[Congressional Record Volume 145, Number 153 (Wednesday, November 3, 1999)]
[Extensions of Remarks]
[Pages E2254-E2256]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
LACK OF SLEEP CAN KILL
______
HON. ZOE LOFGREN
of california
in the house of representatives
Wednesday, November 3, 1999
Ms. LOFGREN. Mr. Speaker, while physicians and patients now pay
attention to the
[[Page E2255]]
adverse health impacts of poor nutrition and inadequate exercise, too
few people pay attention to the harm that can result from inadequate
sleep.
Sleep scientists have linked such ailments as high blood pressure,
cardiovascular disease, and brain damage to inadequate sleep. We are
all aware that drivers who fall asleep at the wheel can kill; not
enough of us realize that inadequate sleep can cause severe physical
ailments. The article ``Can't Sleep,'' published in the summer 1998
edition of Stanford Today, outlines the severity of that threat. It
should be read by every physician and patient in America.
[From Stanford Today, July/Aug. 1998]
Can't Sleep--One of America's Leading Sleep Experts Reveals Shocking
Facts About Your Sleepless Nights
(By Chris Vaughan)
It was 1972, and the pediatricians at Stanford Hospital
were stumped. Raymond S., an 11-year-old boy with an array of
odd symptoms, had been referred to Stanford because his
doctors in the East Bay didn't know what to do. Raymond's
blood pressure was so dangerously--and inexplicably--high
that the 6th-grader was in danger of damage to his internal
organs. Because the boy was also pathologically sleepy during
the day, he was sent over to the Stanford Sleep Disorders
Clinic, the first and only one of its kind in the world then.
The clinic directors--Drs. William Dement and Christian
Guilleminault--diagnosed the boy's disorder as a condition
they had only recently named: sleep apnea. As Raymond slept,
he would literally stop breathing for anywhere between 30 and
60 seconds at a time, they found. Worse still, this would
happen hundreds of times each night. When the boy stopped
breathing, his brain would panic, interpreting his body's
action as suffocation. The result: His blood pressure shot
up, his heart pounded, and he awoke just enough to begin
breathing again, but still not enough to remember the
incident in the morning. Hence his excruciating daytime
drowsiness. Raymond was always sleepy because he was not
getting any real sleep at night.
None of the pediatricians consulted would buy the sleep
clinic's diagnosis. Raymond's condition grew worse. When the
boy started showing signs of heart and kidney failure, his
skeptical doctors finally allowed sleep clinic physicians to
cut a breathing hole in the boy's throat. The difference was
fast: The boy's blood pressure dropped and his overall
condition improved dramatically.
Dement would have counted this as a victory, except that
the boy's primary physicians still refused to acknowledge the
problem. After a few months, they wanted to close up the
hole. ``They still didn't understand that the hole was saving
his life,'' Dement said. Raymond kept the breathing hole and
Dement kept in touch with him for a few years. Eventually
Dement lost track of him, but he expects that current
practices must have allowed Raymond to have the hole closed
and to use alternate therapies.
Since then Americans have learned a lot more about the
importance of sleep and dangers of sleep disorders to the
nation's health. Since the discovery of Rapid Eye Movement
(REM) sleep 45 years ago, Dement, 69, has played a part in
nearly every major development in sleep research and has
attracted star students and researchers, and the money to
fund their work. Former Stanford students and fellows have
spread the gospel and started their own clinics and research
centers around the world. Before Congress and corporations,
and on national radio and television talk shows, Dement has
brought an unwavering message: ``Sleep disorders are killing
people, and yet they are tremendously under-diagnosed.''
In a report for the House Subcommittee on Health and
Environment last year, he declared that sleep disorders
represent one of the nation's most serious health problems,
and that the need for sleep research is virtually ignored.
The numbers are stunning. More than half of Americans have
suffered from a sleep disorder at some time, accordingly to a
survey ordered last year by the National Sleep Foundation in
Washington, D.C. Approximately 30 percent of adult Americans
suffer from moderate to severe sleep disorders, and less than
5 percent are diagnosed and treated. More than 18 million
people--7 percent of the population--stop breathing or
struggle for breath in their sleep more than five times every
hour. In the worst cases, sleepers stop breathing more than
30 times each hour, often for more than a minute. Under these
conditions the heart can stop beating for 10 or 15 seconds at
a time, and blood oxygen can drop to about one-fifth of
normal, equivalent to that of a climber at the summit of Mt.
Everest. Patients with such severe apnea can get
cardiovascular disease and brain damage.
One would think that such a prevalent and dangerous
disorder would receive a lot of attention and be treated
aggressively. Yet Dement says that when he used a computer to
scan 10 million coded patient records, he found a total of
only 72 patients who were diagnosed with apnea. ``I couldn't
believe it,'' Dement says. ``So I hired people to read over
11,000 written patient records.'' They found not one
diagnosed sleep problem.
Apnea is only one of many sleep problems that are
unrecognized or ignored. Sleep specialists estimate that
physicians detect only about 2 percent of all sleep
disorders, and most people have basic misconceptions about
the mechanics of their own sleep. Put it in another context
and the danger is clear. ``It's almost as if no one had every
heard of diabetes,'' Dement says. ``What if we didn't know
that the blindness, nerve damage and other health problems in
one part of the population were due to one treatable
disease?''
Hundreds of sleep-disorders sufferers have testified in
Congress for the National Commission on Sleep Disorders
Research about the shambles made of their lives from apnea,
narcolepsy (sudden attacks of sleep and paralysis), insomnia
and restless legs syndrome--an infuriatingly frustrating
syndrome in which people can't fall asleep because they must
constantly stretch their legs. Statistics from a study by the
government's National Transportation Safety Board show that
sleep deprivation contributes to approximately 72,000
accidents on the roadways each year. The total cost of drowsy
driving amounts to $12.4 million a year. The study also
established that sleep deprivation was a major cause of the
grounding of the Exxon Valdez oil tanker in Alaska.
Even without a diagnosis, many people are sleep deprived
and never know it. Over millions of years, our bodies have
evolved to awaken and to sleep with the rise and fall of the
sun. But the invention of electric lights has given us an
artificial sun and provided a basis for our busy 24-hour
society. As a result, people now get about 20 percent less
sleep than they did a century ago. No wonder we're sleepy. A
study by the National Sleep Foundation reveals that 64
percent of people in the United States sleep fewer than the
recommended 8 hours a night, while 32 percent sleep fewer
than 6 hours a night. Not surprisingly, sleep deprivation is
extremely high among the nation's college students.
Society has been slow to recognize sleep disorders because
of major misconceptions about what sleep exactly is. People
traditionally considered sleep a time when the body and brain
simply turned off. Physicians thought that nothing happened
in sleep; that sleep could not be a source of health
problems.
Overturning such scientific and popular misconceptions
about sleep has been a major activity for Dement, his
colleagues and students since the start of the era of modern
sleep research in 1953. In that year, University of Chicago
physiologist Nathaniel Kleitman and graduate student Eugene
Aserinsky discovered that the body and brain do not shut down
during sleep. Instead, they experience periods of rapid eye
movement. Dement joined Kleitman's lab shortly after and
helped demonstrate that intense brain activity and dreaming
accompanied these REM periods of the sleeper. After
completing his medical degree, Dement carried on his own
research at the Mount Sinai Medical Center in New York where
he took the next step, demonstrating that everyone has REM
sleep.
By the time Dement moved to Stanford in 1962, he was
working on a seemingly rare sort of epilepsy--called
narcolepsy--that caused people to feel weak in the knees,
collapse or fall instantly asleep when they laughed or got
otherwise excited. These narcoleptic patients could even find
themselves dreaming while awake, unable to tell which images
were real and which were dreams. Dement had come across only
five such patients in New York. But when he placed an
advertisement in the San Francisco Chronicle describing
narcolepsy's symptoms and asking for people to call if they
fit that description, he found 50 new patients.
In 1965, sleep apnea had been described in a few obese
patients by French researchers, but the discovery had been
practically ignored because no one realized that the disorder
could be so severe, or that slender people could suffer from
it. The disorder was called Pickwickian syndrome after ``Joe,
the fat boy,'' a lad in Dickens' The Pickwick Papers who
could fall asleep standing up.
Apnea occurs when the muscles relax during sleep, narrowing
the throat where the back of the tongue is anchored. As air
is pulled into the lungs, the suction collapses the throat
and halts breathing. 'When straws were made of paper, I used
to say it was like trying to suck a milkshake through a wet
straw,'' Dement says, laughing about his antiquated
illustration. ``Students now have grown up with plastic
straws, and they don't know what I'm talking about.''
If the air passage is almost closed off, breathing results
in loud snoring as the throat tissue vibrates. Loud snoring
(i.e., easily heard through a wall or closed door) is a
danger sign that someone has apnea or soon might get it.
Apnea is especially debilitating because it deprives the
sleeper of the most important phases of sleep--REM sleep and
deep non-REM sleep--when the muscles are most relaxed.
Although tracheostomy (a hole in the throat) used to be the
only treatment for apnea, there are now a number of
treatments, including surgery to trim throat tissue, and
machines that provide positive pressure in the airway to keep
it open during sleep. A new technique has just received
approval from the Food and Drug Administration: zapping the
throat with a carefully calibrated dose of microwaves to
painlessly shrink the tissue and open the airway.
Research at the Stanford Sleep Center eventually led to the
isolation of a gene for narcolepsy in dogs that experts
expect will help in the search for a human gene. In 1972,
sleep experts realized that when people complained about
being sleep during the day, it was their sleep that should be
examined. The
[[Page E2256]]
Stanford Sleep Clinic was opened to diagnose and treat sleep
problems.
Dement's terminology is probably his most famous
contribution to public awareness of sleep disorders.
``Gentlemen,'' he declared before a House committee in 1985,
``the national sleep debt is more important that the national
monetary debt.'' He estimates that sleep disorders cost the
economy $100 billion a year in lost productivity.
In the late 1970s, Dement and Stanford researcher Mary
Carskadon (now a professor at Brown University) discovered a
way to quantify sleepiness. They developed the multiple sleep
latency test, still the standard in the field, which proved
that sleepiness increased as sleep was curtailed. If they
were surprised to find that the body kept track of each hour
of sleep missed, they were astonished to realize that the
only way to pay back this ``sleep debt'' and alleviate
daytime sleepiness was to get exactly that many hours of
extra sleep on subsequent nights.
In addition, we are tremendously bad judges of our own
sleep debt's size. A study by Thomas Roth, director of the
Henry Ford Sleep Disorders Center at the Henry Ford Hospital
in Detroit, revealed that even among average people who are
pathologically drowsy, as sleepy as those with narcolepsy,
most do not think they have a problem with daytime
sleepiness.
Despite advances in the field Dement worries over the
inability of general practitioners to recognize and diagnose
sleep problems--even among those close to home. Dement tells
of a time when he became so frustrated by the lack of
referrals from Stanford doctors that he walked into a waiting
room at the hospital and offered people sitting there the
chance to get a free sleep test worth $1,000. Of the five who
accepted, three turned out to have apnea.
Although surveys show that the public is more aware of
sleep disorders, they are still tremendously under-diagnosed.
Dement is currently studying how primary care doctors
recognize and treat sleep disorders in small towns. He still
gets shocked by the results: Practically zero cases of apnea
were diagnosed by the physicians, although further
investigation has shown that one in five patients had apnea.
``I had one doctor who had 200 patients with apnea, and he
didn't even know it,'' says Dement with exasperation. ``There
are 200,000 more doctors like him out there.''
The most recent data are even more shocking: 80 percent of
those diagnosed with apnea in the survey town of Moscow,
Idaho, have a very severe form that usually leads to death
from heart attack or stroke within 10 years. ``I almost
couldn't believe the data myself, but it is solid,'' Dement
says.
``I don't like medical malpractice suits,'' Dement says
with anger, ``but some day, some smart lawyer is going to
realize all these people are dying because of an obvious, but
missed, diagnosis, and is going to make a fortune in wrongful
death cases. The signs are so obvious, a 6-year-old could
make a diagnosis.''
____
NOISY IS THE NIGHT
(By Lisa Sonne)
Hi, my name is Lisa, and I am married to an apneac.
Don't think I'm unhappy. Victor is a great guy--a Stanford
man, smart, funny, kind, a wonderful husband and friend . . .
and he did warn me. But for the first six months of our
marriage, we have been taking life ``one night at a time.''
Every evening, we settle in as newlyweds for our sweet
dreams. But then the snoring starts. In order to sleep, I
create Walter Mitty-like scenarios. My husband is Paul
Bunyan--with a power saw--and he's turning already-felled
trees into boards for Habitat for Humanity, or my husband is
a dentist with an intermittent drill helping the mouths of
needy children. I fall asleep with a smile on my face.
Then, his snoring stops with an eerie, breath-defying
silence, and I bolt awake in emergency mode with adrenaline
pumping. I watch helplessly as he begins his nightly ritual
of raspy gasping and groping for air with his whole chest
heaving. Just when I'm ready to shake him to make him
breathe, he inhales a huge gulp of air and goes back to
snoring. I lie there awake, waiting for the next frightening
silence.
Apneacs usually don't wake up enough to be cognizant of
their body's betrayal, but those sleeping next to them often
do. And both have been snatched away from deep rest and
finished dreams. I took Dr. Dement's ``Sleep and Dreams''
class years ago and remember the dangers of sleep deprivation
and REM robbery. In the battle against exhaustion, naps have
become acts of survival for us, not lazy indulgences or
luxuriant escapes.
Fortunately, my apneac is not in denial. He is tired of
being tired, and says he is ``willing to do anything to be
better in bed.'' Determined to move beyond apnea, Victor
endured laser surgery in the spring of 1997 to reduce soft
tissue in his palate that may have been obstructing his night
breathing. He then underwent three separate rounds with an
experimental procedure called somnoplasty. But in March 1998,
another sleep study revealed quantitatively that Victor's
apnea had gotten worse. One hundred eighty-four times during
the night, his breathing was obstructed enough to disrupt his
sleep and threaten the supply of oxygen to his brain. And his
was only a ``moderate'' case. My heart goes out to the apneac
and spouse of a ``serious'' case.
A series of doctors in New York recommended major surgery
to further reduce his soft palate, but their predictions for
success ranged from a high of 80 percent to a low of 50
percent. How can you decide what to do when your brain is
sleep impaired? I wonder if ``no rest for the weary'' was
coined by an apneac. I suggested that Victor try getting some
uninterrupted dream time with a CPAP machine. It uses
continuous positive airway pressure (CPAP) to force air into
your lungs through a face mask while you sleep. This was not
the paraphernalia we had imagined during the honeymoon phase
of our lives. But sometimes the route to ``good dreams''
takes a surprising turn.
For me, the CPAP machine's loud hum was a lullaby compared
to the usual snoring and gulping, but for my spouse, wearing
the mask ``is like standing up in a convertible going 80
miles an hour with your mouth open.'' Exhausted from the
apnea, he was able to fall asleep under the air assault, and
it worked--for a while. The continuing blast hurt his sinuses
and he would rip the mask off in his sleep. Clearly this was
not a long-term solution for us.
So, at last, in our quest for deep sleep, we came to
Stanford's renowned pioneer in sleep surgery, Dr. Nelson
Powell. He spent two hours with us, conducted tests, asked
and answered a wide range of questions. We learned that we
are part of an unrecognized epidemic. Powell thinks that
sleep disorders may be the cause of depression, impotence and
accidents for tens of thousands of people. And then there are
the spouses. He said motor response tests actually found the
spouse worse off than the apneac. Friends of mine started
sharing their nocturnal woes (years of spouses sleeping in
separate rooms) and diurnal daze (nap fantasies and chronic
exhaustion).
We're ready to end this nightmare. My husband is scheduled
for surgery at Stanford: Moving his tongue forward to enlarge
his airway may be the solution. He should be out of the
hospital in two days. Then, when we settle in for sweet
dreams--we may finally be able to finish them!
We look at it this way: We spend one-third of our lives
(eight of every 24 hours) sleeping . . . or trying to. We
hope to be married at least 45 years. That means 15 years of
our future will be spent in bed together. We don't want to
have to wait until we die to rest in peace.
LET SLEEPING DOGS LIE
Why do we sleep? Believe it or not, the question remains an
enigma. Part of the answer, though, may rest with a brood of
Dobermans at Stanford University. These dogs are generally
energetic and friendly, but if they get excited about special
food or a new toy they flop to the ground, completely
paralyzed. They suffer from narcolepsy. Their narcoleptic
attacks last just minutes, and then they rise as if nothing
had happened.
``A normal dog can eat a dish of food in a few minutes, but
it might take a narcoleptic dog an hour because he keeps
collapsing,'' says researcher Emmanuel Mignot. The dogs are
not hurt or suffering, merely afflicted by cataplexy, a
paralysis or muscle weakness that is part of the narcolepsy
syndrome. The dogs can fall asleep briefly during this
cataplectic attack, or they can remain conscious but unable
to move.
Narcolepsy is the only sleeping disorder known to arise
from a glitch in a primary sleep mechanism. By looking at the
disorder in dogs, scientists hope to discover how the brain
puts itself to sleep and what sleep does for the body in
humans with narcolepsy. Recently, Mignot isolated the gene
for nacolepsy--canarc-1--in these dogs and found that it is a
variant of a normal immunoglobin gene. Immunoglobins are
proteins that the immune system creates to scavenge invading
microbes. At this point, researchers don't know why an immune
gene causes sleep attacks. Mignot and colleagues speculate
that narcolepsy may be an autoimmune disorder, like lupus or
multiple sclerosis. But narcoleptic dogs and people lack
other signs that usually accompany autoimmune disorders.
A more tantalizing possibility is that normal sleep is
somehow related to the operation of the imune system.
Mignot and his colleagues are now using their work with the
dogs and other research to search for a human gene for
narcolepsy. Mignot feels he will have it soon, in six months
to two years, and hopes that the discovery will clarify what
causes narcolepsy and suggest a possible cure.
____________________