medicine is about to change. With luck it will fundamentally shift how people treat and view sleep.
What will disappear? The common present treatment format – what I’ll call the “Sleep Apnea Testing Service Model”- after the suggestion of Penn's Dr. Michael Grandner. What will replace it? Hopefully a treatment format that addresses and improves both individual and public health.
Why Is Change Required?
Twenty five years ago sleep medicine was primarily a group of researchers who knew each other and generally got on well. CPAP changed that equation. Here was a treatment that could improve – or save – the lives of tens of millions. And all you needed was pressured air, and you could improve or even fix the stopped breathing episodes of obstructive sleep apnea.
CPAP worked. Sleep medicine mushroomed and sleep laboratories proliferated. They tested with lucrative intensity. In my small town there used to be nine sleep labs, with the studies often “read” by a technician thousands of miles away – or just by a computer program.
Insurance companies no longer want to pay that price.
Home sleep studies presently arrive in many shapes and sizes. Most of the ones commonly used can tell you whether you have pretty bad sleep apnea, and usually not a whole lot more. But they’re cheap.
A full sleep lab based study provides much more information about your health. But much of that information is never discussed or is thrown away by clinicians who zero in on the on the number of stopped breathing episodes per hour – to see if that fit insurance criteria – and precious little else.
You make a lot more money testing patients than you do talking, cajoling, and teaching them ways to get healthy. To do that requires addressing the purposes of sleep.
What Is Sleep For?
Sleep is no longer commonly viewed as a biologically regrettable waste of time. Now the public thinks of it as related to survival, health and productivity.
Why? The human regenerates itself to live. It needs rest to do it. Most of the body is remade in three weeks or so. Take out skeletal proteins and most of the heart is gone and remade inside three days.
You can’t regenerate without sleep.
Different Approaches to Sleep Medicine
Here’s an example of how sleep medicine performs today, and how it might perform using the approach of what I’ll call Regeneration Medicine. First, the Standard Model
Night 1 -You go into a sleep lab. You’re hooked up like an astronaut. At 5:30 your sleep clinician walks in, shakes your hand, tells you have sleep apnea and says you need a CPAP trial – adding it’s an air device to treat stopped breathing episodes.
You’re too sleepy to ask sensible questions or to remember what she said.
Night 2 – You get fitted with CPAP device. It’s weird. It uncomfortable. Your brain has trouble figuring out what this plastic mask is doing stuck on your face.
Your sleep clinician walks in at 5:30. She explains your moderately bad sleep apnea is very effectively treated by CPAP. You will be given a prescription to a durable medical equipment corporation which will take care of everything – including all the problems you will probably face using CPAP.
See you in three months.
Sadly, real practice is often worse.
Regeneration Medicine Model
After your sleep study is over, you go see your clinician. He sits with you for a half hour, and goes over the many implications of what you did through the night.
You’ve got some apneas, but they don’t explain all the many arousals that wake you till dawn. Sleep apnea is just one of the reasons for your insomnia (the majority of sleep apnea sufferers have insomnia,) your constant fatigue and mental dullness, your anger and frustration on and off the job.
There are different treatments for sleep apnea. One is CPAP. Dental devices can help, as perhaps sleeping on your side. But most people develop apneas after gaining weight. And since worse sleep increases weight gain, here is a cycle you really want to break.
Sleep is a critical part of the rebuilding, remaking process that keeps you alive. To properly treat your sleep problems you need to look at what you eat and when; when and how you move; how to remove stress at your workplace and home; what you precisely do in the two hours before you sleep; how, where, and when you go to sleep and wake up; plus the overall physical/mental activity cycle of your day. Your partner/spouse is asked in, as they are usually part of the solution to the many problems poor sleep causes.
The overall goal is health – your physical, mental, social and spiritual well-being.
To survive in an economic climate that looks almost exclusively at cost and occasionally at effectiveness – very narrowly defined – sleep medicine has to recognize the importance of rest to overall health – and then show people how they can get good rest.
Such “comprehensive” care should prove attractive if insurance companies are smart enough to recognize that healthy people save them money. That’s a big if, but there is hope.
Meanwhile, as in lab sleep testing is refused by insurance coverage more and more, sleep medicine will have to become more open and more efficient.
That means recognizing that sleep apnea does not in any fashion equal sleep medicine. America has tens of millions of insomniacs; people who can’t overcome shift work; jet lag sufferers; kids who can’t learn because they don’t sleep; depressed and anxious people who need to sleep in order to get well; narcoleptics and night eaters who can’t get out of bed; and hundreds of millions who might use sleep more effectively if they knew how.
Many treatments are immediately cost efficient. The presently reviled VA System has figured out that group treatments work well. CPAP is often much more accepted and effective when groups of people get together and talk about how to do it – learning from each other. Insomniacs can jointly discover the basic skills let them learn how to sleep naturally and pleasantly.
These days America "does" health care. But it doesn’t do health – work to improve individual and national well-being. To succeed, sleep medicine should embrace the latter. The body can’t regenerate properly without sleep.
That third of life is there for a reason.