- Hi and welcome. My name is Marge Murray, and I'm the Director of Geriatric Services with UW Health. I love looking out at the full house for our program tonight. I have a feeling that the speaker I'm about to introduce is responsible for a lot of it. It is my great pleasure to introduce Dr. Steve Barczi, who is a geriatrician and a sleep medicine specialist. He practices at UW Health and at the VA here in Madison. He runs our fellowship program to help make sure that we train other geriatricians that hopefully are just as wonderful as he is in the future. And I think some of you-- How many of you are here as fans of Dr. Barczi? Yeah, there's a few people that he has seen before. We're lucky to have him, and he is going to talk about sleep and how to do it better, hopefully.  [applause] - Thank you, Marge. And hopefully everyone will be able to hear me project. I am always really feeling privileged when I have a chance to come out here to Oakwood and also to some of the other retirement communities within the Madison area. And I'm going to talk about something that I think everyone in this room can relate to: the issue of sleep. Throughout our lives we become very, very experienced in this process. And almost all of you here are probably experts in sleep in some way or another. Although, we know that as time progresses sometimes our sleep can change. And for some of you in this room, when I mention the word sleep now you might grimace because it may not be so easy or so natural anymore. What I'd like to do today is to talk a little bit about what are some of the thing we anticipate might occur as we age with regards to sleep. Not only that, but I want to share some information we know now about how sleep not only is important for our quality of life but, equally, how it plays an important role for our health status. And increasingly we understand that not only do we want to help people sleep better to feel better, but we know that if we can help people sleep better, we can also help with a number of their underlying health problems. So that's why I'm titling this particular talk as "Sleep is Powerful Medicine." Thinking of it just like any pill you might have in your pillbox. And so let me progress here. So I'm not the first to talk about sleep. There have been people talking about sleep for centuries, as you can see. And William Shakespeare himself kind of, out of one of the acts of Macbeth, and I will not be able to tell you which, specified innocent sleep. "Sleep that knits up the raveled sleeve of care, "The death of each day's life, sore labor's bath, "Balm of hurt minds, great nature's second course, Chief nourisher in life's feast." So I don't know if I can top that.  [laughter]   We also know from referencing another person that some of you in the room might know, someone who had a lot of things to say about a lot of things, Leroy Satchel Paige. And he said, "Old age ain't for sissies." However, I will tell you that increasingly we are being very proactive about the aging process, as has been shared in a number of different sessions before this. And we know that people who maintain healthy lifestyles, which include quality sleep, good exercise or activity schedules, avoidance of some of those vices that can get all of us into trouble, will, on average, have half the risk of disability as they age compared to those who maybe weren't maintaining some of those healthy practices. So I'd like to inspire all of you, maybe in my talk today, to take maybe one or two items out of this talk and leave this auditorium and say, "I'm going to focus on this aspect of my lifestyle or this aspect of my health to be able to improve my sleep." So one of those great myths that's been out there for a long time is that, inevitably, as we get older our sleep will become poorer. And, in fact, I'm sure if I did a show of hands in this room, there would be a handful of you who would say, "I'm quite satisfied with my sleep and it's not an issue." Although, I am pretty confident that if I did a hand count on to how many people struggle,  At all ages, I'm afraid to say, women have more propensity for sleep difficulties than men.  But one thing I will say is that if you look closely at about age 50 to 59, all the way over to this direction to age 70, you can identify that there's maybe a little bit of a flattening of that curve. So it's not consistently worse and worse and worse and worse every year of life.  Now the good news because I just showed you things went up, up, but this particular survey, which was done a few years ago now, surveyed a large number of older adults residing from all over the country and surveyed what was their perception of the quality of their sleep. And then, the very far left here, you see white boxes, 9% and 11%. And those are those who defined their sleep as excellent. And then, in the box just adjacent to that white box, kind of light gray, that's those who said very good. And then, for the middle box, that's good. So I think most of us in this room would want to be in that group of the good, very good, or excellent. And you can see that group far outweighs those who unfortunately rate their sleep as poor or fair. So there is-- This itself shows you that it's not inevitable that our sleep will be poor as we get older.  So I'm going to, for a moment, put on my professorial hat. And I'm going to kind of give you a very mini, mini lecture on what exactly happens when we sleep. Now, 30-40 years ago, if someone were to come up in front of this room, they would have said we are not sure but we think sleep is important for the following reasons. But now days, I think we have a pretty good understanding of what happens, the biology, the physiology of sleep, the psychological aspects of sleep. And what we can say for certain is that sleep is a biological rhythm that we all have, plus mammals and animals, flies.  All creatures sleep at some point or another. And so it's a natural rhythm that we all have programmed into our brain. We all know approximately when it's time to go to bed. I could put you in a cave with no exposure to anything for a period of weeks and you would still maintain some type of a sleep rhythm. It might shift a little bit, if you never see the sunlight, but you would maintain that rhythm. But, as we all know in this room, if we choose to, we can override that internal rhythm. We can decide that we are going to stay up later or even stay up through the night to work or whatever might require us to be up in the middle hours of the morning. So, it's both a biological rhythm, but it's a behavior that we have some control over. And that's where the challenge is because human beings don't like to follow schedules. You know? If you're watching Public Television, for example, and there's a good show on and it's on at 10:00 or 10:30 at night, that might just creep into your sleep time now. And so there's all kinds of excuses we have for why we might not be sleeping when we should be sleeping.  What happens when we sleep? So, this is where I can now start to be more confident in talking about what are the functions or the purposes for sleep. And although I can't tell you holistically all of the different elements, I can tell you bits and pieces. So we now know and I give whole lectures just on the relationship between sleep and memory. And we understand that sleep becomes a very important part of the day for winnowing out the memories that we don't really need to keep. So, for example, what did any of us eat for breakfast 2,013 days ago? Okay? Or, for that matter, one week ago?  On the other hand, we may have other memories that we will store through our entire lives. Possibly important events, like weddings, funerals, and the like. When we sleep, there's a phase of sleep where we believe we start to prune out the memories that aren't so essential and reinforce or strengthen the ones that are. Additionally, has anyone here ever been up almost all night into the next day? I suspect most-- Many hands are raising. Now, I want you-- You don't have to answer this out loud, but you can think about it. Were you the most kind and pleasant person the next day?  [laughter]  I would speculate not. And it's because in fact when we sleep we are also remodeling some of the networks, the neural networks in our brain that help us to be able to deal with emotional stimuli. And when we sleep deprive individuals of any age and the next day we irritate them just a little bit, they are much more emotional in their responses to us. And that happens to be associated with a very specific area of the brain called the amygdala. So, without getting into a lot of technical jargon, I can tell you that by sleeping better our emotional state the next day is also better. Additionally, we understand that if you take, especially animal models or non-human types of experiments, if you deprive a creature of sleep over a period long enough, they will become increasingly susceptible towards things like infection, and it's not quite clear, but possibly even our body's ability to fight off other things like pre cancerous processes. So we are now increasingly understanding that the sleep phase helps out with out immune system, which then helps out with all kinds of other important health tasks that we accomplish, like staying healthy. Furthermore, with regards to other factors, our hormonal state and not just our emotional state, but things like our weight, our appetite, two very important hormones called leptin and ghrelin are very important for helping us regulate what we eat, how much we eat, and how much weight we gain. And when people are sleep deprived, and this has been done in college students, they crave carbohydrates and they eat more than they normally might eat and they gain more weight. So we understand now that sleep is also an important regulatory process for us controlling and maintaining our weight. Finally, there's just the maintenance process. Our brain does an amazing amount of work every day, and there needs to be some housekeeping occurring at night for us to kind of build back up the proteins and other things that are important for our next day's brain activity. Now, when we talk about sleep, there's some, again, technical jargon. We can break down sleep into different phases. And I expect many of you in the room here has heard of REM sleep before. Rapid eye movement sleep. Well, in fact, there are stages one and two, which are very shallow or more transitional, lighter sleep. Stage three sleep is what most of us would consider slow wave or delta wave or deep sleep. And that happens in the very beginning of the night. And then we cycle through the night between non-rapid eye movement sleep, which is stages one, two, and three, and rapid eye movement sleep. That is dream sleep. Dream sleep is very fascinating. And I could spend a lot of time talking about it, but I'm just going to say that our brain is as active as if we were awake, yet our body largely paralyzed in many areas. And so we have a very active mind in a paralyzed  The danger of speaking at this time of the day...  [laughter]  Is that that's a stress test of sorts. And for some of you in the room who have not just achieved quite enough sleep, you might easily drift off into stage one sleep. So I want to point out that from about age 20 or 30 until about age 70 the difference in our sleep need might be 30 minutes, might be 60 minutes, but it would not be two to three hours. When we sleep, there's certain situations or things that need to be met. We have to have a strong and positive association between sleep and a bed. For some of you who might have struggled with insomnia, after having weeks and weeks and months and months of not sleeping well in a certain bed, in fact the emotional response can become negative as you decide you're going to climb into bed. So you might feel tired, ready to relax. You climb into bed, put your head on the pillow, and then you just start to get more alert. And then you start to feel like, oh, I'm not going to sleep. And then all kinds of things run through your head, and your mind gets more and more active and you get further and future away from that elusive moment of falling asleep.  We need to have relaxed mind and relaxed body. So for some individuals who struggle with terrible pain and they lie in bed, pain is not conducive to good sleep, is it?  Or, for that matter, there has to be some disengagement from the day's events or the next day's events. So all of these things are kind of optimal situations. And again, I'm not telling you anything you don't already know. Now, other things. There has to be an absence of sleep disrupting substances, there has to be a sleep-promoting environment, and, ideally, even things, good things, like exercise, need to be separated apart from our sleep. Some of you in the room can probably exercise and fall asleep not long after that. But many people, once they exercise and they increase the core body temperature, they're going to be further away from the ability to fall asleep.  Naps are a good thing. Now I'm not endorsing that anyone nap at this very moment, but the reality is that we now recognize that as much as people say be careful about your napping, we know that napping plays a positive role. And, in fact, there are many studies now. This is just one very small study, conducted a few years back through our geriatrics journal, that shows that if you give people a memory task, several different tasks, and you have them perform that task and then you have them take a nap, not an excessive nap, a nap of approximately 30 to 60 minutes, and then after they wake up you reevaluate how well they did and you compare that to a group that didn't nap at all, those who napped stored and were able to perform better on those types of tasks. Now, on the other hand, there is probably a proper timing for napping. So I do not endorse napping at 7:00 to 9:00 PM and then climbing out of bed or climbing out of the couch into bed and expecting another seven or eight hours. That will not work well. But napping can play a very important role for our health. Now, I'm not going to pose to you, but in the health field there are a number of questions that physicians and health practitioners are guided or suggested to consider when they're interacting with their patients. A very basic question is, are you satisfied with your sleep? Does sleepiness get in the way of day to day activities or routines? And have, if you're fortunate to have a bed partner to observe you sleep, have there been any unusual behaviors or activities occurring during sleep? So those are all things that can help us to kind of point in on is there a concern or is there a problem. 

 When we start to think about what are all the possible problems or issues that might interfere with our sleep, it gets to be a pretty big picture. So what I've done is I use this particular tool when I'm teaching medical and nursing students, other health professional students, physicians in training but also physicians in practice. How do you systematically consider the possibilities for what might be going wrong to make a person's sleep worse? So at the very top of that star are poor sleep habits. And it doesn't matter how young or old you are, you can still have some bad habits. As we move around in a clockwise fashion around that star, you can see illness and medications are another important player. Shift of that internal clock that I was talking about can be a big factor. Emotional or psychological factors can also interfere. And, finally, there are a host of different primary sleep disorders that can make our sleep quality reduced or make us spend a lot of time awake. So I'm going to walk you around the points of the star over the next, say, 15 or 20 minutes. So at the top here are poor sleep habits. And I am quite confident, if I quiz the audience here, I would be able to get just about all of the bad habits.  And, again, it's not because we necessarily want to sleep poorly. It's more because life is complicated and things happen and we tend to shift various activities and so, in effect, our habits can become poor, not because we necessarily wanted it to happen that way. So what are some examples of poor sleep habits? You can see if a person, as I've been talking about, shortens their sleep schedule because there's just too many things to happen in the evening and too many good things to happen in the morning. Then that can pose a problem for that clock. Additionally, sustained time in bed. Some of you may struggle to get to sleep and might lie awake for an extended period of time in bed. But because you're not getting the amount of sleep you think you need, you're going to stay in bed, waiting for the moment when you're going to slip to sleep. The challenge, of course, is that if you spend 12 hours of time in bed and only sleep for five or six hours, what is your brain to learn about the bed? It's a great place to be awake. Not necessarily a place for retiring and actually withdrawing and falling asleep. Poor bedroom environments. Sometimes we have control over this, sometimes we don't. Every now and then there might be a bed partner who snores. There might be a thermostat that doesn't work quite right. There might be a noise associated with the exterior, if a road happens to be nearby a house. There's all kinds of things. There might be dogs next door. There might be dogs downstairs that are barking away. So there's many, many environmental factors that can influence things. Excessive daytime napping. So to distinguish this from what I would say is an appropriate 30- to 60-minute nap, those who might nap for three or four hours in a day. That poses a challenge. Lack of exposure to activity and/or exercise and/or bright light. All of these factors help our brain to know what's daytime and what's nighttime. And when we don't have those elements built into our routine days, then our clock can sometimes become confused. And, finally, there's those vices that I'm certain that everyone in the room has heard many times before, but we know that excessive caffeine, tobacco use, and alcohol use all can have a negative effect on sleep. So, don't stare at this graphic too long. Okay? But it's there for us to show that there are predisposing factors. There's a handful of you in this room that probably have from a very young age had challenges with sleep. And it might even be a genetic factor. And, for you, a minor stress could tip you over from being able to sleep well at night to being up most of the night. On the other hand, there are some lucky souls out there who you could almost put a firecracker underneath them and they could still sleep. Now, most of us are somewhere in the middle. But there are those predisposing factors that we may not be able to control. But there are these precipitating factors. In a college student, that might be a big examination. In someone else, it might be an illness or the death of a loved one. Something that all of us would consider a stress, and that stress will tip us over from sleeping okay to not sleeping well. That would be temporary transient insomnia. And for many people that time will pass and they will return to a good night's sleep. But there are factors that we call perpetuating factors. That once the person has one bad night, one bad week of sleep, two bad weeks of sleep, then we start to change things around us. We start to respond differently, and all the sudden we actually learn how not to sleep. And so that's where we can intervene to try to break the habits, these perpetuating factors, and prevent people from being far over to the left here in this chronic insomnia picture.  So, the next few slides will be things that I think will be familiar to all of you, and I'd be surprised if anyone hasn't at least considered these things before. But we know that daily routines are very important. And, in fact, sticking to a schedule of a fairly typical bedtime and wake time can be very important. And that doesn't just mean the actual bedtime and wake time. It also means the mealtime. It also means the activity time. It also might mean other events of the day. The napping, as I mentioned. And exercise. So, quiz. When do people think that it is the best time of the day to exercise for sleep purposes? Okay? So, how about who believes that the morning is the best time to exercise for sleep purposes here? So I see probably between one-third and one-half of the group. How about mid-day? Around the noon hour or so? I see a few hands that way. How about later afternoon? Okay, I see about a third of the hands go up. How about even beyond later afternoon, into the evening hours? Okay, I don't see anyone because you already heard me say that, right?  [laughter]  So, it turns out it's the late afternoon. Somewhere between two o'clock and five o'clock. That is the best time, if you're going to be exercising for purposes of sleep. And that has to do with our core body temperature, which happens to be at its peak at that time. So we actually increase the core body temperature even more when we exercise at that time. And then, as we start to descend into sleep later in the evening, our body temperature starts to drop, and if you're dropping from here to here versus from here to here, guess who falls further? It's if you start with a higher core temperature. Now, sleep hygiene also has other factors. And those vices that I talked about before, tobacco, caffeine, and alcohol, each have their own unique ways by which they disrupt our sleep. Tobacco is a stimulant. It gets our heart going, and if you were listening before, probably stimulating your body before you climb into bed would not be a good thing. And now there are those who have dependence on tobacco and it's more complicated when they have that, but I'll just say as a rule tobacco tends to disrupt sleep on the front end. Caffeine: I probably don't need to say anything more. Alcohol-- What people don't realize is alcohol can help us maybe to be a little more relaxed and even fall asleep a little bit quicker, but then we wake up out of sleep because as the alcohol gets broken down in our bodies, then all the sudden we become more charged up again. So a common profile for a person drinking alcohol before bedtime is that they might fall asleep a little bit quicker; however, they may start waking up and wake up more often through the night.  Sleep hygiene also has to do with the environment, like I mentioned. So just think about some of these things that are on this picture profile right now. The television. A light. Certain types of lights. That clock that you can see perfectly well as you're looking over to the table versus not. Sounds, as I've described. And temperature. So, from what we understand, most people will sleep better in a somewhat cool environment. The warmer it gets, the harder it is for people to tend to fall asleep. And maybe some of you in the room here have ever been to a tropical area that didn't have good air conditioning and it was in the 80s or 90s and you did not sleep very well. Probably. And then, lastly, there are other factors that can also play a role. Obviously, someone who has a 30-year-old mattress, probably not a good thing. People who have animals in the bed with them, possibly not a good thing.  Circumstances of people-- And you can see in the left upper corner here with the feet, someone who might have neuropathy of the feet where anything touching their feet is painful. Well, take a look. You can create a little cradle. There are these products on the market that will keep the sheets off of your feet. For those who need perfect silence, something in the ears, for those who need a little bit of background noise, something like a fan. So there's variability across the human condition as to who quite needs what. But that's where some trial and error can be very important. Now, I did not come today to recommend a particular mattress type, and I'm not even going to be able to answer that question if someone dares to ask it.  [laughter]   So, we talked about these behaviors. And remember how I said how sometimes we can learn to have poor sleep? We can learn to have insomnia? Well, if we can learn to have poor sleep, then we should be able to unlearn that. And that's the whole purpose of cognitive behavioral therapy, which, by the way, is the number one therapeutic approach recommended for treating chronic insomnia. It's not a pill. It's actually a series of instructional episodes and working with a psychologist, a counselor, or other health professional to relearn how to sleep. And I won't get into all the details on this slide. I really just wanted to portray that there is a very specific process. It's called cognitive behavioral therapy for insomnia. And it is as or more effective than any prescription therapy you can be given. So we're at illness and medications.  In this situation, I have a little graph here that shows some common health problems. Some of these problems are things that you might have in this room here. High blood pressure, diabetes, arthritis, heart disease, a prior stroke, chronic lung problems like emphysema or asthma, or a process like depression. And you can see that in each one of these conditions on this graphic there's a prevalence, a likelihood that a person might have an intermittent or persistent problem with sleep. So those who have serious lung disease or significant depression or stroke are unfortunately more prone to have poor sleep than others without that process.  -  [inaudible]   - Oh.  -  [inaudible]   - Oh, no. So let me explain. I'm glad you asked that question. On this particular graphic here, that's percentage likelihood. So that's 20% all the way up to 80%. But you're right. The question was, and I'm going to probably address the questions mostly at the end of the talk, why do we not have points of 80, 85, 90 on there? And the reality is that the healthcare system and the research enterprise that's part of the academic system has historically, for many, many years, selected out those individuals above, say, 70 or 75 for various reasons. So as you look at research studies, you will see less and less of individuals your age represented well in those studies. But that's a little aside. There are many, many medications. And, again, I will not be able to cover all the medicines nor would I ask any of you to bring down your medication list after this talk. But I can tell you that there are many, many different types of medications that can either make us too stimulated to get to sleep or make us too groggy in the day to stay awake. And either one of those things poses a challenge. So some of the over-the-counter decongestants or cold medications are notorious for doing this. Caffeine-containing pain medicines. Excedrin is-- Most people think it's an aspirin. It's a pain medicine. But it's got caffeine in it. And so, there's a host of therapies that can get in the way. And that's where your pharmacist or your physician or your nurse practitioner, PA, whoever, can help navigate through that.  This is just an example of some of the caffeine-containing medications that are out there. So, Anacin, a little bit under a cup of coffee. Vanquish, a little bit under. Maximum Strength Midol or Bayer Select Headache. And, again, I'm not using these terms to say this is a good medicine or this is a bad medicine. I'm just saying these are common medicines that have caffeine in them, and you can see some of them have almost a cup and a half or two cups worth of caffeine in them.  We talked about the clock for a moment. 

 Circadian rhythms. Circadian rhythms are-- It's the official terminology for that internal clock. Circa, meaning about. Dia, a day. Circadian. So about a day is about what most of our schedules are programmed as. We have a host of things that happen during this circadian rhythm. And during the day, there are different times of the day that are more beneficial for different types of activities. So our lowest core body temperature is about 3:00 or 4:00 AM. We wake up, most people, around 6:00 to 7:00 AM. The highest blood pressure when we first get up, those first few hours of the day as a rule. Post-lunch, most of us get a little bit of a wave because we're not quite as alert. As the day goes on, 3:00 or 4:00 or 5:00 in the afternoon is when we're at our highest peak level of performance for activities like sports. And in the evening hours is when we start to kind of throttle down a little bit. And bedtime for most of us is somewhere between 9:30 and 11:30.  And this is programmed into our suprachiasmatic nucleus, an area in the center of our brain.  This rhythm can shift through the life span. How many people here know of a teenager who didn't get to bed on time? I think that would be the rule rather than the exception. And that's because, in fact, this clock we're talking about, for many teenagers, shifts in a way where their preferred bedtime could easily be 12:00 to 2:00 or 12:00 to 3:00 in the morning. And then, throughout most of our adults lives, as I mentioned, it might be around 10-11 o'clock. And then for some, not all, older adults, it shifts to be earlier, and by 8:30 we're happy to decide we're going to start preparing for bed. And at 3:00 or 4:00 or 5:00 in the morning we're happy to get up, or maybe not happy to get up. It depends. I'm keeping moving around that star. By the end, you're going to see this star when you close your eyes. Emotional factors can play important role. And this does not by any means include or cover all of those actors. But we know, for example, that depression can produce a very specific type of sleep change. For a person living with depression, they may have greater challenges being able to stay asleep and they may commonly awaken in the early morning hours and then not be able to get back to sleep. That's the typical profile for a person with depression and sleep difficulties. Whereas, anxiety or PTSD means post-traumatic stress disorder. When someone has had something really difficult happen in their life and it continues to affect them years, potentially, later. In this case, it's more of a problem falling asleep, and there might be nightmares. A person living with a more serious memory disorder, like dementia, the sleep and the wake cycle starts to get kind of all shifted around so there's periods of wake and sleep and wake and sleep scattered throughout the day, much like a very young child before they learn to sleep through the night. And then Parkinson's disease, another common age related neurologic disorder, may have produced problems both staying asleep, there may be lots of movements happening, and people might be able to move to act out their dreams, as I was talking about a little earlier. This is a particular common phenomenon with patients with Parkinson's, where they have this what we call REM sleep behavior disorder, where they're able to move during their dream time.  So now we're into sleep disorders. If people aren't keeping track, we're at the final point on the star. Now, there are many different sleep disorders, and technically I have a book that shows all the different codes of different types of sleep disorders. And this approaches 70 to 80 distinct problems. But the reality is most patients who experience a primary sleep disorder, it falls into one of maybe six to 10 different conditions. So, what are some of those conditions? Sleep apnea, which I'll talk about in a moment, but is an entity of stopping breathing or under-breathing repeatedly through the night.  Limb movements, periodic limb movements, where people tend to twitch or jerk. And all of us can have a few of these, but some people can have an incessant number where their legs just constantly, every 20, 30, 40 seconds are just twitching, jerking. And sometimes their brain wakes up from those twitches. Restless legs, which people would think when I'm talking about the limb movements, restless legs would be the same, but it's a slightly different process where people have a creepy-crawly, uncomfortable drawing kind of feeling. Hard to describe and it happens starting in the late afternoon or early evening. And when it happens, the only way they can kind of help to make it feel better is move their legs suddenly or briefly. And then it happens again and it keeps happening. And then I mentioned the REM sleep behavior disorder. So one point I want to make is if you look at these two gold boxes, you can see that compared to all adults, individuals over 65 have this happening more often.  Sleep apnea. So some of you might be familiar with the "Pickwick Papers" by Dickens. There was little Joe, if anyone remembers little Joe in the book. Little Joe was sleeping everywhere. Sleeping in the courtyard, sleeping... And it was because, really, for all practical purposes probably Dickens was describing someone with sleep apnea. Lots and lots of daytime sleepiness or tiredness in many, not all people with sleep apnea. There are people that might even be in this audience here who have been diagnosed with sleep apnea and say, "I do not have any sleepiness." And it can be seen more so in older adults with sleep apnea. Fluctuating snoring. Loud then soft. Loud then soft, like a saw tooth. Nighttime gasping or choking for air. Bed partner saying, "You are not breathing." Or "I do not want to sleep near you anymore because you scare me to death as you're sitting there holding your breath for so long." Increased nighttime urination. We know that people with sleep apnea get up more often to go to the bathroom. And then, concentration and memory focus is worse in this process. So, as we lie down, our tongue tends to fall back in some people, and see this little cartoon with the graphic here? You can see that for a person who has sleep apnea where the back of their tongue kind of gets a little bit more lapse and falls backwards. That blocks the airflow. And that then allows people to have this process. And so, again, what you really should be seeing here are squiggles that keep just looking the same all the way across. And every time you see a flattening area there where there aren't those squiggles, that's a place where a person is not breathing or they're under-breathing. At the very bottom of this graphic-- So you see all those spots where there's no breathing, no breathing, no breathing. The very bottom, those little aquamarine or green boxes are what are oxygen levels doing after these episodes. And you can see it's dropping precipitously And then we startle ourselves, wake up again, and then we stop breathing again, and then it drops again. So this recurrent pattern produces all kinds of harm for our bodies. It affects our blood pressures. It affects our blood vessels around our heart, in our brain, and in other places. It leads to a much higher propensity of heart attack and stroke. It takes a diabetic patient and makes it much harder to bring their diabetes or blood sugars in control. And then, as far as daytime functioning, it causes people to make poor mistakes when they're behind the wheel of a car. It causes people to be irritable. It causes people to not remember well. And, finally, it also influences our global quality of life. So hopefully I've convinced all of you that sleep apnea is not an ideal condition to have.  But not every single person who's diagnosed with sleep apnea necessarily needs to be treated. And, increasingly, we're understanding that not everyone is at the same risk for some of these bad things I just mentioned to you. So as a rule, when I'm wearing my hat as a sleep specialist in the University and working with an older adult, I look for are they having problems with sleepiness? Are they having health conditions that I know will be made worse by their sleep apnea, such as a memory problem, such as heart failure, such as high blood pressure or frequent nighttime urination? Or, if that oxygen level is dipping terribly low, then I'm in a situation where I also will often act.  I mentioned the restless legs. Some people call this condition for night walkers because well before we official diagnose it, these are a group of people who would get up out of bed and walk around and then climb back in bed and just couldn't be quite relaxed. Now, it's that urge to move. Uncomfortable sensation in the legs which is temporarily improved with movement. And it has a predilection toward happening in the evening hours right before bedtime or at bedtime.  There are a number of things that we know that can make the process of restless leg syndrome worse. So, caffeine is notorious for making restless leg syndrome worse. Antihistamines. And you might say, well, that's not a big concern, allergy medicines, but many of the over-the-counter sleep aids have diphenhydramine, or Benadryl, in them, which is an antihistamine. And if a person doesn't recognize that their problem with falling asleep is because of the leg process, they would naturally go out and try an over-the-counter sleep aid. And in doing so, they may in fact be making that process worse. And there are other agents too. I won't go through all of them, but a number of antidepressant medicines can make this process worse. Finally, we know that conditions that lower our blood count or lower our iron levels can make this process worse. So these are targets. Things that we can do, things that we can adjust that might help out a person with difficulties with restless legs. And when I'm managing restless legs, these are some goals or targets that I'm doing. I'm looking for iron levels. So anyone who has such symptoms as I've described might want to discuss this with their doctor and see what their iron levels are like, or specifically ferritin levels. Some people will take calcium and magnesium supplements. Exercise is potentially helpful earlier in the day. And, finally, there are a number of medicines that I won't talk about today, but they can be helpful for controlling those symptoms. So we are just about at the end of the talk. I've got one or two more things to say. So, ultimately, who is responsible for this process of improving one's sleep? And, in the end, as much as you might have an exceptional healthcare provider, it'll probably start first with you. And so remember at the beginning I had challenged all of you to think about maybe one, maybe two things that they might do to improve their sleep. For some of you, it might be just having a conversation with your healthcare provider. For some of you, it might be focusing on a couple of those sleep habits that I had talked about. For some of you, it might be talking to your pharmacist or doctor to say, "Are there any medicines on this list that could be directly interfering with my sleep quality in one way or another?" So, ultimately, it's a team process, but you all will probably have to be the initial instigator as you decide is your sleep the way it should be? Are you satisfied? If you're in that group, remember I pointed out that there's a good number of older persons who are happy with their sleep. And if that's the case, then maybe you can just be a champion for others sleeping well. But if you struggle yourself, then you should probably think about some of these points that I have talked about over the course of the last 50 or so minutes. Now, I will provide some of this in forms of-- I don't have a handout today, but I'm happy to share. I consider lots and lots of good sources on the internet. But I think the one that is probably the most pure and the most unbiased, as it relates to sleep, comes from the National Sleep Foundation. And that's www.sleepfoundation.org.  And if you search under sleep, you'll probably have it pop up, if you're so looking. There are other books out there too. "No More Sleepless Nights" is a book that's been written a while ago, but it gets into what can we do to improve our sleep. And then, of course, there are those psychologists or counselors that I mentioned that might work with you on sleep behaviors. So, with that, I have to apologize because we did start a little late. But I do believe that there will be an opportunity here for me to address some questions. I'm happy to maybe address questions over the course of the next 10 minutes or so. And so...  [applause]