Managing Sleep Problems after Transplant

Presented by Eric Zhou PhD, Dana–Farber Cancer Institute

41 minute presentation followed by 10 minutes of Q&A

Summary:

Getting enough sleep after transplant is vitally important, but often hard to do. Inadequate sleep can have a negative impact on your health long-term. Understanding your sleep pattern is the first step toward getting a handle on sleep problems.

Highlights:

• Insomnia is a frequent problem after a bone marrow, stem cell or cord blood transplant.
• Prescription and over-the-counter medicines commonly prescribed by physicians, such as hypnotic sleep medicines or melatonin, are not the only, and may not be the safest remedy.
• Cognitive behavioral therapy can help resolve some sleep problems without the use of medications.

Key Points:

05:00  Insomnia - difficulty falling or staying asleep - is common among stem cell transplant survivors

07:54  Don't ignore or 'get used to' sleep problems; poor sleep can cause serious health problems

17:32:  It's important to tell your doctor if you think you have a sleep disorder.  Most cancer centers in the U.S. do not automatically screen patients for sleep problems

18:40  Doctors often prescribe hypnotic drugs for sleep problems, but are they safe?

21:50  What's really in that bottle of melatonin that you're using to help you sleep?

24:15  The American College of Physicians recommends that patients with insomnia get cognitive behavioral therapy (CBT)

29:29  In order to address your sleep problems, you first need to create a sleep diary to understand what your sleep looks like

31:18  It's important to train your body wake up at the same time every day, including weekends and holidays

39:19  How to find a sleep specialist

39:55  Books, videos and web sites that can help you correct your sleep problems.

Transcript of Presentation:

00:00  Introduction:  It is a pleasure to be here to talk to you about sleep. I complained last year when I had to do this that I think I got a crappy time because it was early. And now I'm going to complain this is a crappy time because this is the lull in your circadian rhythm when you're ready to nap. And that's normal right now to want to nap. If you take a nap now, I will not be offended, because this is what I do.

00:23  Why sleep problems occur and what you can do about them:  So, as I was kindly introduced, we get to talk about sleep, and I recognize that we unfortunately only have about 45 minutes to  talk about sleep, which is certainly not enough of a breadth to be able to talk about everything to do with sleep. I want to focus on probably the most common things that I get asked in clinical practice. And I want you guys to leave here with some specific things that I think you will want to do when you're at home, in the future, because the goal is to enable you to not only understand why sleep problems develop, but also what you can do when they occur in the future. I was just saying that I assure everybody here that you will have a bad night of sleep at some point in your life. Even if you are a good sleeper now, and you're sitting next to your wife or husband who's a bad sleeper, you, the good sleeper will have a bad night at some point. And, so, the goal is to give you that toolkit to think about what to do next.

01:22  Sleep is Vitally Important: Now, I'm not going to pitch this too long because we all understand that sleep is vitally important. Between birth and the average life expectancy for the American male or female, you literally spend about a third of your life sleeping. And I just want you to think about how much gosh darn time you spend asleep. That's a lot of your life you spend with your eyes closed in bed, or on the Lazy Boy. And if you're not doing a third of your life the right way, there's consequences and there should be.

01:54  There are many different types of sleep disorders, and even physicians, unless they specialize in sleep medicine, are often not familiar them and how to treat them: So this is my gospel, or Bible, it's the International Classification of Sleep Disorders, it's a really boring, dry textbook that you should never read. However, what I want to highlight, though, is there are so many different sleep disorders. People are not generally aware of this, and by people I don't mean you, I mean oftentimes your primary care physician, or your hem-onc physician, or other people that you work with, simply because this is not what they've done their entire careers. And some of these sleep disorders are fairly rare, so it certainly isn't something that they've got on their radar.  I want you guys to be your best advocate.

We're not going to talk about all these, I'm going to focus on one, which is insomnia, because this is one that's most common. But if you have questions about symptoms that may look like some of the other sleep disorders, I'm happy to talk with you guys about it after the fact.

02:51  There is no one “normal” sleep patterns that is appropriate for everyone:  Now, in terms of sleep patterns, think about where you might lie. If we look at this up here, we've got noon all the way to left, midnight down in the middle, and then noon again, right, the 24-hour clock, we all can see that. And so if, we'll say, somebody is a good sleeper that you hate — you know, the person who goes to bed, closes their eyes, falls asleep right away, wakes up six, seven, eight, nine, 10 hours later and as happy as a clam — let's just say this is their sleep, okay? It's a solid core block. And maybe they go to bed before midnight, they wake up around 6:30, 7:00 in the morning, they wake up bright eyed, bushy tailed. That's the good sleeper, right?

This is what I like to — I used to live in Miami— what I like to call the Miami or West Palm Beach style sleep. It's where all the retirees, how they sleep. This is advanced stage sleep, which means somebody’s asleep, it's still continuous, it looks good, it's about the length that they need, but it's pushed earlier in the day. So, they're going to bed at like 6:00 pm, 7: 00 pm, and they're sleeping until maybe 4:00 a.m. at the best. This is considered a sleep disorder. However, for particularly those who are older, it's very normative, which means I see a lot of patients who come in and say, ‘Eric, this is what my sleep looks like, you need to fix it.’ And I say, ‘Well, it's actually okay.’ So, this could be you as well.

This is what I call teenager syndrome. And again, this is not delayed sleep phase, but it's also normal. That's why they have all these questions about delaying high school start times. So, teenagers want to sleep later, but that's also physiologically okay. So, this stuff I don't worry about unless that teenager doesn't go to school, for example.  But the idea here is just because you're sleeping different, doesn't mean your sleeping poorly. So, we understand that.

05:00  Insomnia —difficulty falling or staying asleep — is common among stem cell transplant survivors:  This is what I think about for insomnia. This is somebody who wants to sleep, where the red bars are, but because of health issues, be it physical, psychological, whatever the case might be, they're catching a nap in the afternoon, and then take some time to fall asleep, and they wake up a couple of times in the middle of evening and they can't get back to sleep when they want to. This is what I see a lot post-transplant, and we're going to talk about this today.

Now, insomnia, as I define it, which is difficulty with falling asleep or staying asleep. And this causes you to have some daytime consequence, which means you don't feel good during the day, right? It's really, really common no matter where you look at it. So, this is not just an American thing, this is a worldwide problem. So, whether we define it as just having a couple of symptoms, or you're actually meeting the full blown diagnostic threshold for qualifying you for your physician to diagnose you with insomnia disorder, it's high.

So you look at studies in Canada, just having symptoms, about one in every three Canadians have symptoms. To meet the diagnostic criteria, it's about one in 10. In Norway, similar rates. In Great Britain, in France, and in the United States it is pretty much where I say about one in every three people, around the world, but I'm thinking here in the states, are going to have a sleep issue.

Now you're here thinking about sleep, so this is not a great example. But if you guys were out there having dinner, and you're at a restaurant, and you're sitting at the bar and you look to the left and you look to the right, one of you three is likely statistically to have a sleep problem, that's how common it is. And to really drive home how much an issue this is, this is literally every single person along the eastern seaboard in the United States, if you put them all there, all of these people would have a sleep problem, that's about a third of the population in the states. That's how huge of an epidemic it is, so I'm really glad that we're here talking about it.

07:03  Many things compete for our sleep time:  Now, this is a huge issue particularly in 2018. This was last year in April, anybody here have a Netflix account? I was going to say if you don't, where have you been living for 15 years? Or not 15, five years. This was a Tweet that was sent out from the official Netflix account. Why do you think they say sleep is my greatest enemy? That's exactly it. So, the CEO of Netflix® is this handsome fellow named Reed Hastings, and he said in an interview, ‘You know, think about it, when you watch a show from Netflix® and you get addicted to it, you stay up late at night. We're competing with sleep.’ They recognize that their competition is not Hulu® or Amazon Prime Video®, it's your sleep. And that's important for us to recognize, because we have so many things that compete with our time and our ability to sleep now.

07:54  Don’t ignore or ‘get used to’ sleep problems; poor sleep can cause serious health problems:  This is where I'm hopefully going to get serious for some of you who may not be aware of just how much it matters if you do not sleep. All right? So, this is looking at epidemiological research and smaller experimental research. When I say epidemiological, I mean they're following groups of men and women— 10, 20, 30, 50, 60, 70,00 — to be able to study what consequences are of things that you do. So when you turn on the news and you see CNN, or Fox News, or read the New York Times, or the Post, and you see an article that says, ‘Drinking one coffee in the morning makes it more likely you'll have improved cognitive function later in life,’ stuff like that, right? These are the kind of studies that they do to answer these questions.

And when you look at all of the data, for people who don't sleep enough, for people who sleep poorly, this is the list of things that happen. Now I want you to think about this. Are there any items on here that are a little bit of a surprise for you, or did you all know everything on this list, and say, ‘Yup, I knew that, if I don't sleep well long enough this is coming down the pipeline for me.’ You knew all of it? Anything surprised you? What's that? Yeah, you're more likely to commit suicide or attempt suicide if you are not sleeping consistently. So, the peak of when suicide attempts occur is in that witching hour, or hours between, I believe, around 2:00 and 5:00 a.m. Usually when people aren't sleeping.

So, it's really, really impactful, and this is the point I want to drive home to everybody: so many people think, ‘Oh, it's just bad sleep, I've gotten used to it, I've lived like this for so long.’ Well, yeah, you may have gotten used to it, but it doesn't make it okay. Especially because that bad sleep literally gets under your skin to change health outcomes that matter.

10:10  Study of long-term health effects on women with breast cancer:  Now, I want to think about the world of cancer, because they haven't done great research just following folks who've had transplant for reasons other than a blood cancer. But for folks who may have a blood cancer, this is something I want you to be aware of:  So they followed a group of women with breast cancer — we've probably all known somebody who's been touched by breast cancer — and so they followed these women, they gave them a fancy version of a Fit Bit— it's a research version of a Fit Bit, that tracked their sleep. So it told them how their sleep was. And then they followed them for almost 10 years. And they wanted to see, after they tracked their sleep, how long did they live? The blue bar represents people who slept well. We can talk after about what I meant by well. But it's a very clinical definition. The red bar defined people in the group they studied who slept poorly. Now, you don't have to be a mathematician here, if you look at this, which bar do you want to be a part of? We all want to be a part of that blue curve.

11:27  Improvement in sleep can prolong life: So, they actually said in their paper that their data, and I'm sorry if you can't read this, I'll read it out to you, that their data suggests that an improvement in sleep efficiency— which is how they divided people for who are good and bad sleepers, and so we're all on the page, sleep efficiency is a really simple mathematical ratio we can all do; it's the amount of time that you spend sleeping divided by the time that you spend in bed. So if you're in bed tossing and turning two hours every night, and you're in bed for eight hours, you've only slept six hours, right? Six divided by eight is 75%. That's your sleep efficiency, simple as that. They said that if you improve that number by 10%, among women who had a sleep efficiency of less than 85, which is what we consider bad sleep, you could increase your viable rate by 32% in time. That's insane. What I tell all of my friends who are oncologists is if you found a drug that improved a breast cancer patient's survival by 32%, you would be on the cover of Time, and you would be the richest person in the city of Boston. And Bob Craft lives in Boston. You guys aren't Patriots fans, huh? He owns the Patriots. But it's insane how much sleep matters.

12:53  How much sleep people need varies, depending on the person:  So, I hope I've convinced you that sleep is something we need to take very seriously. Now we get to talk about the fun stuff, which is, actually, how we're going to think about this. I was going to ask everybody, how much sleep do you think you need? Pretend you didn't see anything.

Audience member:  You mean in general, or me specifically?

Dr. Zhou:  You specifically, I don't care about her. Just kidding.

Audience member:  For me, nine.

Dr. Zhou:  For you, nine. Anybody else? How much sleep do you think you need, and then I'm going to ask you a question about why you think that. So, shout out numbers that you think is the amount of hours of sleep you think you need to feel good.

Audience member:         Six.

Dr. Zhou:  You're a short sleeper.

Audience member:  Per night?

Dr. Zhou:  Per night.

Audience member:  Six.

Dr. Zhou:  I'm curious, where did you get that number from? I'm glad that I've heard your experience, we need to get to work now, we're going to get you more sleep. But the reality is, is so many people ... so we have a furniture chain in New England called Jordan's Furniture, and they talk a lot about sleeping eight hours. That's in the media a lot, and that's a number that we hear tossed about a lot, that you need to sleep something like eight hours, and that's simply, unfortunately, not true. I think about this chart right here that we actually, in terms of how much sleep we need, we evolve over time.

Now, for those of you who have kids, when you take your child, or when you did take your child to the pediatrician, the pediatrician, at every visit, weighed your son or daughter and measured his or her height, right? And then they plotted them on that growth chart and said, ‘you know, they're in the 58th percentile for this’, and whatever, right? Did they ever, if your child was in the 59th percentile for height, say, ‘We need to start chopping off their legs. They need to be right at 50.’?

No, that seems crazy, right? But when it comes to sleep, I want you to think about that in the same way; that we, actually, as adults here, have very individual needs for sleep. And that range is incredibly big. So, if everyone in here—between 26 and 65 plus, give or take—your range is between five and 10 hours. That's a massive range there. And that range doesn't even include outliers. Which means that there are people out there who are, say, 65, who might need 11 hours of sleep. And that's still okay. So, understanding that you get to figure this out, I think of this as everybody really is a snowflake when it comes to your sleep.

15:46  The amount of sleep you need changes over time:  However, for everyone here who said that they figured out how much sleep they need, I'm going to challenge you, because that sleep need changes over time. And there's no magical way of figuring out when it's going to change. It's like suddenly as you get older, for example. Didn't you just wake up one day and your back started to hurt and just never stopped? It was weird, right, you didn't do anything the day before, it just started. Well sleep is like that too. Sometimes you just wake up and you need more sleep, or you need less sleep and there's rhyme or reason. It happens. So whatever number you thought, I'm going to challenge you. because I want you guys to go from here and collect data to understand for yourselves what your need is. And there's a reason that's important. Okay?

16:33  Expectations color how well you feel you slept:  Now, I'm going to give you two students. One student always gets As, super star, works hard all the time. The other student barely gets Ds. All right? Two kids. If student A, the first one, gets all As, gets 90% on a test, and that's below his average, how do you think he feels? Disappointed, right? What about the student who usually gets 50s and then gets a 90% on the test, how does he feel? Spectacular, right? Same results, the only difference is your expectation.

When it comes to sleep, it [expectation] plays such a huge role. When we wake up in the morning, if we tell ourselves, ‘I needed 10 and only got nine and a half’, no matter how you really feel, your expectation colors how that day looks. So that's why I say it's important that we all get to figure this out, I'm going to show you guys how.

17:32  It’s important to tell your doctor if you think you have a sleep disorder; most comprehensive cancer centers in the U.S. do not automatically screen for sleep problems:  Now, I want you guys to be aware that this is something, if you truly believe when you leave here you have a sleep issue, you need to tell your doctors. Absolutely. They did a really, cool study out in Germany. They followed 10, 14ish thousand patients in primary care. People on the far right had severe insomnia, and 61% of these patients - their doctor had no idea they had sleep problems.

This is not a German medical system issue, this is the same thing here in the United States. We actually did a survey — we looked at all of the really great comprehensive cancer centers in this country.  We found that the majority of them don't screen for sleep problems, the majority of them don't have anybody on site who deals with sleep stuff, and that the providers, very few of them, felt like they knew what they were doing when it came specific to sleep. So, come back to us to talk about it. This is what we get to do. And that overall, more than half of them felt that barely a quarter of their patients were getting the kind of care that they needed for sleep. So, this is important.

18:40  Doctors often prescribe hypnotic drugs for sleep problems, but are they safe?  Now, you go to the doctor, and you tell him or her, ‘I have insomnia’. What are the options they present you with? Sleep pills. What else? Sleep study. What else? Melatonin, good, okay. What else? That's if you're lucky. So, you've got a good doctor, you should tell everyone else to go to your doctor. Because the answers that you guys gave are really common answers. So, the first answer you gave, I would say actually the vast majority of the time is the answer that you are given is, ‘Here's a medication for it.’ I'd say in the data, and in my experience, that's what happens.

However, I want you guys to think that there's more than just that. The sleep study question is for specific sleep disorders, and we could talk about that.

Now, a colleague of mine did a survey, or participated in looking at data from a survey across the country, and what she saw was that, within the past 30 days, one in every five Americans had been prescribed or taken something over the counter to help them sleep. You don't have to out yourselves unless you want to. But in the past month, how many of you have taken anything to help with sleep? Wow, well, that's a little bit of a biased sample, you're here for this talk. I was going to say, you really skewed the curve here. But think about that though. That's the option that you're given.

And I'm going to make a pitch here, that there's something we need to think about. So, hypnotics are often prescribed. So generally what you guys are prescribed, and you can tell me if I'm wrong, is a hypnotic, which means a drug designed to put you to sleep, something like Ambien®, for example, okay? Or Lunesta®. Other drugs that are sometimes commonly used are things that doctors will say is off label, which means they're not used specifically to put you to sleep, but it's kind of a nice side effect, so things like Trazodone®, or perhaps like Klonopin®, or things like Ativan®, or whatever. They'll prescribe those as well. Hypnotics, like I said, are the ones that are designed for sleep, so things like Ambien® and Lunesta®. They've done studies on these for decades.

And it makes me think. In essence, if you take a hypnotic for as short a period of time as a month, you increase your overall rate of mortality. It's not really clear why. I'm not going to even venture a guess, because this is certainly out of my wheelhouse about the specifics. But that, to me, gives me pause. Not to mention the fact that you become then psychologically dependent, and physiologically dependent on that particular drug to help you sleep or not. It matters health-wise.

21:50  Is taking melatonin to help you sleep safe?  Melatonin. Who ... yeah. Vitamin M is what I call it. It is dispensed like candy. How many of you guys have been told by colleagues, or friends, or even your physicians, they say, ‘Why don't you try melatonin when you don't sleep well?’

So I work with a really, really wonderful group of doctors, and one I really, really like said, ‘Eric, I tell my patients to take melatonin because I don't want to prescribe hypnotics.’ Right? Melatonin seems safe, it's natural, you've all heard that, right? It's natural, so it has to be safe. Well, here's the worry. Where do you guys get your melatonin from? Health food store, your CVS, Amazon, wherever, right? That's where most people get their melatonin.

So a group of Canadian researchers, what they decided to do is they said, ‘You know what, let's see what's actually in these dang bottles.’ And so they pulled, like I think it was like 24 or 26 bottles off the shelf, and these really smart chemists, they figured out what in the world was in the actual tablet you are ingesting. And guess what? What's that? Well, sometimes very little.

So they found the range of melatonin in the bottle was as little as 70% less than what it said on the bottle, to as much as 478% more than what was said on the bottle. Exactly, it's not FDA regulated, which is not to say that it's not good from certain brands, or from certain ... in certain circumstances, but it is certainly not nearly as safe as we are led to believe as a culture. So, I really emphasize, there is a time and a place for melatonin, 100%. Just be extraordinarily cautious of what you use because it is not regulated. And oh, I don't have it on this slide, but there is also serotonin. So, if any of you are on antidepressants, like SSRIs, there was serotonin randomly in, I believe, about a quarter of the samples, so it's stuff that's nutty.

24:15  The American College of Physicians recommends that patients with insomnia get cognitive behavioral therapy (CBT):  Now, so what do you do? The American College of Physicians two years ago released a statement saying that all adults receive cognitive behavioral therapy for insomnia. Now folks here who've had CBT, or cognitive behavioral therapy, often have had a prior anxiety disorder, or depression. This is not like that. This is entirely different, they just use the three letters at the beginning, but the other stuff really is different. So if you work with somebody who does this, make sure that they do this. It's like if you have a German car, right, you don't want the guy who only does Japanese cars working on your car, same thing here. You really want them to know this particular approach, in the nuts and bolts of it so you understand what the components are.

The five main components:

25:02  Sleep restriction: One, sleep restriction, which is actually the world's best sleeping pill. It's not sleeping. Any of you who are mothers know exactly what that feels like. Not sleeping for an extended period of time, in this case in a controlled, consistent, purposeful fashion, so that then you reset your body's clock.

25:26:  Stimulus control:  The second piece is stimulus control, which is avoiding your bed for anything other than sleep or sex. Most people think, ‘This is Eric talking about not watching Netflix in bed.’ It is, but more importantly, it's about not doing something in bed which I think is the dirtiest thing you can do in bed, what's that? Well, electronics are bad, but really, it's trying to sleep.

25:49  Trying too hard to sleep is counterproductive:  How many of you guys have ever lay in bed and done this? ‘Please God, if I fall asleep in the next five minutes, I will listen to my wife tomorrow. I swear.’ How many of you guys have literally laid there trying your best to fall asleep?

 If you don't put up your hand, you're lying. Every one of us has tried to sleep. And yet, the harder you try to sleep, the reality is the, worse you sleep if you think about it. Because if you try to sleep, what you essentially do is you get your brain what we call hyper-aroused. It gets ... it starts the car up. And when you're anxious and worried, and thinking about sleep and why you're not sleeping,... well, you're not going to sleep for even longer. So that's one thing that I think is the second dirtiest thing you can do in bed that we try to avoid.

26:36  Sleep hygiene:  Third is sleep hygiene, this is a common term you guys have talked about probably with friends, seen on the internet. These are the things that make your sleep ... behaviors that make your sleep better, or behaviors that can make your sleep worse that you try to do more or less of.

26:52  Managing cognitive challenges:  Fourth is cognitive challenges, which is understanding how much of a role your brain plays in whether you sleep that night. So, we all understand, if you have a job interview tomorrow at 8:00 how well do you sleep the night before? Think about somebody who has really stressful jobs or work responsibilities, and is constantly worried that they're not sleeping well enough for tomorrow. It's every night then. These are things that you need to worry about as well, for the cognitive piece.

27:19  Relaxation exercises:  And the last piece is talking about relaxation exercises. So, these are the five core components. And you can actually do this over the course of a couple of months with somebody who's trained to do this. It's hard work, like all good things in life, but it's remarkably effective. Now, I'm going to leave you with specifics, though, that I want you to do to get you into this general area.

27:43  Your sleep is never about tonight.   Your sleep, it is never about tonight. Ever. Even if I really, really like you as my patient, I don't care how you sleep tonight. At all. And that's your problem, actually. And I don't mean your specifically, I mean that's actually the problem of many people who sleep poorly. They worry about how they feel tonight, or today.

So, think about it like this. What do most people do if, the night before, they couldn't sleep at all? They toss and they turned all night, and now it's Saturday, what do they do? Do they nap? Do they stay in bed longer? Do they go to bed earlier, do they sleep? Yeah, you do all of that because it feels good today.

What ends up happening, though, is you tend to oversleep. Right? It's like what we all do when we go to the buffet. No one ever eats just one plate. You never, ever, when you sleep in, sleep in the right amount. You almost always go too far. So now you're full and you can't sleep that next night. So, we're back to that cycle.

Now it's never as clean as day one, day two, day one, day two. Usually the pattern for people who have insomnia is like two or three or four or five days of really great sleep, and then two, or three, or four, or five days of really bad sleep. And it goes back and forth. And every time they get to the good sleep, they go, ‘Oh, I finally beat it.’ And then it's bad again the next week. That's the cycle that we get to break. So that's why I say to everyone, you must remember, your sleep tonight does not matter.

29:29  You first need to understand what your sleep looks like, in order to address your sleep problem.  Now, the first thing that you can do, and I tell everybody, you absolutely must do this, is you need to understand what your sleep actually looks like. Like people who want to lose weight, if you don't know how much you weigh today, don't even bother, because you actually need to understand and track how you're doing. And understanding sleep is important because sleep changes from day to day. Nobody sleeps the same every single day. Particularly bad sleepers.

I have a reminder here, so Fit Bits® and Apple® watches, how many of you guys wear those? How many of you guys have ever looked at your sleep on those? Well, good news and bad news. Good news: you have a really great pedometer to track how much exercise you got. Bad news: it’s not the world's greatest sleep tracker. Yet. I'm assuming they'll figure it out.

30:29  Create a sleep diary:  So I wouldn't trust that. What I do trust is something like this, which is a sleep diary, or a sleep log. If you just Google sleep diary, sleep log, there's tons of them and I'm happy to talk with you afterwards about keeping them. But the goal is just to use pen and paper, crazy, right? To just track every day how you sleep, and to do that for at least two weeks. Because that gives me a really good snapshot of what their sleep looks like. And you get to see over two weeks, do you struggle falling asleep? Do you struggle staying asleep? Do you wake up too early? Does this happen twice a week, four times a week? This is eye opening, and I cannot underscore how important it is for you to understand what this pattern looks like, because this is a part of figuring out how much sleep you really need.

31:18  It’s important to wake up at the same time every day including weekends and holidays:  The next piece, probably the best single piece of advice I can give you, so if you have ignored me all the way up until now, wake up at the same time every morning. Every morning. Tuesday, same time. Sunday, same time. Your birthday, same time.

The reason for that is we actually, if we think back to my example, if you slept horribly the night before, what do most people do? They oversleep, right? They overcompensate. If you wake at the same time every single morning, 365 days a year, you literally prevent your body from having that opportunity to go to that buffet. And what it means, then, is you stop caring about how sleep functions that night, and you go to bed earlier the next night. And it won't happen on the first day. It might happen three or four days later, but that simple act of restricting your opportunity to sleep in the morning is the most important thing, because you cannot control when you fall asleep.

Did everyone hear that? What did I say? How many of you have even tried to fall asleep at night? Yeah, I want to prove to you guys a point. You two raised your hands, I saw you two. Now, I don't know how much money you are ... how much money you are, how much money you have:  you may be the wealthiest people in the world, and if you are, we can definitely hang out afterwards. But, if I offered both you a million dollars right now, everyone here as my witness, I will give these two lovely ladies a million dollars right now if they can fall asleep in two minutes. You know what, how about this sir, you look like you, as well, want to make a bet with me. I'll give you a million dollars, if you can't fall asleep in two minutes, you owe me 20 bucks.

You guys laugh. No one has even taken me up on that bet, and sadly, because I'd be a much richer man that I am. You two ladies who I first offered this deal to laughed and didn't even try. Either it was because you looked at me and said, ‘This guy doesn't have a million dollars’, or it was because you understand how ludicrous it is to think that you can, within two minutes, on command, fall asleep. Because there's no button that you can push, and yet you do this at night when you try to fall asleep, or when you wake up in the middle of the night and you try to fall back asleep. This is a core component of being able to simply have the hunger to sleep. Sleep and hunger are pretty similar in the sense that if you haven't eaten for long enough, you get hungry. If you haven't slept for long enough, you get sleepy. Itt's that simple.  So, if you don't sleep tonight, and you wake up tomorrow at an early time the next day, or the next day, or the day after, or the day after that, at some point, in about seven to 10 days, you'll get there. You're yawning, but you're still not sleeping.

34:23  Don’t try really hard to sleep, especially when it is not the right time:  The next piece, don't try really hard to sleep. This is coming back to what I had said earlier. For folks here, some of the frustration is trying to sleep. And this conversely is a reminder for me to tell you, try really hard not to sleep in dangerous moments.

How many of you own a really comfortable recliner or a couch that you watch TV on, and then you notice yourself doing this. Those sleeps, those micro sleep episodes, they're what I call dessert before dinner. Because when you guys do that, think about it, how many of you guys have done this, said, ‘Oh, finally sleeping.’ Run upstairs to bed and then lay in bed wide awake? That's dessert before dinner, you literally slept, you gave yourself that ice cream you wanted, and then of course you don't have your appetite when that regular window of sleep is. So not only do you not try to fall asleep, you must try to not fall asleep when it's not the right time.

35:33  Keep to your sleep schedule:  So let's just say you set your wake-up time consistently every day for 7:00 a.m. because that gets you to work. Maybe your bedtime is any time later than 10:00 p.m.

 For many people, the danger zone is like 9:30 pm, 9:45 pm because they'll be on the couch and this will happen. So, what I tell them is sit on a kitchen chair, stand up, have a shower, go out with your husband. Do something so you stay awake until at least 10:00 pm because what you do is you prevent yourself from ... remember at the beginning I showed you that red bar where they were broken up lines? That's what you want to avoid, because continuous sleep feels much better than broken sleep, right? If you had a choice of getting six hours, for the sake of example, from 12:00 a.m. to 6:00 a.m. or six hours starting at 10:00 pm, ending at 6:00am, and you wake up in the middle, which one would you pick? Yeah. And that's the goal, where I say to people staying up later is perhaps a good thing in making your sleep consistent.

36:35  Sleep hygiene is important, but it can take a long time to recover from the effects of prior bad sleep habits:  The next piece, this is sleep hygiene, this is stuff everyone has thought of. So, electronics, people brought that up a couple of times. This stuff matters a lot, however, not in the same way that you think of it. For most people, they think, ‘Well, if I turn off my ... ‘ I have my phone right here, people think, ‘Well if I turn this off and I put it down today, my sleep is going to be great. I quit Facebook, I deleted that stupid thing, I'm going to sleep gloriously tonight.’ But think it's going to happen like that? Of course not, it's like that person who says, ‘Today I ate a salad, I'm going to lose 40 pounds.’ No. This is a slow process because it took a long time to get to the point where your sleep struggled so much.

37:17  You need to practice sleep hygiene consistently for weeks and months:  Doing these things matters if you do it consistently. And by consistently, I think like weeks and months. I'm talking about collecting details, making sure you figure out for you what the right temperature in your house is. If you have a nice thermostat, literally for two weeks, set it at 70. For two weeks set it at 69, for two weeks set it at 68, and you figure out your sweet spot.

For your electronics, turn it off an hour before your bedtime, and leave it off for a month and see how you feel. Now, for electronics, my only addition is it's not so much the light I worry so much about, I do worry about that. What I really worry about is your electronic device that is designed to keep you awake. We saw that quote from the CEO of Netflix®. If your phone was boring, Apple® would not be as rich as they. All of those apps would not be as rich as they are. They're designed to keep you hooked and staring at them for hours. Sleep is not. That I worry about.

Other things, like when you eat, keeping your bedroom clean… these are all things that matter if you do them consistently over time. Nothing changes overnight when you do this stuff. Give it an opportunity.

Now, I say to everyone this is really as easy as trying to lose weight, it's hard. I mean, the rocket science of losing weight is eating healthy and exercising more. But it's a really, really hard thing to do. I have a Pepsi® right now, that's terrible for me. But I like it.

That's the challenge when it comes to sleep, is you're going to say at 7:01 a.m. when the alarm goes off, ‘That stupid Eric told me to wake up, screw him, it feels really good in bed right now’ then what I would say to you is, ‘Fine, I'm stupid, that's fine, you can insult me, but you used to sleep until 9:00 am. Do me a favor, get up at 8:00 am, limit the damage.’ That's what I want you to think about in terms of making some change that helps you, because maybe waking up at 8:00 allows you to sleep 30 minutes earlier that night, so you feel 1% better. That's what I mean by trying these changes.

39:19  How to find a sleep specialist:  Now, finding a specialist is tough. This is heat map of where providers are in the United States. It's not all encompassing, but the idea is, it looks like if you don't live in New York, Philadelphia, or Chicago you're kind of screwed. And the reality is that it's not that barren, but it's like most specialty services, there just aren't enough good people to do it.

There are website. If you go to this website, BehavioralSleep.org, there's a list of providers by state, and you can see if you have somebody in your state who can do this work. I really hope so. If not, let me know, we can try to figure some way that I could connect you with somebody.

39:55  Books, videos and web sites that can help you correct your sleep problems:  Or, you could think about — if you're the person who can watch a YouTube video and build a garage by yourself — then you can read these books and fix your sleep by yourself. Like I said, there is no rocket science. I told you, in five pieces, what the components of this are. It's really, really straightforward, but you have to be motivated to do it. And, so, these books up here are books that you can absolutely go out and get. They're like $12 on Amazon, and they'll tell you what I would tell you in person ... I mean, they're less entertaining, I hope, but they're all the same ideas.

Or websites, you can go to different web sites. These are actually two that have been ... there have been research trials conducted to show that they work, and they do. It's the same idea. Here you pay more money, but you can actually get the same ... a little bit of the back and forth that you might with a provider.

I hope I didn't run out of too much time, thank you guys for this opportunity. Happy to answer questions.

40:55  Audience question about getting back to normal sleep after a long period of time in the hospital where they wake you every two hours:  Okay, so we spent about 300 nights in three different hospitals, and the one thing I noticed, my husband being the patient and I stayed with him the whole time, they let you sleep for two hours, and then they wake you up. And getting off that cycle for us has been almost impossible. For the first three months we couldn't sleep any more than two hours, now maybe we're up to three, four.

Dr. Zhou:  So, I'm sorry. I really wish that hospitals ... like some of those things that they did, I'm going to go out on a limb and say they didn't need to do every two hours. It's policy and it's stupid. I'm going to take something that you said, and I'm going to make lemonade out of lemons.

Which is for everyone here, did you hear the comment that was this lovely woman's husband was in the hospital, they woke him up every two hours, so now even months later they're waking up every two hours?   I hope what you heard there was the positive, which means for three months they were made to sleep in an incredibly abnormal fashion. What did their body learn how to do? Yeah. You guys did exactly what I told everyone here to do five slides ago. If you wake up every day at 7:00 for three months, what do you think your body's going to do every day at 7:00? So, thank you for providing the evidence. I've got your $5.00 for after. Yeah.

But to answer your question, I'm assuming that what ends up happening is now, during the day, do you take naps? Not even on the couch in the afternoon for short periods of time? Okay. I would start to track how much sleep you get, and my hunch is, for many folks what they notice, especially if you’re eyeing each other, trying to catch each other, is that you do experience some brief moments. Because it's really hard — let's just say you historically slept seven hours for the sake of argument — and now you're down to three every night. That would be really hard. I don't know of any people who can change that much.

Which means you're getting maybe not four extra, maybe you're getting only two extra, but you're getting them somewhere. They might occur every week, they might occur when you're driving him home from the hospital. Those moments happen. It's about figuring out when they happen and not allowing them to happen, because then you increase that sleep drive for later that night and trying to squeeze your window to match how much sleep he's actually getting. So we can talk about specifics after, but the idea is just always to give him a specific window, and to only allow it to happen during that window, and maybe a nap in the afternoon, sometimes, if it's helpful. But to be consistent about it. We could talk about how that looks. Yes.

43:49  Audience question about how to get enough sleep when you have terrible leg cramp: I had a transplant 12 years ago and was on an oral maintenance drug for six years, and one of the side effects was leg cramps. Well, I still have those leg cramps today as a result of having been on that drug. And I like in high altitude, about 1,000 feet higher than here, and I have leg cramps almost every night, and sometimes I can go right back to sleep, other times I cannot. And sometimes I succumb to Ambien®. And I take the pickle juice, I take L-glutamine, I exercise, I try it all, but my body has grown used to all those remedies. Anyway, what is your suggestion for getting enough sleep when you have these horrible, gut wrenching leg cramps?

Dr. Zhou:  So you're fighting a battle that I think many people here are fighting. Maybe they're not dealing with leg cramps, but they're dealing with something, we can replace leg cramps with another symptom. But I would say, first, is to make sure that that symptom is managed the best you can, which means, for example leg cramps, I think about for some patients of mine who have RLS, or restless leg syndrome, things that help them are things I'm assuming you've thought of, and I apologize if this is too basic. But things like massages, things like heat compresses, things like warm baths, etc. These are things that I want you to think about consistently, though.  That's the thing most people don't do. Just like that sleep hygiene list that I provided earlier. If you did that every day, even when you didn't have leg cramps, for two months, maybe the severity reduces enough that it lowers the number of times you awaken from three to two. That's one thought.

The second thought, and this goes for every other physical symptom, the second thought for you is how often do you take Ambien®? How often do you succumb, as you say?

Okay. So, what I would say to folks is that is the worry about how you feel tonight. And the reality is, if you didn't take Ambien® that night, and you stayed up all night that night, I would bet that the next night or the night after, you would be so sleep deprived you would fall asleep. Even if you had the world's worst leg cramps. And if you want to run a test, try pulling two straight all-nighters and see how well you sleep on the third night, even if your leg cramps are keeping you feeling horrible. That's the power of sleep drive. And that's why I say to folks that Ambien® fixes your sleep that night, but really what it does is makes you more aware of what it feels like not to sleep the next night, and the next night, and the next night.

Well I was going to say ... it does. Taking sleeping pills is shown to impair cognitive function the next day, but what I would argue is so much of Ambien® is what's called placebo effect. So, they've looked at studies to show that about 60% of the benefit you get from taking a pill to help you sleep is simply believing you took a pill to help you sleep. If any of you guys have kids, you should try it. You should tell them, ‘This is going to put you to sleep,’ and give them like ... I don't know, a vitamin. It really does matter. Because think about this. What do you do if you can't sleep, and the doctor says, ‘I'm going to give you a drug, this is going to put you out’? How do you feel? You go, ‘Finally.’ And that is exactly that arousal that I said is the opposite of what happens when you start to worry and obsess about sleep.

48:04  Audience question:  Are recurring nightmares the same as night terrors?  I was wondering if night ... if reoccurring nightmares are the same as night terrors?

Dr. Zhou:  No. So, nightmares are things that you remember the next day. Night terrors are things that, if I awoke you during that terror, you would say, ‘Eric, what are you doing? I don't remember any of what just happened.’ So, they're distinct. They also tend to be ... how do I say this? Medications can play a role in this. If you've had prior trauma it can play a role in this. Also, if you don't sleep sufficiently, and you mentioned you don't sleep a lot, it can play a role in this because of what's called REM rebound, that could play a role as well. If you have nightmares, there is a form of treatment called imagery rehearsal therapy that is effective for nightmares, but that's not night terrors. And I can answer more of that question afterwards too.

49:03  Audience question:  If you have vivid dreams, does that mean you don’t sleep deeply?  If you have a lot of dreams, vivid dreams that you remember every night, does that mean you never sleep deeply?

Dr. Zhou:  Nope.

Audience member:  No?

Dr. Zhou:  Nope, not at all. You actually dream more, closer to the beginning of the morning, because that's when more REM is actually occurring, which is not deep sleep, that's actually really light sleep. So, no, not at all.

Audience member:  And what did you sleep ... I mean, if you dream all night?

Dr. Zhou:  I don't know how you could actually prove that you were dreaming all night. I'm not saying you don't. And the reality is, if you do or you don't, and you feel good-

Audience member:  No, I don't-

Dr. Zhou:  It's like if you sleep on your side, or you sleep on your belly, if you like it, you like it.

Audience member:  I'm exhausted, I mean the dreams are nonstop and I wake up and I remember them all and I'm exhausted from my dreams.

Dr. Zhou:  That might be something where I would actually say you may want to get a sleep study done to see what your sleep looks like, to see the architecture of what your stages look like.

Audience member:  Okay. All right. Thank you.

Dr. Zhou:  Yeah.

Moderator:  Okay, thank you so much Dr. Zhou.

Dr. Zhou:  Thank you guys.

Moderator:  Thank you.