[Congressional Record (Bound Edition), Volume 145 (1999), Part 19]
[Extensions of Remarks]
[Pages 28306-28308]
[From the U.S. 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 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

[[Page 28307]]

     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 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

[[Page 28308]]

     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.

     

                          ____________________