Sleep Apnea May Be Tied to 'Silent' Strokes

Sleep apnea, the disorder marked by abnormal pauses in breathing during sleep, is already known to boost the risk of stroke. Now, a new study links sleep apnea to so-called silent strokes, in which there is tissue death in the brain without symptoms.

In another new study, researchers found that rapid memory loss before a stroke boosts the risk of the stroke being fatal.

Both studies are slated for presentation Wednesday at the American Stroke Association's International Stroke Conference in New Orleans.

Stroke affects 795,000 Americans annually, according to the association.

In one study, Dr. Jessica Kepplinger, a fellow at the University of Technology in Dresden, Germany, and her colleagues evaluated 56 patients who had a stroke. They knew that silent strokes had been linked to an increased risk of strokes. However, "there are barely any studies that have investigated the relationship between sleep apnea and the so-called clinically silent strokes," she said.

To look at the relationship, they first gave patients in-hospital testing for apnea. "We found an overall high frequency of sleep apnea, 91 percent, in our study population of acute stroke patients, which underlines the importance of this stroke risk factor," Kepplinger said.

The team also performed brain-imaging studies. Those with sleep apnea were more likely to have the silent strokes, as evidenced on the brain scans, the researchers found. Having more than five episodes a night was linked with having silent strokes. The higher the severity of the apnea, the more likely these silent strokes were found on brain imaging.

The more severe the apnea, the less favorable the outcome when the patient was discharged.

The patients were on average 67 years old, and just over half of them were women, the study authors noted.

While the study found an association between sleep apnea and stroke, it did not prove a cause-and-effect relationship.

In the second study, Qianyi Wang, a graduate student at the Harvard University School of Public Health, and colleagues evaluated nearly 12,000 men and women, all above age 50, enrolled in the U.S. Health and Retirement Study.

All were stroke-free at the start. The men and women were given memory tests every two years for up to 10 years.

Over time, 1,820 strokes were reported, including 364 people who died after the stroke.

The others were stroke-free for the entire follow-up period, the study authors noted.

The research looked at the memory declines over time. Those who later survived a stroke "had memory decline that is nearly twice as fast as stroke-free individuals, even before their stroke," Wang said.

"For people who do not survive stroke, this difference is even more striking," said M. Maria Glymour, an assistant professor of society, human development and health at Harvard and a study co-author. "Prior to stroke, people who later died shortly after stroke were declining three times as fast as the stroke-free."

The study was funded by the U.S. National Institute on Aging and the American Heart Association.

"Our study is the first national picture of how memory changes over the long-term before and after stroke onset, compared to individuals who do not have a stroke," Glymour said.

Both studies provide some valuable information, said Dr. Ralph Sacco, chair of neurology at the University of Miami Miller School of Medicine and past president of the American Heart Association. He reviewed the findings.

"It's been mainly in smaller studies that sleep apnea has been shown to be a risk factor for stroke," Sacco said. The new research, he noted, goes even further by linking sleep apnea with the milder "silent" strokes.

"There are many reasons to treat sleep apnea, including reducing the risk for clinical and now silent stroke," Sacco said.

The memory-loss study, he said, "is telling us that those who have the worst memory loss may have a greater death rate when they have the stroke." Those with more memory loss in the study may also have had more risk factors for stroke, Sacco added.

Even so, he said, the message seems to be that taking care of brain health may help us in several ways. "What is good for our memory may also be good for surviving a stroke," Sacco said.


Because these studies were presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

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10 Ways to Start Your Day Without Caffeine

We all know the feeling — waking up groggy after not enough sleep or poor-quality sleep, only to be slammed with a full day of obligations. It’s only natural to reach for that cup of coffee as a pick-me-up. In fact, according to the National Sleep Foundation’s Sleep in America poll, 43 percent of Americans are “very likely” to consume caffeine to stay alert during the day.

And new research indicates that your caffeine addiction may well be genetic: Scientists recently discovered that people with certain gene variations drank about 40 extra milligrams of coffee a day — the amount in an 8-ounce can of Diet Coke — compared to people with different versions of the genes.

Whether in coffee, tea, soda, or chocolate, caffeine helps improve alertness and can help you feel more awake by increasing adrenaline levels while lowering the chemicals that encourage sleep. Unfortunately, your daytime jolt of joe might actually be sabotaging your attempts to get a good night’s sleep.

Caffeine as a Stimulant

While caffeine can give you a jolt almost immediately, it stays in the body for hours. In fact, it takes six hours for just half of the caffeine ingested to make its way out of the body. This essentially makes any caffeine-filled beverage or food enjoyed after noon a potential culprit in sleep problems.

Anyone getting more than 250 milligrams of caffeine per day (three eight-ounce cups of coffee), which is considered moderate, could be at risk for caffeine-related sleep problems. Symptoms of too much caffeine consumption include insomnia, anxiety, irritability, headaches, nervousness, and rapid heartbeat.

There are two ways to approach reducing your dependence on caffeine. The first is simple: Consume less of it. The second is a more holistic approach. “I concentrate on patients achieving better-quality sleep. Sleeping seven to eight hours is enough for most people to solve their sleep problem and not feel the need to jump-start their day,” says David C. Brodner, MD, medical director of the Center for Sleep, Allergy, and Sinus Wellness in Boynton Beach, Fla.

10 Steps to Ease Caffeine Withdrawal

Here are ways to cut down on your caffeine consumption:

Know your ingredients. Study the ingredients on foods and drinks and watch out for caffeine. Caffeine is added to many sodas and energy drinks.
Decrease caffeine consumption gradually. Plan your caffeine withdrawal in stages. “Caffeine is addictive. If you throw out one-third of your morning coffee today, wait three days and then throw out another bit so you are drinking half, you are off to a great start,” says Susan Roberts, PhD, professor of nutrition at Tufts University and author of The “I” Diet. “If you want to give it up completely, just keep going in steps.” This reduction will help lessen caffeine withdrawal symptoms such as headaches, irritability, jitteriness, and nausea.
Water down drinks that contain caffeine. They will still have the taste you enjoy, but contain a lower amount of caffeine and carry less risk of caffeine withdrawal symptoms.
Try something new. Consider changing from coffee in the morning to tea. “Herbal teas are fine, but green tea is really healthy,” says Roberts.
Try decaf. Switch to decaf coffee, decaffeinated soda, or even better, water or fruit juices.
Don’t add to a caffeine habit. Ask yourself if you really need that extra cup in the late morning. If the answer is no, then skip it.
Try a tea shortcut. Brew tea for a shorter amount of time to reduce the amount of caffeine in it.
Instead of a large cup of coffee, next time order a small. “Starbucks medium and large both contain two shots of espresso, while a small has only one,” says Dr. Brodner. “Another caution: Even those sugary milkshake drinks [like frappucinos] contain caffeine.” Ask to have yours made with decaf.
Mix it up. Alternate one cup of coffee with one cup of herbal tea, or one can of soda with one can of caffeine-free soda or water.
Check your pain reliever. Many over-the-counter medications, especially headache remedies and menstrual pain relievers, contain caffeine. If yours does, change to a different kind.

Between cutting back on caffeine consumption and getting a better night’s sleep, it is certainly possible to not only survive, but to thrive without a daily caffeine fix.

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The Link Between Sleep and Weight

We all know that diet and exercise are the cornerstones of a weight-loss program. But can sleep also help you maintain a healthy weight or even drop a few pounds?

"There are more and more studies showing that not getting enough sleep or not getting good quality of sleep can [contribute] to weight gain," says Raj Kakar, MD, MPH, the medical director at the Dallas Center for Sleep Disorders in Plano, Texas.

Sleep and Body Weight: What the Research Says

Just as obesity has become a worldwide epidemic over the past few decades, more people have also become chronically sleep-deprived. According to National Sleep Foundation surveys, 35 percent of Americans were sleeping for eight hours a night in 1998, compared with just 26 percent in 2005. Researchers believe that the growing obesity and sleep deprivation epidemics may be related.

A recent study followed a group of 40- to 60-year-old women for five to seven years and tracked their weight and sleeping patterns. The researchers found that women who reported having trouble falling asleep, waking up frequently at night, or having trouble staying asleep were significantly more likely to have "major weight gain" (gain of 11 pounds or more).

Another study examined the eating and exercise habits of a group of young healthy men after sleeping for eight hours and four hours on two consecutive nights. The researchers found that the men ate significantly more (an average of 560 excess calories in their daily diet) during the day after they were sleep-deprived, compared to what they ate after having a good night's sleep.

Researchers believe that sleep-deprived children may be at especially high risk of having weight problems. Studies have consistently found that getting less sleep than recommended is associated with childhood obesity. In fact, based on sleep studies in children, researchers have calculated that a child's risk of being overweight or obese is reduced by about 9 percent for each additional hour of sleep per night.


The Link Between Sleep and Diet

Kakar says that it is thought that sleep is associated with body weight for two reasons. First, people who are sleep-deprived may have less energy throughout the day and therefore less motivation to exercise regularly. In fact, people who don't sleep enough report getting less exercise than people who get enough sleep every night.

Second, the amount of sleep you get seems to affect the appetite-controlling hormones ghrelin and leptin, which can leave you reaching for high-carbohydrate, calorie-dense foods when you haven't gotten enough sleep. Studies show that sleep deprivation can lead to elevations in ghrelin, which is appetite-stimulating, and reductions in leptin, which is appetite-suppressing.

"Those hormones are thrown out of whack, so as ghrelin gets ramped up and leptin gets pushed down, you are more likely to go for high-carbohydrate foods and high-energy foods, which give you a boost of energy, but can then lead to weight gain," says Kakar.

Can Sleep Help You Lose Weight?

While mounting evidence indicates that your sleeping habits are related to your body weight, researchers still don't know for sure whether getting more sleep could actually help you lose weight.

Currently, researchers at the National Institutes of Health are conducting a study to determine whether sleeping for a healthy amount of time each night (about 7.5 hours) can help sleep-deprived people lose excess weight.

Until more research is conducted on the sleep-weight loss association, it makes sense to put "get enough sleep" on your checklist of habits to maintain a healthy weight and keep from gaining unwanted pounds.

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New Animal Study Might Explain Jet Lag Differences

The way the human circadian clock sets itself may explain why jet lag tends to affect people more severely when they're flying west to east compared to the other direction, a new animal study indicates.

The circadian clock, which regulates many body processes, has to make regular adjustments to stay synchronized with the light-dark cycle of where a person is and does this by delaying or advancing its time in response to light.

Typically, these adjustments occur without notice. However, the process is disrupted by sudden major changes in the light-dark cycle, such as when a person takes a long flight.
Previous research found that delaying and advancing the circadian clock occur in different pathways in an area of the brain called the suprachiasmatic nucleus. This new study found that the molecular mechanisms in these pathways are significantly different.

"We have known for decades that, in humans and other organisms, advances are always much harder to achieve than delays. For example, compare jet lag going to Europe with that coming back," Horacio de la Iglesia, an associate professor of biology at the University of Washington, said in a university news release.

"One of the reasons may be that these two forms of resetting the clock involve different molecular mechanisms at the clock level," he suggested.

The findings from experiments with hamsters could help in efforts to develop remedies to jet lag, according to the researchers.

The study was published online recently in the Proceedings of the National Academy of Sciences.

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Sleep Stages

When you sleep, your body goes through several sleep cycles, each involving different sleep stages.

Most adults need seven to eight hours of sleep every night, and during this time, your body goes through different phases. 


The four sleep stages of sleep include:

Three stages of N sleep, short for non-rapid eye movement (NREM) sleep. N sleep occupies about three-quarters of an adult’s sleeping time and is identified in stages: N1, N2, and N3 or deep sleep. NREM is the first phase of sleep your body slips into.
The fourth stage of sleep is R sleep, or REM sleep. This stage of sleep is characterized by quick eye movements and facial and finger twitching. Most dreams happen during R sleep.
Sleep patterns vary according to age. Most adults go through four to six cycles of all the stages of sleep — each cycle usually lasts between 90 and 110 minutes. Kids go through much shorter sleep cycles. For example, a 1-year-old may experience a sleep cycle that lasts only 45 minutes. By the time a child is about 10 years old, his sleep pattern will closely resemble that of an adult.

REM Sleep Confusion

While rapid eye movement (REM) sleep gets a lot of attention, researchers are still trying to decipher the biological purpose of REM sleep, according to Lisa Shives, MD, a sleep specialist at Northshore Sleep Medicine, in Evanston, Ill., and spokesperson for the American Academy of Sleep Medicine.

Dr. Shives says that a common misperception about sleep is that people mistakenly think REM sleep is deep sleep. “Deep sleep is stage 3. We also call it slow wave sleep, because that’s what the EEG [electroencephalogram] looks like.”

“The reason there’s confusion is because REM sleep is considered very important to feeling refreshed and having good cognitive function,” says Shives. “There’s a lot of talk about REM sleep, and people think deep sleep is the only good sleep.” Shives agrees that REM sleep is very important — one of its peculiarities is that it remains stable during a person’s entire lifetime, from the age of 6 to 96.

While REM sleep involves about 25 percent of sleep time throughout our lives, deep sleep rapidly declines even as we enter our 20s, says Shives. She says it’s very normal to see 50-, 60-, or 70-year-old men who don't experience deep sleep. "We do know that sleep becomes more difficult and more fragmented as we get older, and people have more sleep complaints,” she says.

Confusion also abounds about deep sleep. “When we say 'deep sleep,' people think we mean something more,” says Shives. Deep sleep literally means the sleep that is hardest to wake up from. “We’re not sure it’s somehow qualitatively better for you physiologically.”

The Debate About REM Sleep

"Sleep doctors are obsessed with REM sleep," continues Shives. "To a sleep doctor, there are three states of being, not just sleep and wake — it’s REM, non-REM, and wake."


REM sleep is unique. “Everything in the body is different during REM — your hormones, your breathing, your heart, your immune system, your muscles, your cardiac," explains Shives. "But we don’t know why. We don’t know the evolutionary purpose of it. We know that if you don’t sleep, you’ll go crazy and die, but we also know you don’t have to have REM." The big question stumping current sleep doctors and researchers is how this unique physiological state is not necessary for life, but may be necessary for well-being.

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Remedies for Sleep Problems Due to Aging

As people get older, their sleep patterns tend to change. Many older adults report being less satisfied with their sleep than they were when they were younger. But insomnia and other sleep problems are not a non-negotiable part of aging, and there are steps you can take to sleep better well into your later years.
Your sleep patterns are in part controlled by your body's internal clock. This clock helps determine when you feel awake and when you feel sleepy. From infancy to old age, hormonal changes and natural changes in your body clock cause shifts in your sleep patterns.

Learn about the different stages of sleep.
These shifts are thought to be why older adults tend to go to sleep earlier and wake up earlier than younger people. They also may be the reason that older adults nap more during the day and awaken more frequently during the night, says Phil Gehrman, PhD, CBSM, clinical director of Penn Medicine's Behavioral Sleep Medicine Program at the Penn Sleep Center in Philadelphia.

Age-Related Sleep Problems

Lifestyle changes that often occur with aging can also create sleep problems in older adults:

Health problems. Certain medical conditions related to aging can disturb sleep, says Dr. Gehrman. Older people are at an increased risk for obstructive sleep apnea, periodic limb movements, acid reflux, arthritis, chronic pain, and other ailments, all of which can alter sleep patterns.
Changes in your schedule. After retirement, you tend to have fewer responsibilities and can enjoy a more relaxed daily schedule. While not having to keep a rigid routine is one of the perks of getting older, it can also disrupt your sleep patterns and put you at risk for insomnia.
Less exercise. While some adults stay active throughout their lives, many of us tend to become less active as we age. A lack of regular exercise can make it harder for you to fall asleep and stay asleep throughout the night.
Nighttime waking. Natural changes in your body clock cause you to sleep "lighter" as you age. "Sleep definitely becomes fragmented as a function of age," says Gehrman. Frequently waking up at night can lead to daytime sleepiness and problems with sleep.
Stress and worry. Life events that are common among older people, such as the loss of a loved one or financial difficulties, can lead to a racing mind and excessive worry that can cause sleep problems.
Check out this photogallery for 12 tips on good sleep.
10 Sleep Tips for Seniors

If sleep is becoming more difficult for you as you get older, try these steps:

Talk to your doctor. If you have a health condition that is making it difficult for you to sleep, such as severe arthritis, chronic pain, or obstructive sleep apnea, getting it treated may help you sleep better.
Limit caffeine and alcohol. Gehrman recommends avoiding excess caffeine and alcohol, since these substances can interfere with your sleep patterns. As a rule, you should avoid caffeine after mid-afternoon.
Set a sleep schedule. "If you have a regular bedtime and a regular wake time, then you tend to promote sleepiness at night and alertness during the day because you are promoting your body rhythms," says Gehrman.
Skip naps. If you have trouble sleeping at night, napping during the day can aggravate insomnia. Skipping your nap can make it easier for you to fall asleep and stay asleep.
Keep a journal. Gehrman recommends writing down your problems and their solutions during the day. "By doing that, you tend to lift them off your shoulders so your mind doesn't churn over the problems at night," he says.
Exercise at least four hours before bedtime. "Exercise is good for sleep, but only if it is done at the right time," says Gehrman. Exercising too close to bedtime can cause a rise in your body temperature that makes it difficult to fall asleep.
Try relaxation exercises. Learning to relax before bedtime can help you sleep better, so consider trying progressive muscle relaxation, yoga, or meditation before bed.
Remove your clock. Gehrman says that people who have sleep performance anxiety should not keep a clock in their bedroom. "The clock is putting time pressure on you," he says.
Use your bed only for sleep and sex. If you eat, read, or watch TV in bed, you begin to associate your bed with activities other than sleep.
Don't lie awake in bed. "Get out of bed if you can't fall asleep," says Gehrman. "Do something boring like read the phone book, and then go back to the bed only when you get drowsy."

Following these golden rules for getting better sleep should leave you feeling more rested as you wake up to greet each new day.

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A Glossary of Sleep Terms

Many people think getting a good night’s sleep is as easy as putting your head on your pillow and closing your eyes. Those with sleep disorders, however, realize there is much more to it than that, starting with medical terminology that sometimes barely sounds like English. Use this glossary of important sleep-related terms to better understand your condition.

Advanced sleep phase disorder: People with this sleep disorder go to sleep very early, typically between 6 p.m. and 9 p.m., and wake up extremely early, anywhere from 1 a.m. to 5 a.m.

Bright light therapy: Used for jet lag and sleep disorders such as advanced sleep phase disorder and delayed sleep phase syndrome, bright light therapy exposes you to a light much brighter than regular household light; if used at certain times of the day it can help to reset your body clock.

Cataplexy: Cataplexy results in a loss of control of one’s muscles. It can happen during emotional situations and also in people with narcolepsy.

Circadian rhythms: Circadian rhythms, controlled by the body’s biological clock, are the changes that occur during the cycle of a day, making you alert in the daytime and tired at night.

Continuous positive airway pressure (CPAP): Often used to help treat sleep apnea, CPAP uses an air compressor and a mask that covers the nose and mouth. A continuous stream of pressurized air blows into your airway to keep it from collapsing during sleep.

Delayed sleep phase syndrome: This circadian rhythm disorder keeps you from getting sleepy until later at night — often not until the early morning hours — and to sleep later than most people. Individuals with delayed sleep phase syndrome often go to sleep between 1 a.m. and 4 a.m. and wake up anywhere from 8 a.m. to 11 a.m.

Insomnia: This is the recurring inability to fall asleep or stay asleep for a necessary period of time. It affects up to 60 million Americans each year.

Melatonin: This hormone helps regulate biological rhythms including sleep. It is made naturally in the body and is also available as a supplement to help treat insomnia and jet lag.

Narcolepsy: This sleep disorder causes sudden attacks of deep sleep that last from seconds to more than half an hour. Cataplexy, temporary paralysis, and hallucinations can also occur.

Obstructive sleep apnea: Also called sleep apnea, this disorder causes you to stop breathing while you’re asleep. During deeper phases of sleep, a person with sleep apnea will have periods when the muscles in the back of the throat and around the upper windpipe relax so much that the opening in the airway collapses, leaving you without oxygen for anywhere from 10 seconds to a minute. Eventually the lack of oxygen rouses you enough for the upper airway muscles to tighten and air to flow in again. Often, though not always, sleep apnea is accompanied by snoring. People with this disorder are awakened many times a night, though they are usually not aware of this, and can experience daytime sleepiness and other side effects.

Periodic limb movement disorder (PLMD): PLMD causes you to move your legs every 20 to 40 seconds, severely disrupting your sleep. People with PLMD may also have restless legs syndrome.

Rapid eye movement (REM) sleep: REM sleep is the stage of deep sleep when your eyes move in a rapid motion and your breathing and heart rate are faster. This is also the stage of sleep when you normally would dream.


Restless legs syndrome (RLS): This disorder causes a tingling, crawling, or prickling feeling in the legs. During the day, constantly keeping your legs moving can help ease symptoms, but at night, RLS may cause insomnia. A number of people with restless legs syndrome also have periodic limb movement disorder.

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