How to Sleep Better for Your Health – The Effects of Poor Sleep

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From foggy thinking to the impact on mood and physical health, interrupted sleep has consequences for your health. Kingman Strohl, MD, a specialist in sleep medicine, shares common causes – from stress to complex sleep disorders, and what you can do to get a better night’s sleep.

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Pete Kenworthy
Everybody needs sleep, right? Some people don’t need much, younger people need more. And while total sleep time is undoubtedly important, what happens when you don’t get enough sleep or worse, don’t get quality sleep? Uninterrupted sleep. There are definitely nights that I wake up two to three times throughout the night. What’s the impact on my brain performance, my mood, and my overall health?

Macie Jepson
And Pete, you know this. There was a time in my career before coming to UH that I never got more than four hours of sleep a night. And I’d take a nap and then I’d go back to sleep for four hours and then I’d go to work at one o’clock in the morning. And I thought, what in the world? I mean it really concerned me. I thought, what am I doing to my body? I gained weight. I wondered if I was increasing my chances of dementia. And what can I do to improve my sleep to reduce any potential risks? I think that’s the question that’s on a lot of people’s minds. Hi everybody, I’m Macie Jepson.

Pete Kenworthy
And I’m Pete Kenworthy, and this is The Science of Health. Joining us today is Dr. Kingman Strohl from University Hospitals in Cleveland. He’s the Program Director of Sleep Medicine. Thanks for being with us today.

Kingman Strohl, MD
Thank you.

Pete Kenworthy
We want to cover a lot of things today. The importance of continuous sleep. In other words, what are the benefits of that? What are the causes of interrupted sleep and the impact interrupted sleep can have on your health? So let’s start with a basic lesson on sleep. What happens when we fall asleep and go through non-REM and REM sleep?

Kingman Strohl, MD
The purpose of sleep and non-REM and REM sleep are really to go into stages of sleep that restore your brain. Non-REM sleep is a period in which you get rid of all your misfolded proteins that have been building up while you’re awake. And REM sleep is where you reset your personality and be able to kind of be yourself again. So you clean out the debris from your brain, the trash from your brain at a time in which it’s pretty quiet. Now, the concept of uninterrupted sleep or the concept of having sleep that doesn’t seem to be too chaotic is one that we sort of pretend that is important in our culture because other cultures can sleep two or three naps a day, two or three periods a day. So the idea is to get sufficient sleep so your brain flushes out the old proteins and makes your brain work again for your personality the next day so you feel refreshed.

Macie Jepson
Let’s talk about the importance of getting this type of sleep on our bodies, on our minds.

Kingman Strohl, MD
Well, the best evidence is the amount of sleep that people get in terms of longevity. Around six to seven hours of sleep at night is associated with the lowest long-term mortality in the population. More than that, and less than that is associated with higher mortality. Now, less sleep primarily through metabolic changes: glucose, diabetes and other metabolic disorders is probably the driver of that because then it brings you cardiovascular disease. Too much sleep we don’t understand very well, but it may be just a reflection of people who are ill and those people who have the slings and arrows of life that have them sleep longer. Depression is one of them.

Macie Jepson
If I’m understanding you correctly, you’re saying that it could be the reasons behind the less sleep that are causing the outcomes. It’s not the less sleep itself. Am I understanding that correctly?

Kingman Strohl, MD
Well, I think you have to be predisposed to having diabetes and a shorter sleep, it sort of doesn’t make your diabetes, but it may come on faster or with a greater type of intensity. And so weight gain will increase in our population, weight gain has increased in the United States according to the decrease really in total sleep time. We sleep one hour less than we did a hundred years ago. I don’t think we’ve changed biologically. I think that what has changed is our expectations for what we need to do to sleep.

Pete Kenworthy
Before we move on to the causes of interrupted sleep, I want to just clear one thing up. You talked about six to seven hours is kind of the optimal amount of sleep time, but you’re talking about for adults, right? I’ve always read that teenagers need say 12 hour sleep, right? And so at what stages of your life do you need more? And then when does that shift over to needing less?

Kingman Strohl, MD
So you remember the babies, they sleep 18 hours. And then you get to be, oh, say nine years of age, you probably need around 11 hours of sleep. And then when you get to be an adolescent, the ideal amount is about nine hours of sleep. And no one gets that. And then as you get to be an adult though, it’s still at that six to seven hours from age 20 up to age 80.

Macie Jepson
And the more sleep is required because the body and the brain are growing and developing. Is that the connection there?

Kingman Strohl, MD
Well, certainly when the baby is born, sleep is an important driver for cortical connections and for the sorts of what we call post-synaptic growth and differentiation that occurs at that time. Now, adolescent sleep is probably important because that’s when the other big pruning of your brain occurs in which the sorts of activation patterns that people develop are there. But we’re now starting to know that even in your 20s and 30s as your frontal lobe is developing to make judgment that that’s also an important time for sleep because sleep deprivation impairs judgment, impairs reaction time, impairs really your ability to learn things.

Pete Kenworthy
Alright, so here’s the loaded question for you because I know there’s a lot of answers here, but what are the causes of interrupted sleep?

Kingman Strohl, MD
So I think the first thing to think about is what is the interruption that you have? And waking up once a night and going back to sleep fairly quickly is not really an interruption. If it occurs frequently, you want to ask someone who’s watching you sleep. Do you do something unusual? Do you snort? Do you snore? Do you kick your legs? Do you get up and move around? Do you do things that are not really part of sleep? And you may not be aware of those things. So ask someone else. And then do an inventory of how you feel in the morning according to your amount of sleep that you had that previous night. And do it for a couple of weeks and figure out what your sleep needs are and how that is. That interrupted sleep may have a factor. Now, people have bad nights and have good days and people have good nights and have bad days, so it’s not as though it’s a one size fits all.

Pete Kenworthy
Let’s run through some of these possible causes of interrupted sleep. I just want to get your thoughts on all of them because I wrote down a number of things here. I have here that age could be an issue. Sleep fragmentation is often a problem for older adults. Is that true and why?

Kingman Strohl, MD
So the interesting thing about aging is that there is a study in the ‘80s in which they looked in 5,000 people in Seattle to find healthy people over the age of 80. They found 12. And in those 12 people their sleep was like a 30 year old. So what happens as you age is you have the slings and arrows of life. You have your other conditions that affect you. You have the other responsibilities you have. And in this day and age you also have insecurity that comes with both food and financial and social and those sorts of insecurity. And those particular things impact upon your ability to kind of be comfortable in sleep. Also, you forget how to go to sleep. You need to kind of get into sleep. You need to do something about it to be able to be active. Sleep comes to you. You don’t go to sleep. Sleep comes to you. And that’s really something that is important for people to know and learn early in life.

Macie Jepson
And you talked about diabetes being a health issue that could affect our sleep, but let’s talk a little bit more about issues like restless leg syndrome being a problem, having to get up and go to the bathroom in the middle of the night, cardiovascular issues. So health in general is related to our quality of sleep, right?

Kingman Strohl, MD
Right. Well, the two most common things that interrupt sleep are sleep apnea, which is snoring, and then restless leg syndrome. Restless leg syndrome is one in which a person has unusual or uncomfortable sensations in their legs or their arms with an urge to move them. The movement improves it and occurs as you’re going to sleep. And it’s not there in the morning. So it must be distinguished from things like neuropathy from diabetes. It must be differentiated from back pain, from congestive heart failure and other causes that could have sort of odd sensations in your legs. So that’s one of the major things that happens. I mean the major factor that I encounter with people is too much caffeine when they get older. That’s really a factor. Caffeine is our number two commodity in the world. Starbucks caffeine level is like 300 milligrams, where in the 1950s and ‘60s it was 200 milligrams in a cup of coffee. People drink it later. And when you’re young, your metabolism is such that you get rid of it within four hours, but as you get older, it takes eight hours, 10 hours to get rid of it. And anything that would lighten your sleep. Now, you could go to sleep, you’re very sleepy, but it can wake you up because you just don’t have that drive to stay asleep when you have caffeine.

Pete Kenworthy
Along with caffeine, another thing that I think about that impacts sleep is alcohol, right? And are they similar or are they kind of opposites in terms of impact on sleep?

Kingman Strohl, MD
Well, alcohol has an interesting duality in sleep. It can help you go to sleep because it is a sedative, but it also releases epinephrine in your brain, an alerting molecule. So as you get your sleep over with during that sleep cycle, it then can alert you and keep you up. And so people will find that if they drink before they go to bed, they might have shorter sleep. They’ll wake up saying, I feel pretty good, but that next day they will suffer from short sleep.

Pete Kenworthy
Or too much alcohol, they won’t say they wake up feeling pretty good.

Kingman Strohl, MD
Well, especially if they have sleep apnea, which causes more snoring and more sleep apnea as well as alcohol does.

Pete Kenworthy
Yeah. And let’s talk about that because you touched on apnea. What is that impact? Right, and apnea isn’t just snoring, right? There’s kind of different kinds of apnea?

Kingman Strohl, MD
Well, we put it into this particular area called sleep disordered breathing. That is as you go to sleep, it disturbs your breathing. And so it’s called sleep apnea. It’s not wake apnea. So the first thing is sleep. And unfortunately we can’t do much about that. And then the act of going to sleep changes your respiratory drive. You either can stop breathing altogether or if you decrease your drive, it’ll collapse your upper airway and you’ll snore or you’ll obstruct your airway so you can’t get air in. So those are the different types of apneas. And the severity is based really on the number of events you have per night and its effects on your blood pressure, your heart and your overall sense of well-being.

Macie Jepson
And a common scenario is you think you’re getting a good night’s sleep, but your partner knows better. So we find out that we’re not sleeping well. What are some symptoms that we should look for during the day that are related to that?

Kingman Strohl, MD
So I think the major distinction that lack of sleep gives you is sleepiness, not fatigue, sleepiness. That is a tendency to fall asleep. And if it’s severe enough, it’s fall asleep under circumstances in which you would normally be awake: driving an automobile, talking on a phone with a good close friend, being able to sit around. It’s not just sitting around passively and you fall asleep or watching TV as much as you’re actively sleeping. Now if you fell asleep listening to me, that would be passive, but if I fell asleep talking to you, that would be active.

Macie Jepson
That makes sense. Before we talk about the consequences of this, I want to talk about kids for just a minute and electronics, and adults for that matter and electronics. How much of that is an issue today?

Kingman Strohl, MD
Well, I think that people have not thought about what they need to do to go to sleep. And electronics has been that sort of replacement of what your mother probably did when you were young, which is read a book. Reading a book to sleep has the effect of actually narrowing your focus. You get interested in these paragraphs. You know you’re sleepy because you don’t remember what happened on the last paragraph and you’re able to put it down and go to sleep. Electronic devices, and especially television, are there to kind of get you excited about the advertisements, get you excited about the activity, get you excited about the dark corners that come around, whatever those things are. So I sometimes get into an interesting conundrum with people who use a lot of electronics and I sit there and say, do a book. How about history of Canada? And they all laugh and they say, they’ll put you asleep. I go, yeah, history of Canada or a sleeping pill, which one do you want? History of Canada is a lot more interesting and actually it’s our biggest neighbor, trading partner. History would be important and things of that sort. And Catherine the Great is also a good biography.

Macie Jepson
Well, you mentioned sleeping aids. So we have a solution. It’s in a gummy. It’s in a pill. My kids who are in their 20s have done that before, which is a little concerning for me. It seems like an easy fix, but is it?

Kingman Strohl, MD
Well, it is an easy fix. It’s probably too easy. But on the other hand, the things that they try to have you go to sleep, and if you go to the drug store, you’ll find all sorts of things. I think people don’t do an inventory of how much sleep they’re doing, what they’re doing before sleep. Compared to nutrition and exercise, there is no elementary school or even college education about sleep. And so even physicians come to the patient who complains about sleep with that same lack of kind of basic knowledge that if you’re sleepy, you’re not getting enough sleep. It’s not because of X, Y, Z. And then if you complain that you can’t get enough sleep, the answer could be a pill. And I think that the pill is there and is useful, especially for short-term periods of insomnia and bereavement or stress or post-traumatic stress disorders or in those things that are there in which a sleep period can improve those or mitigate those outcomes.

On the other hand, chronic use of sleeping pills I think needs to be reevaluated. Certainly there are certain people that have, I don’t want to really say imbalance in their neurotransmitters, but they… manic depressive… need medications which will even out their mood swings. And so you have to take a history about what the sleep is. You have to know what the person’s psychiatric history is, psychological history, what their circumstances are, what their stresses are, and be able to understand what the impediment is to having a sleep plan. What’s your plan for sleep? Is it just take off your clothes and go to bed? That’s probably not a good plan. It’s not a good plan for your kids.

Pete Kenworthy
Let’s expand on the gummies a little bit because Macie was talking about melatonin, but there’s other things that people consider gummies or things that they take. Can you go through some of those?

Kingman Strohl, MD
The background of that, in any test of a sleeping pill, the placebo group also sleeps very much better. So if you’re taking something before you go to bed that makes you think you’re going to sleep, you’re going to sleep better. And now we have just everything available in gummies. We have THC, we have melatonin, we’ll have probably tryptophan, we’ll have other nutraceuticals, which we call them, which you’ll find over the counter in your store, in your drugstore on a big shelf. And they’ll be an eye level to make you think, oh, this’ll get you to sleep, particularly if they can hook you to say, oh, I’m not sleeping well, but don’t think about why.

Pete Kenworthy
What’s the danger of that?

Kingman Strohl, MD
Well, I think you become reliant on that. I mean, people come to me as a sleep doc. Now, they don’t come to me for the initial drug. They just come to me after they’ve tried everything. And they come to me and they say, you must have the secret sauce. And I say, my secret sauce is I’d like to see how you would sleep and wake on a desert island without medication. And they go, what? They go, I say, I don’t know if you actually need that. So I will to get them off of those and get it into what is shown to have a durable effect on insomnia called cognitive behavioral interventions. And those are about a six week, seven week cycle of asking questions, having people examine their sleep, having people do practicing things like sleep restriction to see if they could sleep better, have people practice not using coffee and get to a point in which they can sleep better like you would with an athlete to train to do something for a sport. And you would sit there and say, but this is not a sport. Sleep’s not a sport; it’s a necessity.

Pete Kenworthy
But what you’re not telling me is, is there any danger? Right? So if you’re not telling me I can take melatonin every night, I can take THC every night, I can take tryptophan every night, what’s the danger of that if that helps me sleep?

Kingman Strohl, MD
So the science is mainly for the molecular things or in test tubes and not necessarily in people, but it does say that high dose of melatonin will disturb your immune system. I don’t know if that happens. I don’t know if that happens. I know that sleeping medications that are prescribed, that the major thing in older people is that they get up in the middle of the night and they fall and they break their hip. And so you have to figure out if that particular medication is worth that risk. Now, in between is it’s a $400 million industry. And if you’re paying, I don’t know, $30, $40 a month for something that may or may not work because you think it will help you in terms of your ability to sleep, but you don’t think that it might be that you have tests coming up, it might not be that you might lose your job, it might be those sorts of things, you just sort of have to rethink what those are. And that’s where they talk about the education about sleep earlier on in life. So people can fall back and do an inventory of their sleep, ask other people how they’re doing and not feel funny about it. And ask your physician about it. And if they don’t really seem to know, they’re really at the same level of education often as people walking around the street.

Pete Kenworthy
Alright. Let’s get into the risks of interrupted sleep. What are those?

Kingman Strohl, MD
So the interrupted sleep risk is it can change your glucose in the morning so it can be higher and your insulin levels are higher and give you metabolic problems. But the other thing of interrupted sleep is that you’ll be sleepy the next day. And the major cause of car accidents that’s a medical cause is obstructive sleep apnea because people fall asleep at the wheel.

Macie Jepson
And I would think less productive during the day, which can affect your job. It just kind of goes on and on.

Kingman Strohl, MD
Well, I think the sleepiness that’s there, people, there’s called presenteeism that is you’re at your job but you’re not really working at your highest level. Both insomnia as well as sleep apnea as well as restless legs is accompanied by greater absenteeism as well as what they call presenteeism.

Pete Kenworthy
I have a list of things here that I wrote down as potential risks of interrupted sleep. So I kind of want to go through those, too, and get your answers on the impact on those. And the first one on this list is neurodegenerative disease like dementia and Parkinson’s. Is there science to back that up?

Kingman Strohl, MD
Yeah, there’s some ideas that you, but the chicken and the egg. It may be that the neurodegenerative disease changes your sleep/wake mechanisms and does so at an earlier point in time than you would expect and that that might be the first sign. Now, does getting more sleep help? Well, the recent work shows that if you’re able to have better sleep at a given level of dementia, that you have less plaques in your brain and that there is a system in your brain called glymphatics which clears out the junk and that doesn’t work as well in Alzheimer’s and it doesn’t work as well with interrupted sleep.

Pete Kenworthy
What about mental health disorders like depression?

Kingman Strohl, MD
Well, depression, part of its diagnostic term is sleep problems. Now if you have insomnia, you are at four to fivefold higher risk for developing depression. Medical students who have insomnia 40 years later are at higher risk of having depression and suicide. So it is something that you sort of think about as a risk factor for that. And we’re very interested in our research here on the relationship between insomnia and suicidality as well.

Pete Kenworthy
Cardiovascular disease.

Kingman Strohl, MD
So I think the problems with sleep, I think of it this way. BAS doesn’t make the water skis; it makes the water skis go faster. So sleep disorders don’t give you the heart disease or the arrhythmias, but it may come on at an earlier age or with greater severity.

Pete Kenworthy
Obesity, immunodeficiency, diabetes.

Kingman Strohl, MD
Well, obesity is the easy one because we talk about snoring and obesity being fairly well associated, but in the 40 to 55 year old group, only half of the people who have severe sleep apnea are obese. So it’s not as though it’s the only thing. And remember, you’re equally obese when you’re awake as when you’re asleep. And it’s still called sleep apnea here. Now, immunodeficiency, that’s an interesting area. It’s not very well understood. There is some relationship to, experimental relationship that if you shorten a person’s sleep that they don’t respond as well to a vaccine. And there are some large statistical studies that show that your antibody level is higher if you have your vaccine in the morning than you have it in the afternoon. But what that individual impact is not very well understood. And your last point was?

Pete Kenworthy
Diabetes, which you touched on a little bit. The chicken and egg, right?

Kingman Strohl, MD
Well, it is, but it’s also, we have a nursing group here in the school of nursing that’s really focused on Type 1 diabetes, which really starts in adolescence. And the management of those of type one diabetes is linked to circadian rhythm and sleep and sleep length. And that’s a challenge because the adolescents are just learning how to take on their own responsibility for their care. And if they don’t understand that relationship or their doctors don’t understand that relationship, it could be a crucial part of their management.

Pete Kenworthy
Is there an increased risk of cancer from sleep issues?

Kingman Strohl, MD
The same studies that showed what an optimal amount of sleep would be also said that in the higher rates of death, in longer sleep or in shorter sleep, that cancer was a factor. Now it could be that sleep interruption or sleep apnea with its hypoxemia fuels that particular relationship. There is some interest now that the fitness and losing weight after a diagnosis of breast cancer is important because it can delay or even stop the occurrence of a second cancer. And so those particular interventions are now being looked at on a practical level for patients.

Pete Kenworthy
I have one more for you. Can you develop a higher sensitivity to pain due to interrupted sleep?

Kingman Strohl, MD
Well, the anecdotal evidence that if you sleep well, that your pain for a particular problem is much less. And the clearest example is sleep apnea in which you take a person with sleep apnea that has osteoarthritis, you treat their sleep apnea, they’re sleeping better, they’re more refreshed during the day and their pain levels, their medication levels can be reduced.

Macie Jepson
One thing that really sticks out in my mind when you were talking about supplements is the issue with we as Americans. We want instant gratification. We want a quick fix. We don’t want to do a six week program. We want to take a melatonin and take the easy way out. That’s where we are in America. At what point though, Doctor, do you really need to get yourself in to see someone and maybe spend some time in a sleep lab? How do you know when you need to walk away from the easy fix and get to the solution?

Kingman Strohl, MD
So most people ask their mothers, their fathers, their friends about what their problems are and there’s where they get the idea that you should take a supplement or not. A lot of people don’t like to talk to their doctor for two reasons. One is that they kind of like are embarrassed that they snore and they don’t want to really talk about that particular problem or they don’t think. And the other is that the doctor when he hears that may not have the tools or the experience or the knowledge to sort of see what is the next step. And I think this inventory of your sleep, asking people how you’re sleeping when you are the snorer and they are the snore-ee, that is the person who’s hearing them, and are they making snorts and having pauses during sleep. Those particular things are important to kind of package and know about and understand its impact on you.

Most of the treatments of interrupted sleep that improve sleep, improve the quality of life, and they do so in a very kind of subtle way. And some people will just, for some people it’s dramatic. Some people, it’s just very subtle that I can now finish a painting that I had never been able to finish a painting before in the next day. And that they’re paying attention to their family. They’re not falling asleep at a meeting, they’re not falling asleep in those particular ways. And so what we take as being normal that is falling asleep during the day really means you’re sleepy. And for people to understand why you’re sleepy, you need to know how much sleep you’re having and what the quality of that sleep is from the outside. And quality is a hard question. It’s not like doing an automobile. It’s really trying to say what are you doing on a regular basis? And if it goes on for three months or more, I think you talk to your physician. Now, they may say, try this, try that and check again, but don’t forget it.

Pete Kenworthy
You say, try this, try that. Right?

Kingman Strohl, MD
Weight loss, fitness, getting better nutrition, avoiding alcohol. I mean, these are the sorts of things that they will look for, which are your risk factors for having sleep problems, which in your case might be those factors in which you gain enjoyment when you’re awake, that’s affecting your sleep.

Pete Kenworthy
But then, yeah, that’s great because that’s what I was going to ask you is what are those high level things people can try, right? And obviously the cause of that interrupted sleep comes into play here, but those things you just rattled off are good first steps, right?

Kingman Strohl, MD
Well, I think in some ways you forget what are those habits that made you feel as though when you were 18 to 22, it was the best sleep of your life. You were very active during the day. You were physically active, you were mentally active, you probably didn’t have too much money to drink alcohol, you weren’t too overweight. And when you hit the bed, you went to sleep. Now that’s another sign. If you are hitting the pillow and sleep before you even think you are, you’re probably too sleepy. You should stretch out your sleep a little bit.

Pete Kenworthy
Before we wrap up, can we touch a little bit? You mentioned that, and Macie touched on the six week, the six week therapy, you talked about cognitive behavioral therapy.

Kingman Strohl, MD
Cognitive behavioral therapy, yeah.

Pete Kenworthy
What is that and when is it time to resort to that?

Kingman Strohl, MD
So we have this sleep hygiene idea you can find in the internet, you can have all this list of things that go on. It’s a terrible term because it sounds like teeth hygiene. It sounds like, to keep yourself clean or things of that sort. But it’s really what we were talking about is are you ready to go to sleep when you’re going to go to sleep? Are you having enough time in bed to be able to sleep? Are you having enough focus on why is it important to sleep in terms of alcohol, exercise, other things in life? And cognitive behavioral therapy really sort of tries to unpack all those separate things. And they do it as a coach. Now, it’s hard to read something on the internet called sleep hygiene and do it to yourself because you’ll try it for one night and say it doesn’t work. But a coach will sit there and say, I want you to do this for seven nights, and for the first three or four nights you’re going to have terrible sleep. And you go, why? That’s because I’m going to have you sleep only five hours of sleep a night and you’re going to do it for four nights and you’re going to feel so sleepy that you’re going to enjoy sleeping and enjoy sleeping throughout the night. Now, that discipline comes from a coach. It doesn’t necessarily come from a book.

Macie Jepson
And where do you find a coach? Would that be through your…

Kingman Strohl, MD
So the psychology, there is our board certified behavioral psychologists for behavioral sleep, and there are people available in most academic medical centers that have sleep disorder centers.

Pete Kenworthy
Who needs that?

Kingman Strohl, MD
Well, I think when people come to their physician and then get referred for insomnia, we break down all these issues, that is the first thing we do is we give people a sleep diary. And that is they keep track when they go to bed, when they wake up, how often they’re doing it. And we say, come back in two weeks. Now, those people that don’t come back in two weeks, they’re not going to be cognitive behavioral therapy people, right? You give them back and forth. They’re just not ready to make that change. Are you ready to kind of think those change? Now, sleep apnea, you have to make sure they don’t have sleep apnea. You have to make sure they don’t have restless legs. You want to make sure that they’re having odd behaviors at night called parasomnias in which they’re doing things. And you want to make sure that they aren’t taking a medication or they aren’t taking habits like smoking and alcohol. You have to put that into the equation to see what freight can they throw overboard to improve their sleep and then get to a point to refer them for cognitive behavioral therapy. The advantage of cognitive behavioral therapy is when you stop it, you have that learning that continues. The problem with a pill is you stop the pill, you get your insomnia back. So it’s really the expectations of what you do.

Macie Jepson
A long-term approach. Doctor, as we wrap up, is there anything you’d like to add that would just kind of put a bow on this as a piece of advice for someone who has trouble sleeping or has a partner who does?

Kingman Strohl, MD
Well, I think we’ve talked about many of the issues here and the recognition and other things that might inhibit recognition, that is that you think that falling asleep in the middle of a meeting is normal, that you think that you normalize sort of the things that you’ve done mainly because you’ve been doing it for a while and you don’t realize the stress that’s going on. I think taking an inventory and how to take an inventory of your sleep and your sleep/wake, when do you sleep? How do you sleep? We haven’t talked about shift workers. That’s a tough, tough row. The nurses are doing third shifts, second shifts, all those things. And you have to kind of realize that there may be things that you can do and then there may be things that you really can’t do yourself. And treatment of sleep apnea might be one of those.

Pete Kenworthy
Dr. Kingman Strohl from University Hospitals in Cleveland, thank you so much for joining us today.

Kingman Strohl, MD
Thank you.