to everybody .

>> And good evening.

Thank you so much for watching HealthLine on PBS 39 PBS Fort Wayne.

I'm Mark Evans, your host and very interesting show tonight especially if you or someone you know and love has a sleep disorder and those are very common or becoming more common these days we have returning to our panel I haven't seen him in a while but we like so much we want to come back again.

It's Dr. Sreenevasan David David, Nathan, Devin, David, Nathan.

>> You did it well, I'm going to get it there, Doctor.

It's always a pleasure.

We were actually kidding around before the show about how your name gets mixed up a little bit.

Nice to be back.

Yes.

It's nice to have you.

We had a great show the last time you were here and you brought somebody along from the office.

Her name is Desiree Haim and she's a nurse practitioner.

It's nice to have you and this is your first time on the show.

It is.

All right.

Very good.

Well, doctor and nurse practitioner, we're going to go ahead and get started and before we do so I want to go ahead and plug that phone number on the screen.

It's 866- (969) to seven to zero any time in the next half hour we have a question.

Please call us.

We'll get to you as soon as we possibly can.

>> So doctor and nurse practitioner, we are going to be primarily talking about the REM sleep behavior disorder but we kind of have to get there first going through a couple of paces.

Would you provide some statistics about sleep disorders especially in the United States these days?

>> Yeah, I think the common sleep disorder that we run across in most cases are obstructive sleep apnea where your incidence rate can be as high as 20 25 percent almost similar to the range of asthma patients and then you have a series of other sleep disorders restless leg syndrome parasomnia which we call which of which REM sleep disorder comes into play narcolepsy the percentage of a disorder that we're going to talk about today is about probably about two percent but I think it's underestimated because the lack of recognition of symptoms or lack of awareness of the symptoms as to what they lead to OK, very good.

>> And how many let me ask it this way who is most at risk to have a sleep disorder?

So if you're talking about specifically REM sleep behavior disorder.

Yes, Then we have to think about different causes.

OK, and oftentimes we find that this disorder is present in people who could have an underlying neural neurodegenerative predisposition neurodegenerative disorder predisposition, Parkinson's disease, Lewy body dementia, multisystem atrophy so they have certain proteins called Alfa's nuclear empathies which are found in the brain that can lead to these problems.

REM sleep disorder becomes a manifestation of those patients .

You have a group of people that take mood stabilizing medications like those which influence the serotonin, the northern end and nor adrenergic pathway that can affect their movement their night.

You have a type of you have a group with narcolepsy which can have this disorder as well.

You have other non neurodegenerative neurological disorder patients who can have this.

But this seems to form a larger variety of this group REM sleep which OK and of course the reason why we're talking about REM sleep because is so important but there are some other stages of sleep before we get to that REM mode and if you don't mind if you can briefly go over those nerves.

>> Yeah, there are two main stages of sleep the first one being non REM sleep and then the second being REM sleep REM for the rapid eye movement during REM sleep is when our body is what you could say paralyzed.

It doesn't move as much and during that stage of sleep is typically when we dream and our brain is transferring memories our brain is working really hard to process the things that we encountered throughout the day.

>> And so why do those sleep stages matter?

I mean they all have to be fairly well tuned to work with each other, is that correct?

I mean you can have problems with stage one sleep and then I'm sure that will cause some problems for eventually the remote sleep.

>> Is that correct?

So we have to think about sleep as a continuum during the night.

OK, that's a good way to put it .

So while we categorize and sleep medicine different stages non REM and REM sleep with the different stages of how it was described recently with the stage one, two and three three being the deep sleep REM sleep is a separate group among not outside of non REM sleep and people transition from room to room and back to non REM and then REM and this transition is is not a set timeframe like for instance we expect somebody to fall asleep in 10 20 minutes as a normal sleep on the latency we expect the person to get into REM sleep in about 90 to 120 minutes after they fall asleep again that's an expectation which can be changed or influenced by medications and Fryer's sleep deprivation and all those things.

But the whole continuum helps because what we have to remember is sleep is the time frame where we are asleep.

But your brain is very active, right?

It's processing all the information.

It's trying to get you to understand what all is going on.

Whatever you learned during consolidate information transferred from one part of the brain to the other part of the brain and so sleep has to have this changes in different groups.

If you think about the deeper sleep, that's when our breathing at a relatively normal stage.

When you think about REM sleep, it's more erratic.

There are muscles that act in REM sleep, the eye movement muscle.

That's why it's called rapid eye movement.

You have the diaphragm which is erratic, your sphincter tone is preserved but all the muscles are quiet because the brainstem sends those pulses to the nerves that supply the muscles to say remain quiet because that's the time it's trying to process all the information to retain the memory and consolidation so the brain knows that this change in stages are required for somebody to gain the benefit at that stage of sleep.

>> I see.

And there are some factors that affect these sleep stages.

What would be are those fairly common depends on which stage we talk about and that's a separate topic.

OK, but I would say that generally if you try to maintain a certain consistency in bedtime and wake up time you can expect these stages they can be influenced by you know, for instance in women it's generally considered that they might have a little bit more deep sleep than men if you have periods of sleep deprivation and you try to go back to sleep, you can have a REM rebound or deep sleep rebound first and then REM rebound.

So these can be influential for the stages of sleep and how important is a normal or regular sleep schedules say for instance you need to go to bed ten o'clock.

>> How important is that to this particular disorder we're talking about?

I think the most important thing is independent of this disorder.

It is basically it's an important aspect of maintain good sleep hygiene practices, maintain a consistent wake up time, a consistent bedtime in order to feel rested in order to wake and feel rested.

So a lot of people will come stating that in general you know where we were, where their sleep patterns can be shortened and therefore they are noticed to be more sleepy during the day.

So in order to get a decent amount of time so you always talk about less quantity quality and the influence of medical conditions and medications in it.

>> So it's important to maintain that consistency.

Well, and I'm sure as a physician as a nurse you probably recommend eight at least eight hours of sleep a night.

I mean is that a common number of hours?

>> That's that's a general ballpark.

I've heard six to eight I probably am right there in the seven category .

It seems to work for me.

It seems to be a kind of a personal thing as far as amount of sleep that you need.

>> Am I correct?

You are correct.

But there are also some individuals who were called short sleepers who can survive on five hours of sleep and some that are long sleepers would need nine 10 hours to function.

So it's a it's a variation.

OK, well that answered that and so with that said, as you're sleeping, how much REM sleep do you really need for your body and your brain about 20 to five percent is the general expected amount of REM sleep on a given night?

>> OK, now what happens if you don't get enough REM sleep?

Does it affect both physically and mentally so physically to the extent that you know you start feeling tired you're not able to maintain that concentration, you're not transferring all the information that you need getting lesser amount of time sleep.

But then if they have a disorder that effects in that REM sleep that creates activity that then tends to affect physically then that would be a different scenario.

That doesn't happen in normal REM sleep.

It occurs as a result of an abnormal behavior in REM sleep the physical part but the mental part is like REM is usually even as it's considered a lot of individuals think it's a deep sleep.

It's not a deep sleep, it's a lighter sleep.

The muscles are quiet.

The brain is helping you preserve all the information transfer and restore and wake up more rested so that mental part is affected when you get less REM sleep but the physical part of the REM sleep is the more that REM sleep behavior disorder that we are going to talk about.

Right.

And we're going to slide right into that very, very soon.

I did want to ask you about how this particular disorder, the REM Sleep Behavior Disorder, the main key of our conversation tonight how is that diagnosed?

>> So REM sleep disorder requires a detailed evaluation this that's a disorder that you don't usually pick up and diagnose on a sleep study.

OK, because you need additional monitoring apart from the standard I joke about it, I'd say you're going to look even more denser than a Christmas tree because you're going to have more monitors on you and the monitors will be focused on not only that in addition monitors and the arms there's all these monitors of the legs in a sleep lab but these are helpful to also know that there's activity in the chin and the legs and the arms and we have to have a camera that's focused on the patient especially when they're covered .

We got to see that any subtle movements and we have to look at certain characteristics because the American Academy of Sleep Medicine has characterized REM sleep disorder recognition through a separate abnormalities and their movements are what we call a muscle tone.

The amplitude of the muscle which has to be picked up during REM sleep to say that this is characteristic of REM sleep disorder so it's usually diagnosed through what we call as a video parly sonography.

Right.

You have the video camera on you and you have a detailed evaluation of all the channels.

I've had one of those before.

I've got sleep apnea so I had to have a sleep study.

My issue was I just have a problem sleeping anywhere but my own bedroom.

So it was kind unusual setting for me plus the wires I don't remember sleeping the entire night but they said that I went through enough of my sleep cycles and stages that they got enough information to diagnose me.

So I thought that was fascinating in itself.

So very few people I would imagine sleep all the way through that night but at least it's something and you get enough of a sample for that and that was many years ago.

So I'm sure there have been a lot of advances in the last 15 years or so.

>> So I want to remind our viewers that we have our phone lines open 866- (969) 27 two zero asking questions about the sleep disorder REM Sleep Behavior Disorder.

>> So with that said, if the sleep disorders that are associated with REM sleep we've already discussed and we're getting deeper into this with this particular entity.

So I want to ask you about some of the symptoms and safety concerns about this particular sleep disorder.

>> Yeah, so symptoms of RBD REM behavior sleep disorder can range from mild to complex so your mild symptoms that you may see would just be a simple movement of the hand or the foot as simple is a facial grimace.

It can get as severe as two patients swinging their arms and such a punching motion or kicking their legs as though they're running or even attempting to like jump out of bed in the frequency of the symptoms can vary.

It can occur, you know, just a few times a year or as often as nightly.

They can also exhibit vocalization during this time it can be as simple as laughing or talking.

Sometimes it can be as loud as shouting or screaming as well.

>> And what is that prompted by what they're dreaming a lot of times if you wake of a person during this episode they'll be able to recall what the dream is and what's going on and why they're running or screaming.

>> Yeah, and I think it's also amazing because I know everybody dreams but I really remember mine unless they really, really stuck out.

It's like why did I dream that last night?

>> And that's another whole subject right there.

We could talk about some other time but so with that said, are there any type of neurological concerns or disorders that come along with that?

>> Sure.

So being so the first and foremost as REM sleep disorder is called a parasomnia parasomnia parasomnia is an abnormal behavior during sleep and we you know, the way that we have always been started is in REM sleep you have to parasomnia one is nightmares and the other one is REM sleep disorder.

The nightmare ends and Ari and it's part of the REM sleep REM so that's how we remember it.

But the thing about REM sleep disorder it's can be associated with neurological consequences like patients with Parkinson's disease or Lewy body dementia etc.

So there are certain characteristics that we look for in these groups of individuals that are called pheno conversion markers that suggest that these individuals could later develop the disorders or they can actually have the disorder diagnosis first and then they come to come to think about it.

They come to express all this activity.

A lot of times it's more about this agitation.

You know, they feel like they're running away from somebody.

They're being chased by an animal.

They're kicking at someone.

They are beating up somebody they're loved one in fact not knowing that they're doing it because they're trying to respond.

The dream is so intense and for them it's so real that they want to protect themselves.

They want to but they're not intentionally hurting anybody but they are in the process of defense and that defense can lead to offense and that offense can lead to injuries.

>> Well, before the advent of sleep study medicine.

How are these people diagnosed?

What what how were they treated?

I, I, I would say probably the lack of knowledge about this disorder was rampant while in fact the in fact the the doctor the other neurologist um who actually described this is name is Dr. Carlos Schenck and he is the one who brought the world aware of this disorder.

He and another doctor, Dr. Mark Mahowald basically brought in fact there's a book called Paradoks Lost where there's a lot of description about different people's expressions of all that they faced.

There'd be people who have told me that I felt like I lived with an animal.

They would be so many different scenario because create so much panic and fear and scare for the individuals lying next to them because quite frankly ironically even though they're acting on all this and they may remember partially they don't know that they're doing it.

>> Yeah, yeah.

My father had the same thing.

My stepmother would tell a story.

So your dad had a bad night last night and Dad didn't like to talk about it.

He knew that he had these episodes but he was never he died at the age of 52 so he had heart disease and all that other before they even said hey, you have a sleep apnea problem as well.

>> Right on that regard, Mark, there are some individuals who have sleep apnea who could have activity that results were treated sleep apnea.

You have some individuals with narcolepsy.

You can have this disorder.

OK, but the the difference are those with the neurodegenerative tendencies tend to present more agitated behavior than the ones on medication that could create this or narcolepsy because their movements are not I would say not as agitating as I see we do have a call came in.

>> I'm going to see if I can read it.

It's for some reason that's my issue.

But some reason it's a different color.

>> How does I can't tell with menopause affects what's it Perriman OK perimenopause menopause rather how does that affect sleep baby menopause is that stage of the hormonal changes are so rampant that oftentimes people who have chronic insomnia that that's the presenting symptom hot flashes, insomnia, inability to handle different temperature in the room etc.

So it's sort of a different context from what we are talking about but it can affect more in the form of insomnia.

>> OK, that's a good question.

Thank you for that.

So we call that and she preferred to be off the air.

We don't have to have your voice on the air if you don't want to.

We'll certainly transcribe your question if you'd like.

Let's move on.

In fact, if you're just joining us, we're talking about REM sleep behavior disorder.

Of course REM stands for Rapid Eye Movement and this is a disorder within the other disorders that are very common .

But I wanted to ask you how you can improve your REM sleep.

Are we talking medications or how does one actually improve or REM sleep?

>> How do you get these people out of this?

I think they couldn't so you can't get people out of this REM sleep behavior disorder.

There are certain medications and certain treatments that I don't want to get out talking about in a public forum because that's something that has to be individualized for the patient.

Oh sure.

Sure.

But as far as a normal REM sleep, it's good to kind of try to get that through establish bedtime wake up time routines and waiting periods of sleep deprivation and rebounds.

So if a person has this they're going to come in and see you every so often.

>> Yes, that's the recommendation.

OK, and what would you do when they come in for these checkups?

What kind of testing or what kind of questions would you happen to ask them?

>> You want to take them?

Yeah.

Yeah.

So we're just going to reevaluate and see how often they're experiencing the symptoms and if they are on any form of medication to treat it how that is working for them it's really helpful if the patient brings a bad partner with them because most of the time it's their bed partner who's reporting the frequency of the episodes.

>> Can this be handed down from generation to generation?

Is it inherited?

Not that we know of .

OK, you haven't seen us not that I am aware of I should say.

OK, very good.

All right.

Talked about treatments.

So is this particular disorder is it entirely curable or is this something that this person will be dealing with with treatment and it gets better?

You know it's usually no it's usually something that they deal with that they deal with themselves.

OK, all right.

And when should you talk to your doctor or when is it a good time to bring this up?

I know some people drag their feet.

They don't want to have to deal with it.

But I think that if you would go a long period with this it's only going to be more destructive to you if I'm correct.

>> So when is it time when do those red flags pop up?

Yeah, I think it's important.

You know, if you start to notice those symptoms to monitor them, if it's causing injury to yourself or to your bed partner, you definitely need to bring it up with your physician and discuss the behaviors that are being noticed and who should you see first and should you discuss this with your family doctor?

Do you need to be referred to a sleep specialist?

>> I think to answer that we can talk about the safety involved in this.

I want to share some thoughts.

>> Yeah.

Yeah.

So safety in regards to the sleep disorder, it's really important to evaluate your sleep environment, your bedroom or whatever location you're sleeping at.

>> You want to make sure that if you have a bedside table that there's nothing on it that you can pick up or throw nothing that will break like lamps if you're able to move a table away from the bed that's ideal.

If you're not maybe consider padding around the edges.

>> Bedrails are really important for the sleep disorder just to help prevent patients from falling out of bed.

Some patients may even consider putting their mattress on the ground to prevent any injury from falling out of bed or placing padding on the ground if there are any firearms in the house it is very important for these to be locked up outside of the bedroom and a safe just for the safety of everyone in the home.

It's also important to consider the safety of a bed partner as well.

For some patients it's safest for the bed partner to sleep in a different bedroom.

>> Is this associated with sleepwalking?

So sleepwalking is a non REM parasomnia.

OK OK so that's a little bit of a different entity compared to the REM sleep disorder.

A lot of people apparently be a disorder may get brief moments shout scream, yell, punch kick do a lot of different things and then they just go back to sleep.

What if the sleepwalking it's part of the spectrum that rises from non REM sleep which is the earlier part of the sleep cycle and they get out of the deeper sleep usually comes out of the deep sleep and so they start they wake up.

There's a confusion arousal.

They don't know what they said.

They just wake up and that that may lead for them to get out of bed and start walking and that can also lead them to like sleep eating.

So it's a continuum that can occur in that group.

Well, the reason I ask is because we're talking about this particular sleep behavior disorder and you said any weapons and things like that have to be hidden.

That's why I'm asking and it's kind of like a sleepwalking disorder as well.

>> I mean so why is it so necessary to hide all those weapons?

Well, we just don't want them on the bed say benzyl jaspar anywhere within reach.

>> Yes.

No accidental discharges.

I gotcha.

OK, what we have about a minute left in the show and I always take this time to maybe do some take home notes and maybe support our viewers and let them know this is OK. >> They just need to get help.

Sure.

I think the summary is, you know, REM sleep is important.

It helps us to help to retain retention of memory consolidation is very important in REM sleep.

REM sleep is a quiet sleep.

REM sleep is very useful but some people have a disinhibition of the quietness if I may say and that's when they start exhibiting all these agitated movements so they start noticing agitated movements and their bed partners that sort of follow a frequency occurring about one afterwards after they fell asleep and especially it was early morning hours and they started getting more agitated.

They started to feel that their their own safety is compromised.

The patient safety is compromised.

They really need to seek help.

They need to talk to their provider, see what's going on there.

There are a few other differential diagnosis for this disorder but that we can't get into that at this point when it's important to talk about because as we recognize that important recognition of this disorder is critical because it is treatable, you can limit the activity but you also have to foresee any possible neurodegenerative changes that can occur so that you can have a more combined approach of involving additional specialists in and treating this and for the safety of the patient and safety of the family and others.

All right.

Dr. David Nathan, do it right.

You have close enough right and nurse practitioner Desiree Home.

>> Thank you so much both of you for coming.

Thank you for it's always an interesting conversation with the doctor and we thank you for watching and for your calls tonight and of course we'll be back next Tuesday night with another episode of HealthLine.

You can check out YouTube for this and other HealthLine episodes until next time.

>> Thanks for watching.

Good night and good