Sleepless in Portland

The Maine Sleep Institute tries to help us all get a little rest. We could use it.

By Amrita Narayanan Bruce

SLEEP WATCHER: Michelle Mistler takes notes on the sleeping patterns of patients at the Maine Sleep Institute.

“Sleep the death of each day’s life, sore labor’s bath, chief nourisher in life’s feast” — William Shakespeare, MacBeth

Remember Edward Norton’s portrait of an insomniac in Fight Club? Extremely glorified. The sleep-deprived people in the waiting room of Chest Medicine Associates, staffed by doctors George Bokinsky MD and Robert McArdle DO, make Norton’s character look refreshed. The clinic is a gateway screening facility — the most ill of this group will go on to the Maine Sleep Institute for further testing.

As they wait to see the doctor, none of the patients are perusing the excellent magazine selection. They all stare fixedly in front of them. All of them look haggard. The stark, dark circles under their eyes would put Hollywood’s best heroin addict look to shame. There are two couples and both hold each other tightly for support. It’s hard to distinguish who is unwell and who is accompanying their partner. Two children walk in. They too look exhausted and one of them is staggering rather than walking.

“You walk into a room, forget why you are there. You can’t remember the names of people you’ve known for years. Your memory and concentration are badly affected,” says sleep supervisor Mark Cole, describing sleep deprivation. He is speaking of symptoms he’s experienced firsthand — before his recent promotion from technician to supervisor, he worked nights at the Sleep Institute and developed his own sleeping problems as a result.

Sleeplessness (including difficulty sleeping and experiencing poor-quality sleep) is a growing problem in Maine

and in America. According to the National Sleep Foundation’s (NSF’s) 2001 “Sleep in America” poll results, a majority of American adults (63 percent) do not get the recommended eight hours of sleep needed for good health, safety, and optimum performance. In fact, nearly one-third (31 percent) report sleeping less than seven hours each week night, though many adults say they try to sleep more on weekends.

This year’s poll also shows that more than one-third of Americans say they get less sleep now than five years ago. So the numbers are rising. “Forty percent of Americans will have sleep problems at some time in their lives,” says Dr. George Bokinsky, medical director of the Maine Sleep Institute, a Portland-based laboratory and research facility for those with sleep related illness.

This year, the Institute has already done over 1000 studies of sleepless people, the most in its seven-year existence. Patients come from all over Maine, even New Hampshire and Vermont. “We’re struggling to keep up with demand,” says Cole.

Why are we sleepier today than we ever have been? “Like most things, it’s a lifestyle illness,” says Bokinsky. “We tend to burn the candle here in America — there are so many people who work very hard all day and then stay up late watching TV.” Americans are known for working hard and managing on minimal vacation — the national standard of two weeks of paid vacation a year is very low compared to other developed countries (almost a month of paid vacation in Britain). And many Americans work even on those rare vacations. (Heck, I’m writing this over Thanksgiving.)

Achievement and high levels of motivation are classic American values, but, out of balance, they topple us over. As a nation we are working and playing so hard that staying still has become challenging. According to the NSF report, American adults spend less time involved in leisure and social activities, having sex, and sleeping compared to five years ago. Many of Bokinsky’s “insomniac” patients are overstressed and highly strung and in need of psychotherapy and relaxation therapies (such as massage).

Lack of exercise and overeating are two other major factors — sleep specialists have found a correlation between obesity and poor sleep. This is because excess fat makes it difficult to breathe, and poor breathing is the single largest cause of sleep problems that are not psychological. Obesity in Maine is slightly higher than the national average, (around 56 percent, or around 1 in 2 people, are overweight) making Mainers especially susceptible to sleep disorders.

Broadly, there are four types of sleep disorders:

1. Insomnia: difficulty falling asleep or getting back to sleep after being awoken, usually caused by psychological or lifestyle issues.

2. Sleep apnea: disturbed sleeping patterns characterized by a feeling of exhaustion after an apparently good night’s sleep and caused primarily by difficulty breathing.

3. Restless Leg Syndrome: as the name implies, problems sleeping due to a limb that shakes or moves.

4. Narcolepsy: loss of control over the sleep function and falling asleep at inappropriate moments, caused by a genetic mutation.

Bokinsky reports that most people he sees either have trouble sleeping (insomnia) or are waking up after a night’s sleep and feeling poorly rested (probably because they have had fragmented sleep caused by breathing problems — sleep apnea). While insomniacs generally recognize their problem, apnea sufferers often don’t realize they have breathing difficulty and are only aware of not feeling rested after sleep. “You won’t believe how many people come in to the sleep institute because their partners complain of excessive snoring,” says Bokinsky, explaining that snoring sounds are caused when there is an obstruction of the free flow of air through the passages at the back of the mouth and nose.

The history of sleep problems in Maine dates back to 1978, when Bokinsky and an associate performed the first sleep test in Maine. “We had a patient in the hospital who was very ill [from lack of sleep]. We used very basic equipment and actually stayed right there at his bedside watching him,” recalls Bokinsky, adding that, today, technological advancements, more research in the field, and an increased budget allow sleep specialists to use video cameras and sophisticated equipment to monitor 17 variables in sleep including heart rate, respiratory rate, brain waves, muscle movement, air movement, and carbon dioxide build-up in the blood (versus four back in 1978).

At the time, there was also no specialty in sleep medicine, and when the American Board of Sleep medicine was finally created in 1991, Dr. Bokinsky was one of the first in the state to get board certified. Today, there are seven doctors in Maine who are board certified in sleep medicine, two in Portland (Bokinsky and his work partner, osteopath Dr. McArdel). The other five are located in Brunswick, Bangor, Waterville, and Lewiston.

Growing interest in sleep and the escalating numbers of sleep-deprived people has created a need for increased education on the subject. “We are trying to develop a faculty to teach people about sleep,” says Bokinsky, who teaches monthly classes on sleep in Portland at Maine Medical Center. To an audience that includes a number of invited doctors, psychologists, and psychiatrists, Bokinsky lectures on a variety of sleep-related subjects such as how sleep deprivation affects children. Bokinsky’s partner, Dr. McArdle teaches at New England College of Osteopathic Medicine, and the two are in the process of looking for funding so that the sleep institute will eventually be able to offer a year-long internship for medical students focusing exclusively on sleep and sleep disorders.

It’s 8 p.m. in the sleep institute offices at 930 Congress Street in Portland, and Dr. Bokinsky looks undaunted by the task of having to work a night shift immediately following his day shift. Instead, he is somewhat excitedly perusing the brainwave and sleep activity charts that technicians have collected the night before. The charts depict the patients’ sleep and wake patterns, breathing, eye and leg movements, among other data.

He introduces me to the sleep technicians who will actually stay up all night watching patients sleep.

“I set up the patients in bed and then I just watch them,” says sleep technician Michelle Mistler, gesturing towards the video screens in front of her that capture four patients, each struggling to sleep. Mistler will stay up all night to take notes on their sleep positions and patterns. “The sleep technicians are the unsung heroes in this,” says supervisor Cole. “They sacrifice their sleep for others.”

“It’s a very rewarding field,” Bokinsky says. “The diagnostic tools give us good results and we are able to act upon them.”

Talking to and observing the patient and their brainwave patterns allows Bokinsky and McArdle to make a diagnosis identifying the problem as apnea, insomnia, or another disorder. For apnea, they often recommend C-PAP (Continuous Positive Air Pressure)a specially designed nasal mask that creates enough pressure to keep your airway open when you inhale, thus facilitating good breathing. Before the invention of the nasal C-PAP, a recommended course of action for a patient with sleep apnea or habitual snoring was a tracheostomy, a surgical procedure creating a temporary opening in the windpipe. The C-PAP treatment has been found to be nearly 100 percent effective in eliminating sleep apnea and snoring when used correctly, and has eliminated the necessity of a surgical procedure.

On the other hand, the causes of insomnia are primarily environmental or psychological. Doctors might recommend counseling for stress- or trauma-related insomnia, or changes in sleep environment if they believe that the patient is not sleeping in sufficiently restful surroundings. Other patients may have a “learned insomnia” — they were not able to sleep on some occasion (say the death of a loved one) and absorbed this bad sleeping habit so deeply they are unable to sleep long after the disturbing incident has passed. For this, the Institute may try “sleep restriction therapy” — forced sleep deprivation in order to reset a person’s normal sleep pattern.

ýtill others may have insomnia due to a disturbance in their sleep/wake cycle (circadian rhythm cycle). This type of problem is often experienced by night workers — people like Sleep Institute supervisor Mark Cole. Those who work nights may not be able to sleep during the day because the light affects their body, impeding sleep. For some people, their body clock slowly resets once they cease working night shifts, others may need photo-therapy: simulated sunlight shone on the patient’s body to indicate to the brain that it is time to wake up. All these treatments are largely successful and 90 percent of patients sleep better after six months of treatment or counseling at the Sleep Institute.

The practice of sleep medicine is different from other specializations in the field in several ways. For example, in sleep medicine the doctor spends long periods of time with each patient and emphasizes the therapeutic relationship between the sleep doctor and patient.

“If you listen to a patient long enough, you’ll find out what’s wrong with them,” Bokinsky says. “You will also find out what’s right, and then come up with some sort of strategy to solve the problem through testing. Once you address the problem you need to follow through. If you don’t do all those steps you haven’t completed the circle of therapy.”

To most of us, too familiar with being shuttled out of the doctor’s office with the feeling of being rushed, this is a new concept. “Once we accept somebody in our practice, it’s not just a here-today, gone-tomorrow-type thing. We try to avoid the situation that someone comes in, disappears, and is never heard from again. Both doctors and technicians have a strong relationship with patients,” adds Bokinsky, making it clear that his field is a mind-body science that relies on both physical and mental interventions.

Another difference from standard medicine is a sharp departure from reliance on pills, as commonly seen in today’s medical practice. “Medication is reserved for the seriously ill,” says Bokinsky, “such as people who can’t sleep because of Parkinson’s disease or those who are acting out their dreams at night.” Sleeping pills are seen as only temporary palliatives. “As a patient, you need to ask the doctor, ‘Why am I being prescribed these pills? Is there any other alternative?’ ”

Bokinsky has five reasons for advising against sleeping pills except in the short term (i.e. a week or two): “One, if you suppress the symptoms, nature and doctors might delay addressing the real reason of what’s wrong. Two, sleep induced by pills suppresses deep sleep and is lighter and more fragmented than natural sleep. Three, you might develop a resistance to your sleeping pills and need increasingly higher dosages. Four, there are times at which it’s important to stay awake — say your house is on fire. And, five, there’s a carry-over effect the next day and you might feel tired or groggy.”

SLEEP DOCTOR: Dr. George Bokinsky helps Mainers hit the hay successfully.

The “carry-over effect” of sleeping pills applies to the sleep deprived who need a sleeping pill to put them to sleep at night and a big espresso to wake them in the morning. Many of Bokinsky’s patients fall into this category, and they eventually approach him in order to be weaned off their medication.

“First thing in the morning, you shouldn’t really be needing caffeine,” says Bokinsky sternly. “You could use it as you need it, if you need it for a mid-morning energy lift or something. But if you have to use it in the morning to get started when you first wake up, you should ask yourself Why do I need this? And if I do, why did I not get a good night’s sleep?’ “

Bokinsky isn’t the only one addressing this question. A host of side industries have grown out of sleep disorders, including companies that make diagnostic equipment and others that make products promising to cure your sleeplessness.

The Maine-based sleepagain.com is a classic example. The company caters exclusively to the sleep industry, selling diagnostic equipment to sleep labs and to individuals for personal use at home. “This [sleep medicine] is a new field that is poorly served,” writes CEO Richard Haslip. “There are thousands of people suffering from sleep apnea and other disorders. These people are at high risks for many health problems as well as being chronically fatigued. I wanted to have a service to assist physicians in diagnosing these problems.”

Mainers can also access a host of other “sleep promoting” products, including white noisemakers (designed to improve the sleep environment through sounds), snore guards (prevents snoring), not to mention a range of mattresses designed to promote sleep.

However, this approach is hardly scientific. “I can’t tell you too much about white noise makers, special mattresses, snore-guards, or the breath-right strips,” says Bokinsky of the many self-help products for poor sleepers. “They must help some people. If they didn’t help some people they wouldn’t exist. But most people whom we see have sleep problems that are not so easily fixed.”

Herbal remedies for sleep are also on the rise. Toms of Maine recently expanded their product line to include herb tinctures (extracts) including those that promote sleep. However, a skeptical Bokinsky isn’t sure there is sufficient scientific evidence showing herbal remedies to be helpful. Thumbing through his sleep bible (Practices and Principles of Sleep Medicine 2000) index, he says “Kava-kava is not under K, Valerian root is not under V. There just haven’t been enough tests done for it to be scientific.”

Just because the tests haven’t been done, however, doesn’t mean these herbs are not effective, and Bokinsky acknowledges this by saying: “We are not so set in our ways that we would dismiss any alternative ways of sleeping such as those offered by Chinese medicine.”

While he is not a proponent of herbals meds, Bokinsky does believe in progressive relaxation — best exemplified in yoga and mediation. “Meditation is listed under M,” he jokes, looking at the sleep bible index once more.

“The unexamined life is not worth living,” he quips, quoting Socrates, “and I think meditation is always a good thing. Yoga is also really helpful. Both help people to relax and slow down their breathing.” Additionally, both yoga and meditation “decrease physiological arousal and cognitive arousal,” he continues. Translated, they reduce body tension and slow down the pace of thoughts so that the practitioner can relax enough to fall asleep. “I don’t always think of suggesting meditation though,” confesses Bokinsky. “We just weren’t trained to do that back when I was in medical school, but there’s much more evidence for it now.”

Before he can get the opportunity to prescribe meditation, however, Bokinsky has to get access to these sleepless sufferers. All patients at the institute have to be screened by several sets of doctors before they arrive. People having sleep issues may see their primary care physician, a neurologist, or other doctors before making it into Bokinsky and McArdle’s clinic (Chest Medicine Associates) where the doctors spend time talking to the sleep-deprived to figure out if they need further testing at the Maine Sleep Institute.

Interestingly, most insomniacs don’t make it into the institute. “Insomnia is just a symptom of another problem,” explains Bokinsky. “It’s important to address what’s actually going on. Often it’s stress or depression.” Bokinsky believes most people can be talked out of their insomnia by effective psychotherapy and sleep counseling.

In addition, insomnia is often misdiagnosed. “Some people wake up because of a respiratory problem and then have trouble falling asleep,” says Cole, “but that should not be treated as insomnia, it should be treated as apnea because it’s a breathing issue.” Over 85 percent of the cases at the Sleep Institute are some form of apnea.

But how is sleeplessness manifesting itself in the real world? Well take the example of Portland’s public schools, where the issue of sleep deprivation is a recurring problem.

For the past several years, kids at Deering High School have been running sleep surveys and articles on sleepy students in the school newspapers. “The first survey was at Deering in 1999, and since then there have been several surveys and articles including a recent one at Lyman-Moore Middle School,” says Deering journalism teacher Elsie Whidden. Whidden, who supervises school newspaper activities, says that most teachers feel students are lacking enthusiasm and verbal participation in first period due to sleepiness. Portland students heard about survey results on this subject in the national press and since then have done some research of their own.

“We’ve imposed sleep problems on high school kids by making them get up and go to class before their brain is fully awake,” says Bokinsky.

The solution that has been thrown around is a later starting time for high school kids. “With puberty comes a delay in the timing of teens’ internal body clocks, or circadian clocks, which regulate sleepiness and wakefulness. Teenagers aren’t able to fall asleep until at least 11 p.m. or later, and awaken later in the day,” says research from the National Sleep Foundation. “Because of their unique sleep needs, teenagers’ brains are not ready to be alert until long after the typical high school day has already begun,” explains Richard Gelula, the NSF Executive Director.

The word is spreading. “I think the administration is finally going to do something about it,” Whidden says hopefully, explaining that the issue is currently under consideration by the central office of the school department. However, while most high-school kids admit that their concentration is affected by their late nights and early mornings, many do not support a schedule change because they would rather have more free time in the afternoon.

The sleep debate in the Portland public schools may take a while to be resolved, but the fact that the debate is taking place at all is an encouraging indication that officials and students are becoming aware of the problem of sleep deprivation. If kids are waking up to the importance of their nightlife (and how it affects their day-life) adults might be next in line. When they do, those in Maine will find a wealth of research, advice and some very dedicated sleep technicians and sleep specialized doctors to help them improve the quality and quantity of their Z’s.

Amrita Narayanan Bruce can be reached at amritabruce@yahoo.com.