Summer 2004

With Miles To Go Before I Sleep

A good night’s sleep is a distant dream for many American adults and the lack of it a nightmare, possibly signaling serious health problems. Finding out the source of the problems and treating them keeps some IUSM clinicians up late at nights.

Brian H. Foresman doesn’t mind if patients doze off when they visit his clinic at Indiana University Hospital. In fact, the Indianapolis pulmonologist prefers they plunge head-first into Lullabyland. Veterinary euphemisms aside, Dr. Foresman and his colleagues share the goal of putting their patients to sleep and having them emerge several hours later fully rested and healthy.

The pursuit of a good night’s sleep is an elusive dream for many Americans. The National Institute of Neurological Disorders and Stroke estimate that at least 40 million experience long-term and chronic sleep disorders annually and another 20 million have occasional sleeping problems. Sleep deprivation related to these disorders affects their job performance, social activities, relationships and their overall health.

Scientists at one time believed that sleep was an inactive state, a time solely for the body to rest and reenergize. But the medical mindset has changed.

“We know now that sleep is not a passive state at all and that our brains are very much active,” says Dr. Foresman, DO, MS, director of IUSM’s Sleep Medicine and Circadian Biology Program and clinical associate professor. “What the medical community needs to understand is that sleep disorders are emerging as a health problem in our society because they affect the quality of life and morbidity.”

Sleep disorders have been linked to maladies ranging from cardiovascular disease to various forms of mental illness. Often the disease is the source of sleep problems and specialists in the IUSM program are consulted to make diagnoses and to devise treatment plans. They come from the fields of otolaryngology, neurology, cardiology, gastroenterology, psychiatry, gerontology, nephrology and dentistry.”

“Our program truly is interdisciplinary and I think this is what defines our success as a lab and a clinic,” Dr. Foresman says.

The IU sleep program began in 1988 with a one-bed laboratory and limited equipment. Today, it is an expansive eight-bed clinic and laboratory at IU Hospital and is an around-the-clock operation. The rooms are private, two of which are designed for the disabled, and have storage and showers. Upon arrival, a patient fills out a medical history, receives a brief physical and is then escorted to his room where he is prepped for an evaluation, including a full-fitting of electrodes and other sensor devices.

The facility has the latest monitoring equipment to measure patients’ brain activity, eye movement, respiration and other functions. Clinicians and technicians closely watch video monitors that show body movements and review a constant output of computer printouts. Each patient’s information is securely stored on an electronic database.

The Children’s Sleep Disorders Center at Riley Hospital for Children is Indiana’s only pediatric sleep clinic and the largest in the world. The facility, directed by Deborah C. Givan, MD, professor of pediatrics, specializes in evaluating and treating children ranging from premature newborns to 18 year olds. The physical and emotional needs of children are very different from those of adults. This is especially true in the area of sleep disorders, and an adult approach to evaluating and treating sleep problems is often not appropriate or successful for children.

In Search of the Big Sleep

Five years ago, Vince Sheehan would wake up in the morning tired and would remain sluggish throughout the day. At nights, he was capable of producing more audible Zs than a zonked ZZ Top zealot in Zimbabwe. Those stentorian episodes, though, often were interrupted by periods of stony silence and no movement. He received his first diagnosis from his wife.

“She was watching a segment on the news and she woke me up and told me I had this thing they were discussing on television,” recalls Sheehan, IUSM’s chief information officer and associate dean for Information Technologies. “Before that, she would occasionally touch me at night when I was asleep to see if I moved because I seemed to stop breathing. I saw my doctor and she referred me to the sleep clinic at IU Hospital.”

It turned out his wife’s diagnosis was accurate: thirty minutes into his sleep study pulmonolgist Frank Sheski, MD, associate professor, determined Sheehan suffered from obstructive sleep apnea. It’s a condition that largely affects middle-aged adults. Patients with apnea experience interrupted sleep and are prone to develop cardiovascular problems because of the repetitive cycles of snoring, shrinking airway space (if a patient is overweight or has a receding jaw) and continuous arousal from sleep.

Apnea is among the many disorders diagnosed and treated at the IUSM sleep clinic. Other conditions are restless legs and periodic limb syndromes, movement disorders, narcolepsy, sleep walking, sleep talking and insomnia. Earlier bedtimes and afternoon and early-evening naps taken by seniors often account for insomnia, the latter of which is said to be chronic in more than 40 million Americans.

“Changing sleep hygiene by limiting or eliminating naps and establishing routine sleep times helps reduce insomnia and improves sleep,” Dr. Foresman says. “For seniors this might mean that they need to stay up later. For younger people, it means maintaining a routine time of awakening and going to bed to ensure a good sleep.”

Sheehan’s solution came in the form of a continuous positive air pressure machine. During sleep, muscles in the airway relax allowing collapse and any excessive tissue in the throat, such as tonsils, adenoids, tongue, or the uvula to block the airway. This system gently delivers oxygen into the airway through a nasal mask and keeps the airway open, thus eliminating obstructions.

“It took about a week to get use to the mask, but I was able to adjust,” Sheehan says. “I can feel a big difference. While I don’t sleep any longer in terms of hours, my sleep is much deeper and I wake up rested and energized.”

What Dreams May Come

Dr. Foresman leans toward the video monitor and computer console; he alternates looking at the slumbering patient and scanning the digital readouts recording her vital signs and brain activity. To the untrained eye, it’s just a person lying in bed sleeping; for Dr. Foresman, the recorded information he is reviewing draws the perennial scientific response: Hmmm, now this is interesting…

The IUSM sleep program provides training opportunities for medical students, residents and other health care professionals and is an American Academy of Sleep Medicine training program. A research fellowship recently was established in the program and is one of the few in the nation. Six IUSM faculty members are board-certified or eligible for certification as specialists in sleep medicine.

“We’ve just scratched the surface in studying the nature of sleep and disorders and how they affect our health and overall well-being,” Dr. Foresman says. “I believe the School has given us the opportunity to advance that understanding through continued research.”

For Vince Sheehan, a good night’s sleep is all that is necessary.