problem solving, we need REMC for. If we're deprived selectively of REM sleep, we will lose deep sleep. If we are losing deep sleep, we usually will short out on REM sleep as well. So we want all of them. And the encoding part of the information, we usually have to go through two of these cycles, so deep sleep, REM sleep, deep sleep, REM sleep, along with the lighter stage sleep for any information to get through. So if you're getting less than 2 cycle lengths, which is about 4 hours, you are not getting the information encoded. All right? So that's important to remember. Now, in addition to how much sleep, the timing is also important, right? Because we know that when we were younger, or for those of us, you know, if you have teenagers around the house or those that are younger, they are much more likely to be night owls. As we mature over time, we have this. Crossover and more of us become morning people. Part of the reason is actually the the deterioration in parts of the brain that help us regulate the so-called sleep-wake cycles. And we can talk about that further, but that's why teenagers are, they have a hard time going to sleep and they have a hard time waking up. And part of the reason is that their clocks, most of us, our internal clocks are not exactly 24 hours. Most of our clocks are longer than 24 hours, but the teenagers, they are much, their clocks are much longer, 24 hours, 45 minutes. So you can imagine if they go to sleep at 2 o'clock, there's no way they can get themselves up and be ready for school. Now, if you continue to have these genetic traits persistent to adulthood that you may also have a hard time, if you had a long commute, you had to work in person instead of at home, then good luck getting there before 11. Some of you can function OK from 9 to 10 with caffeine on board, but we know what caffeine does to sleep. If you don't, we're gonna talk about that further. So this is not aligned with the clock time and I have plenty of patients that ask me, well, I wanna go to sleep at 10. I would say you're wasting your time. So it's like putting me to bed at 4 in the afternoon, you know, if I'm sleep deprived enough, I can do it, but most often, I would struggle. And so sometimes people can come in presenting with symptoms of insomnia, which we're gonna talk about next. Occasional insomnia, like, like I said, catching a plane, someone who's ill in the family, someone that you care for, there was an accident of some kind. So these situational circumstances can cause us to have occasional insomnia, maybe a couple of nights, maybe a week or so when the acute stress is over, we recover, but we all have had the experience. So occasional insomnia could be affecting 90% of the population at some point during our lives. What makes it chronic is that when it happens more than 3 nights in a row and it continues for 3 months. So if this is your pattern, then you do have chronic insomnia. And the more important thing is some people are comfortable with their sleep schedule. For instance, some of the night owl, they realize I have always been a night owl. I'm not a morning person. They have the workaround and they have occupations or they have a school schedule that is consistent with being up later and waking up later. So they do not have daytime symptoms. So chronic insomnia, when this happens, it's only when you have daytime symptoms. If you're sleepy, you can't concentrate, you're irritable, any of the above. We talked about while female sex is more likely to be affected by insomnia, um, and however, like I said, it could be a symptom of other disorders, not just insomnia itself. They're commingling with other things. Now, women are more predisposed to have insomnia. One of the reasons is that women, or I should say female infants, now that we can study things a little bit better with imaging. It's found that the female fetus has more cells that store basically norepinephrine, which is a chemical, uh, or neurotransmitter that tells us that we are stressed and we need to secrete adrenaline, OK? So it's been found that some women are particularly more prone to have not just more cells that would secrete adrenaline. But they have more connections between the neurons that will allow the release of this stress chemical. So if we have more availability of adrenaline, it may persist throughout our lifetimes along with life stressors that pumps out even more adrenaline. So, from teenage years onward, I would even say some female, um, some infants may manifest symptoms when they become toddlers. So at age 3, we have some kids begin to have some anxiety and, and fear of symptoms too. But it's typically by school age, we will see discrepancy, the blue, uh, green, uh, the men, and then the, the kind of Uh, fuchsia of the women through our lifetime. So although the prevalence of insomnia goes up as we age anyway, but there's proportionally more women being affected as we age. And the model for insomnia, there are 3 major factors. This is Doctor Arthur Spielman who passed away, model. So called predisposing factor, one of which is what I talked about earlier. Some people just have more. Neurons in the brain that store, uh, Lucus Aurelius that stores nore norepinephrine, they're just more available, but we kind of lie underneath the threshold. We don't have symptoms yet. There's usually some kind of precipitating factor, um, taking the board exam, for instance, for me, it could be one of those life stressors, but other things that being audited by the IRS, you know. Whatever. So something can just push us over, but it's what we do with the symptoms of insomnia that sometimes can do the so-called perpetuating, uh, the insomnia. So some people, they have a surge, a life event, the life event resolves and they go back to the subclinical threshold, but some people created these. Typically beneficial type behaviors just because I'm sure you all have been told about sleep hygiene, how important that is. So some of, some of us may carry that too religiously and that becomes now associated with insomnia. And now they have a more chronic condition and we talk about um what some of those may be. And one of which are the additional requirements I call them. So the additional requirements could be, I certainly have had patients wear eye masks, nothing wrong with that. But if you use an eye mask and you have blackout drapes and you have a sound machine and you have aromatherapy and you have a weighted blanket and you have a special pillow and you need a special mattress, so every additional thing that you require for better sleep, um, is gonna make it more difficult, right? Just because it just, it's like a laundry list, the more items that you require to get your sleep, how reproducible is that going forward if you go to a hotel, if you travel, so if you can't carry All of these items with you, can you get to sleep. So I usually say start with less. So at least trim one item or two and see if you can actually go to sleep. The second most important piece of this is go to sleep later. I know I'm gonna be, you know, I'm gonna have lots of comments about that, but the reason we want to go to, we want you to go to sleep later is because That increases the sleep pressure which accumulates during the day. So in theory, if we wake up early morning, And we feel refreshed. We had gotten a good night's sleep, we should have zero sleep pressure. And then we build up the sleep pressure as we progress during the day, whatever the substance is, and by the time we go to sleep, it should be 10 out of 10. We cannot keep our eyes open and we have to lie down to relieve the sleep pressure. But if you were put to bed 2 hours earlier, Well, your sleep pressure may not be a 10. It may not be, you know, it could be a 6, it could be an 8, it could be a 7, doesn't matter, but the sleep pressure is not 10. So what happens then is that your brain goes into the lightest stage of sleep that I talked about earlier. It may fluctuate between stage 1, stage 2, stage 1, stage 2 because it's not time yet for you to get that deep sleep. So when that happens, well, you still can have intermittent reception in stage one of sound. So that's why sound bothers you, because if I'm kind of drowsy and someone walks by and talks to me, I'm gonna wake up. So that's why we want you to go to sleep later, is to enhance the sleep pressure to push you into deeper sleep, because when we're in stage 3 sleep, we do not have audio perception. So that's why you cannot wake up a sleeping teenager. They can interact with you, but they are oblivious to the world. That's the stage of sleep I want you all to get into when you go to sleep. It's a very little stage 1, stage 2, boom, right into stage 3. And we have done experiments to try to wake people up. We can wake people up stage one, we can wake people up stage two with audio, uh, input. Very hard to wake someone up from stage 3, not impossible, but very hard. So that's why we want you to go into that stage, hopefully pretty soon right after you fall asleep. The second part is that we need the biological rhythm that I talked about. So timing is really key in terms of when you get your best sleep. So most of us, we can stay up a little bit longer, but to go to sleep a little bit earlier does make your sleep lighter. And so some of us in an act of desperation that we have had insomnia for a while, would use AIDS, sleep aids, whether they're over the counter, um, some people use alcohol, none of which is advisable, and some of us may use melatonin. Now, of course, you all have heard that melatonin is not regulated, hopefully, most of you, by the FDA, um, so there is no inspection in terms of the quality and the quantity. What was surprising in one of the sleep research journals published is that the researchers, along with consumers report, bought off the shelf melatonin preparations and began to analyze them. How much active ingredient did it contain? So, no surprise, some of them had no active ingredient whatsoever. The surprising part was that some of them actually had serotonin. Now we know serotonin is a happy hormone, you know, if we have enough serotonin, we usually are not as depressed. We, we have a lifted mood. Serotonin eventually metabolizes, it becomes melatonin in our bodies. But if you have, you were given a good amount of serotonin at bedtime, it's gonna keep you awake because it is one of those chemicals normally being secreted to help us stay awake during the day. So if you end up with a bath of melatonin that has a lot of serotonin, you're not going to sleep, OK? Now, the other common thing that's been found is that melatonin, I just took this off the internet, you know, 5 mg. So a lot of the preparations out there are too much for what our bodies may need for a short-term basis because our brains can secrete melatonin. It may not be at the time that you would like it to secrete. Which can be earlier or later, and most of us do fine with between 1 to 3 mg if the preparation has a USP P in Peter label on it. That just means the pharmacist or someone in the uh pharmacy has tested it and determined that it's of decent quality. So if you're gonna buy any over the counter preparation, be sure to look for the USP label. Now, besides that, it really depends on what you need it to do. So for people that have trouble going to sleep, the immediate release would make sense, whether it's liquid or chewable, it doesn't really matter. For those that wake up in the middle of the night, well, they probably want a more sustained release preparations because you don't have trouble going to sleep. If you need to stay asleep, you need things that act a little bit longer, but not overly sedating that when you wake up in the morning, that you're groggy because melatonin can make you groggy. Second part is melatonin can amplify any dreams that you have. So if it's a pleasant dream, You have a more pleasant experience. If it's a nightmare, it will become also more vivid. So just beware, particularly if you're taking the higher dosage. More importantly, this is one thing for safety, please do store the, if you use gummies, put them away. To a place where a child or other individuals where they are not meant to be used, don't have access to them. During the pandemic, we have had kids Taking gummies of melatonin and having toxicity as a result. So it can damage uh or cause sedation at the minimum. And so, um, we definitely don't want children to, to have problems, but a lot of times they may be out because parents during the pandemic, they're doing so many different things on top of them, they're being teachers, so they may want to help their kids sleep a little bit better and to start off the day OK and they may be giving melatonin to their children. So put them in a safe place. Other supplements out there that people have tried and thankfully less and less so are kava kava, usually in religious ceremonies in my Tongan population, they may serve a kava tea, however, uh, at higher doses, it can cause liver toxicity. There were, uh, police reports stating someone was acting like he was driving drunk. Police pulled the driver over and found that They had drunk some coffee tea. So it can affect you that way, um, and then commonly over the counter sleep aids are usually antihistamine of one sort or the other. So having sleepiness as a sedation side effect is not truly what it's meant to do. You are gonna end up with some grogginess in the morning and you're gonna have probably some dry mouth as well as a result. So be careful, dosage, 1 to 3 mg is more than adequate for melatonin. Timing is highly variable. It depends on what you need it to do. So for sleep induction, meaning to help you fall asleep, I usually prescribe about an hour before, um, for you to stay asleep similarly. Some practitioners like you to take it a little bit earlier, some may even say 2 hours before, but it really depends on what you're doing. Um, and what you're, whether you're trying to change your biological rhythm. Effectively blocks, we have all had these experiences. Not only have we a hard time focusing, when I was going through training, I had a hard time writing my medical orders, uh, for patient admissions. I have to keep reminding myself which line I was on so I could retrieve from memory what I was doing yet again. Irritability for sure depends on how, uh, how much mental resources you have to begin with during the day. So if you already have been sleep deprived for a couple of nights, well, that may be the day that you could get very irritated or annoyed by something very, very small. And then, of course, that closing eyelid tells the whole story. Um, there were some supposedly sex differences between men and women that according to the sleep studies that were conducted, seemingly women. Uh, adult women have more ability to Uh, be resilient in that women may accrue sleep debt faster, but recover faster as well. Uh, there is currently a little bit of debate because that has not been borne out in women, shift workers, for instance, nurses. Um, sometimes the nurses that are chronically sleep deprived actually. In the reports that were cited have a little bit more errors compared to the male partners, and there may be other factors playing into it. So this area is actually up for debate. So what do we do to counteract sleep loss? Well, some people suggest spanking sleep, and this is harder to do than, than we think. What does this mean? Well, if you know you're gonna go into shift work, if you know you'll be traveling to different countries abroad, in theory, in preparation before your trip or before your shift, we start taking naps during the day or start going to bed a little bit earlier, 1520 minutes. It's about what the brain can handle. We cannot will our brains to go to sleep an hour before. We just don't have that ability. If we did, daylight saving would be a lot easier, but we don't. And, uh, to schedule a naps whenever possible, so we're talking about short naps, 2030 minutes at a time. You could schedule multiple naps, which some people do, uh, as long as your schedule allows you to do that, but we also have other underlying traits to help us counteract the effects of sleep loss. So I know in my patient population, there are some people that are chronically getting 4 hours sleep, not that you should never had a traffic accident. However, there are those that were missing 2 hours of sleep, they can crash their cars. So there are a lot of variability in terms of how we tolerate sleep loss, but those that have better blood flow in the hemisphere of our brain, particularly the front towards the thigh area, they tend not to have this drowsy response, um, that along with a lot of adrenaline stored in the brain can be helpful to prevent traffic accidents. But not everyone has the same pattern. Now, the other part I'm gonna talk about quickly would be sleep disorders. So for those, it is true that, that not everyone who snores has sleep apnea or obstructive sleep apnea, breathing problem during sleep, but those that snore for a while loudly bothering their bed partners, bothering their partner mates, bothering their next door neighbor. You should see someone because something is blocking your airway and that's why it's so noisy when air is coming through. Those that can, that prefer not to sleep on the backs anymore because the tongue may be blocking your airway. So that's, those are symptoms of sleep apnea. Those that have really uncomfortable, twitchy legs during the day, those that keep needing to bounce them up and down, may have restless leg syndrome. It's a real thing. So they may need to be seen and get that treated. Um, and at least get evaluations for iron deficiency that may contribute to that. And we're not talking about leg jerks or twitches that happen when we, you know, sometimes fall asleep and the brain misfires. Those are called hypnotic jerks or sleep jerks. Those are completely benign, but the twitchiness that persists 1st 90 minutes, sometimes throughout the night, and enough to bother bed partner, then that may signify something called periodic leg movements of sleep. But more importantly, if you wake up tired, right, you just don't have energy, which is the fatigue and tiredness part, or sleepy, you want to crawl back into bed. Well, that's not a normal response, so if your sleep quality is not good, we should probably talk to someone about it. Um, persistent loud snoring is not normal, OK? So in the western countries very often we kind of accepted the fact that sleep is equating snoring sounds. No, they are not. Normal sleep is quiet. And the snoring in pregnancy for sure is not good, uh, proportionally about triple the percentage of women may snore during pregnancy the last trimester, but early on if they snore before they get pregnant, certainly not good, and particularly if they snore loudly within the first trimester, there is a higher risk of gestational. High blood pressure and diabetes, so that individual ought to talk to someone and get checked, um, because ultimately what happens is it's more likely to cause problem with the placental development and if the blood vessel is not developed correctly, it could affect the developing fetus or baby. So, um, that pregnant woman should get seen. Now, we're gonna go through some fun slides. Some of you might have seen it and then I'm gonna wrap it up. These are tip-offs that we don't think about that makes it just obstructive sleep apnea. So this is a nose, I know, but we're looking at this horizontal creasing. So this likely is someone that has allergy and was rubbing his or her nose in childhood or at least for quite a while to get this line. So, this person may have a breathing problem from nasal congestion. And if you do have this kind of anomaly, this is courtesy of an ENT surgeon, a colleague of mine, um, you all should have a picture and looking up your noses once in a while because if you have this kind of deformity when you inhale. And then it becomes normalized when you exhale, the valve inside the nose is collapsing. So you could be helped by using some of those nasal dilator gadgets, either rings or um a surgical grade steel to help open up your airway, and you may want to consult ENT surgeon down the line. Line to see if that you need to get this fixed. The reason being that this may also impair your exercise tolerance during the day. If every time you inhale and the side collapses, you rely on one side to do all your breathing and so when you do cardio type exercise, treadmill, elliptical, running or walking, you are not gonna get as much air through. Um, either we have this or someone in our family may have this. The lower jaw is smaller and backwards, so this already sets the tongue backwards. It really doesn't take a lot of effort for the tongue to block off the airway. So beware, particularly if this person has nasal congestion chronically, that likely this person is gonna have some sleep apnea where they stop breathing during the night or they intermittently wake up with a gas. Or choking sensation. This person has teeth grinding, also chipped the teeth in several different places, and these are worn out on the bottom, the incisors, they are like down to nubs here. So we don't often correlate grinding our teeth with sleep apnea, but anything that is indicating there's crowding, lack of space can sometimes cause problems. Because the tongue is not fitted well for that space, and therefore, uh, teeth lining may be a sign of obstructive sleep apnea as well. Stress certainly plays a role, but besides that, if this person tells you he or she snores, then there's a pretty high, uh, propensity. And if we are at rest breathing like this, I have seen people that have allergies with their tongue literally sticking out of their mouths. So, and they may have so-called open bites on the side where the teeth are not touching. So we do a pretty good oral exam, uh, to look for all these features that I'm pointing out. And um this is looking up at someone's heart palate in the front. There's crowding of the front teeth. The incisors are overlapping. This is almost triangular in terms of when, when it should be rounded, right? Our teeth already should be more rounded. And this is well, not quite Gothic arches, but it's very high arched hard palate, the bony portion here at the top of our jaws. So you can imagine the tongue is not gonna fit in this very narrow confined space. Then if the tongue goes back, it's gonna block off the airway in the back, um. This is not perhaps something that you look at, but we look at. So when we examine you, we're gonna put a tongue depressor somewhere around here and have you say ah. But first, we have you do it first and see how much space right in the back of the throat can we see. So it, this is normal, so there's adequate space that dangly parts called uvula, and I would even argue this is really too large. It should be about 2/3 the size. And so progressively, we have less and less space, and I bet you this is gonna be two tongue blade depressor person with a very, very strong gag, and even then I may not be able to see the opening in the back, but the higher the tongue position is, then the more likely um there's gonna be a problem with the airway. Um, for those of you that don't want to see the, it's too late, sorry, for those of you that don't want to see the anatomical slice in the back of your throat, uh, go away for 10 seconds and then, uh, you know, come on back, but I'm gonna show you in. Life subjects, what happens. So, number one is that there are teeth marks along the side of the tongue. They also have a fissure right here, uh, on both sides of the tongue. So teeth indentation could be a tip-off. 2, that uvula, the dangly part is way too fleshy. There's Too much of it. And then this person also has small uh tonsils. The next slide, I'm gonna show you giant tonsils again for those people that don't wish to see it go away for five seconds. So this is the tongue in the front. These are the giant tonsils in the back. This is the only opening the person has. So breathing could be very difficult, let alone this person can pass out because if there's any saliva or food getting caught, you can imagine the airway is completely blocked. OK, for those of you that went away, you can come back. Measuring sleepiness, we have a couple of scales and then I'll tie it up. One of which you might have been, uh, either you have been using in your practice for those are practitioners, um, for those that are patients, you, you will likely encounter one of these cause we give them out to you when you come to our clinic and mostly asking you what are the chances of you dozing off if you remain inactive. So, we have a version for children that are not driving, so we asked them what would happen if you're playing a video game. So it's such a dopamine, um, Latent thing that they are highly engaged. Usually, they should not have a high chance of dozing off. If they do, this kid needs to be seen. And then we have a stop bang for those that snore louder. It's very skewed towards men because it is a risk factor. We need better tools for women. Uh, we also use sleep diaries. It goes with flavor something like this. The patients filled it out about what time they go to sleep, uh, what time they're in bed, pardon me, what time they're actually sleeping, estimations about how long they were awake, whether they consume caffeine or not, or whether they they take naps, did they have alcohol, do they exercise? They're very different versions. This is American Academy of Sleep Medicine's version which I like. And we have patients fill them out. So for, for instance, this person went to bed about 10 good sleep hygiene, right? Except they don't fall asleep for about 2.5 hours. So that's 2.5 hours of struggling and not being able to go to sleep. So this probably was more of a night owl version, which is the reason they wake up for 1.5, 2 hours in the middle of the night and they had to compensate by drinking caffeine the next day. So it's very educational for myself as well as for the patient. We have all kinds of sleep trackers out there. Last piece I want to emphasize is family history. If you have not done so and you do have surviving relatives, please talk to them because there may be some kind of pattern that you're not aware of. We talk about all kinds of medical history, but what about your sleep history? Have there been relatives that sleep more than 9 hours? Are they snoring very loudly? Do they have any trouble with insomnia at night? Was it severe? Did they talk in their sleep, eat in their sleep, acting out dreams? Have they ever injured themselves? Do they have restless legs? Restless legs is familial. So, and they have a ton of leg movements that's, you know, days of the water bed used to bother everybody else. So all these are relevant things that you should know about your sleep history that would help us in the long term. So to get better sleep. Number one, you should understand what your internal clock wishes for you to do. Not what time you wanna go to sleep, but when you're on vacation with very little stressors, it's not one of those, you know, go, go, go vacations. What time does your internal clock want to go to sleep? Now, it could be 2 a.m. like the example I gave you, yet every night you're going to sleep at 10:00 or 11 or midnight. Well, I would just say you just increase your hours of frustration. It's not gonna help you go to sleep any sooner, not without medications, unfortunately. Um, have you always been a morning person, and now all of a sudden because your roommate is a night owl, you're kind of forced into their rhythm. Like I said, going to sleep later is always easier, but it depends on how much later, right? So if your roommate goes to sleep at 3, but you prefer to go to sleep at midnight, it ain't gonna work. And so you need to find out what your pattern is, but we cannot, no by what people tell you, you cannot make up for your sleep loss. We just can't. So that sleep that does get paid off, but your function is gonna be compromised, meaning that you're not optimizing your productivity. Uh, we think we are, but typically, uh, it's very hard to do. The things that are under our control, room temperature, sure, you don't want it to be too hot, you don't want it to be too cold, so the range could be anywhere. Some of my patients, they like it in the high 50s, low 60s. For me, that's a little bit too cold. So 65, 68 could be reasonable. For some people, they, they can't survive below 72 °F. So you're gonna find for you what the optimal temperature is gonna be and not perspire during the night. And then you negotiate with your bet partner or your family members. Sound and light optimization to a limit, yeah, but a common thing that we do when we put in earplugs is that we listen and see if they prevent all sounds. They don't. So that could be a hyperalert reaction that we have, like, oh my gosh, I can still hear that dog. Yes, you will. It's just gonna be muffled. So for these individuals that are very sound sensitive and, and adaptive sound machine. That can mask human speech, dog barks, and so forth, because human speech is actually the most annoying sound when you're trying to go to sleep besides dogs barking. So just because human speech has all kinds of dynamics, loudness levels, um, so it's very hard for sleep to occur when you're having insomnia, but a sound masking machine that I adaptive, meaning that the louder that person is, the more the sound tries to mask it, it's a little bit more helpful. It also helps people with tinnitus, by the way, which is another factor for insomnia. Uh, limiting screen time could be important because we know that, you know, too much blue light can also affect the secretion of melatonin. So we don't want to push away melatonin, and there is actually one study showing that even dim light overhead light, um, preventing the, those subjects that were in the laboratory compared to the peers that did not have a dim overhead light bulb in sleep. The group that had the light bulb had more disturbed sleep, and these are healthy individuals. So I think with that, I'm gonna end and try to answer some questions.
