Learn to Sleep Well and Do It Early – Advice from Sleep Expert Prof. Michael V. Vitiello

FOREWORD Disordered sleep can negatively impact both physical and mental health. It is no exaggeration to say that sleep disturbance affects all aspects of people's everyday lifes. Sleep research is steadily clarifying the full nature of sleep relationships with health. Prof. Michael V. Vitiello, Emeritus Professor of Psychiatry and Behavioral Sciences at the University of Washington, is an internationally recognized expert and active researcher in sleep, circadian rhythms, and sleep disorders in aging. This interview with Prof. Vitiello was an impressive conversation that spanned the 15-h time difference between Beijing and Seattle. During his long research career exploring the impact of sleep disorders and ways of improving sleep, particularly in older adults, he and his excellent colleagues have conducted and published extensive descriptive, intervention, and meta-analytic studies. Prof. Vitiello's interview was full of gratitude and respect for his many colleagues as well as a sense of satisfaction with his research production and continuing enthusiasm for the future of sleep research. As a successful sleep researcher, Prof. Vitiello generously shared some of his key findings in sleep disorders in aging, as well as advice for optimizing one's sleep. We hope you find his comments informative and inspiring. INTERVIEW RECORD Question 1 You have been an active researcher in the area of sleep and aging for 40 years and are the author of over 500 scientific publications, with an h-index on SCOPUS of 65. Among all your excellent publications and achievements, which are the most important to you? Prof. Vitiello I think there are two lines of my research that are most useful to people. One is a 2004 meta-analytic study.[1] Working with Drs. Maurice Ohayon, Christian Guilleminault, and Mary Carskadon, we conducted a systematic review and meta-analysis evaluating objective sleep data across the human life span. We not only confirmed and expanded on what was already known but obtained important new findings in older adults. When we looked across the full adult life span (18–100 years), we confirmed the changes in sleep that have typically been associated with "aging," such as decreased sleep time, increased awakenings from sleep, and less slow-wave sleep. However, when we examined only older adults, 65 years and above, those changes were not seen. Hence, the changes that we typically thought of as occurring with aging, actually occurred earlier in the adult life span, ages 18–60 years. This meant that in older adulthood if an individual stays healthy, it is likely that their sleep will remain relatively unchanged with advancing age. Conversely, older adults in poorer health showed a continued decline in their sleep quality. These findings provided clear evidence that sleep quality does not inexorably decline with age, but the decline is more likely associated with the increasing medical burden that occurs with advancing age. I personally found it very satisfying to demonstrate that growing older does not necessarily mean sleeping poorly. The other line of research has been very personally satisfying, was the last series of studies that I've done, which evaluated the usefulness of cognitive behavioral therapy for insomnia (CBTI) to improve sleep in older adults.[2] Again, I got to work with excellent colleagues, specifically Drs. Michael Von Korff and Susan M. McCurry. We specifically looked at CBTI to treat chronic insomnia in older adults with osteoarthritis (OA), a major cause of pain, who represent 25% of the older adult US population. It had previously been assumed that the OA pain was causing the insomnia and that sleep would improve if the pain was successfully treated. However, we demonstrated that sleep could be improved if treated directly and that by treating sleep we also saw improvements in pain. Our research showed that sleep and pain interact and that treating sleep in patients with chronic pain can not only improve their sleep but also decrease their pain.[3] This line of research clearly illustrates the importance of quality sleep in staying healthy. Question 2 How do you deal with insomnia? Could you share some tips to help people sleep better? Prof. Vitiello How you would deal with the problem really depends on the severity of the insomnia and how impactful it is to a person's daytime function. Chronic insomnia that is regular and frequent difficulties obtaining sufficient sleep over weeks or months likely requires seeking professional help and likely receiving CBTI. However, most of us have occasional bad nights of sleep and we may feel impaired the next day. If it's only occasional then it is typically not something one would formally treat although there are some things that one can do even for such occasional times when sleep is difficult. One that I personally like because it's very easy to teach, very easy to do, and very useful is a deep breathing exercise – breathing in a very intentional manner, slow deep breaths, and focusing only on the breathing.[4] You might have a sound you want to associate it with if you want to think of it as more a meditative thing. So you can use that sound. And you don't worry about if you think of something else during your breathing you just recognize that you're doing that and then go back to breathing. What you're doing is focusing on your breathing. This intervention has a natural advantage, as everyone has to breathe. This technique blocks the intrusive thoughts and distractions that may keep us awake, something that I call busy brain, people who are thinking a lot and worrying a lot, whereas they're asleep or trying to sleep and so they anticipate all the bad things that are going to happen, all the terrible things that have happened. This kind of thinking generates anxiety and activates the sympathetic nervous system releasing stress hormones, which make it physiologically less likely to be able to sleep. Deep breathing works by decreasing sympathetic nervous activity and increasing parasympathetic nervous activity, which decreases heart rate, lowers blood pressure, and puts an individual in a much better place to fall back asleep or to fall back asleep more quickly. People can use this technique very easily, it doesn't take a lot of training, just takes a little bit of instruction and can be used in a lot of situations, such as before going to sleep, after an awakening from sleep, and even in daytime situations when feeling anxious or stressed. Typically, such a relaxation technique is in the larger package of treatment (CBTI) that is used if a person has chronic insomnia. Question 3 As an internationally recognized expert in sleep disorders in aging, could you briefly talk about the latest research area and findings of this field? Prof. Vitiello There are some very exciting things going on in sleep and aging research, particularly the emerging role of sleep in dementing disorders, that is the loss of cognitive function that occurs in older adults. Sleep may have a key role in the development of Alzheimer's dementia which is the most common form of a dementia. This work is based on the examination of the glymphatic system, a brain system comparable to the body's lymphatic system, that moves waste products away from brain cells allowing the cells to function normally. If those waste products accumulate that can have a severe impact on the cells and indeed lead to neurodegeneration. Those waste products include Tau protein and beta-amyloid protein. The buildup of these proteins in the brain are key features of Alzheimer's disease neuropathology. It turns out that the glymphatic system is sleep dependent.[5] What I mean by that is during sleep, the system "opens up" drawing waste products out of the brain. Indeed, you can interfere with the glymphatic system's function by disturbing sleep which results in a slowing of the transport of waste proteins out of the brain. This, of course, suggests that interventions to improve sleep will result in better glymphatic function. Logically, sleep should be improved as early as possible, well before the onset of Alzheimer's disease, as you cannot reverse the problem, you have to prevent, or at least slow, the problem. This is very exciting because it links a specific sleep-related neuromechanism to a major neuropathology of aging. This newly discovered mechanism has drawn a lot more interest into the sleep world by a lot of people who are interested in neurodegenerative disorders. Question 4 I'm aware that you have done some researches on improving cognitive function in healthy older adults and in patients with amnestic mild cognitive impairment (MCI). Do you have anything to share regarding this topic? Prof. Vitiello This involved a series of studies examining the somatotropic axis of the brain. Somatotropic hormones are growth hormone (GH) and related hormones that facilitate cell growth and maintenance. Most GH is secreted by the pituitary gland at night, particularly during slow-wave sleep, as a result of the secretion of growth-hormone-releasing hormone (GHRH) by the hypothalamus. We were originally interested in whether GHRH would trigger slow-wave sleep and could therefore be used to improve sleep. It turned out that the compound that we were using was not good for sleep because of immediate onset and short term of action. However, while the sleep of these GHRH treated subjects did not improve, we observed improvement in their cognitive function.[6] We followed up these studies in health normal subjects by studying GHRH's effects on cognition in both normal subjects and subjects with MCI, a pre-Alzheimer's condition.[7] We found that in the controls we again saw an improvement in cognitive function. In the mild cognitive impaired group, we did not see an improvement but what we saw was a stabilization, they did not decline as was observed for the placebo-controlled MCI subjects. Question 5 You have been actively involved in the efforts of promoting a better understanding of the importance of sleep in healthy aging. Could you share your views on healthy aging? Prof. Vitiello In the 2004 meta-analysis, I discussed above we showed that if you stay healthy your sleep stays the same. This suggests that if you're sleeping well, you are probably buffering your health against a wide range of adverse effects by decreasing risk from cardiovascular disorders, metabolic disorders, neurodegenerative diseases, depression, anxiety, and pain conditions. So the idea of learning to sleep well and continuing to sleep well and doing that early is one of the key factors that will contribute to healthy aging just as being moderate in your diet, getting regular exercise, not smoking, not drinking, or not drinking too excessive are all key factors in healthy aging. This is something that people need to start to do sooner. You don't want to have the system run down and then try and recoup because you're better off taking care of your health along the way rather than waiting until you're ill and then trying to seek treatment. Prevention is very important and ultimately better than intervention. The idea is you should not sacrifice your sleep now because you'll pay a price in your health later. It is important to recognize that if you're not sleeping sufficiently, you're not functioning as well as you might be if you were sleeping sufficiently. We know, for example, that people are terrible at being able to judge how sleep impaired they are. In fact, the more sleep impaired you are the worse you are at making that judgment. Hence, if you are chronically sleep-depriving yourself, you're not in a position to accurately judge the impact of that sleep insufficiency on your daytime function. If you feel you are having sleep difficulties, particularly if these difficulties are chronic, there are people that can help you. You should seek either medical or psychological aid to improve your sleep. Question 6 What kind of physician, psychology doctor in particular, do you expect in the future? What professional skills are necessary for a qualified psychology doctor? Prof. Vitiello In terms of sleep medicine, you need all the usual skills of a psychologist which is an appreciation of human behavior and how it is potentially modifiable or not. Because sometimes it isn't. Furthermore, you need to be able to recognize when problems are serious or not as you will approach them differently. But obviously, the very important aspects of it for sleep are the full recognition of what makes for good sleep and what makes for bad sleep, and the ability to provide therapies that are state-of-the-art and efficacious to help people improve their sleep. That's not necessarily CBTI for everybody. There are lots of other therapies that are potentially useful, mindfulness and acupuncture, for example, which come out of Eastern traditional medical approaches and have been shown to be efficacious for treating insomnia. A good appreciation of the interaction between sleep and mental disabilities, anxiety and depression in particular, would be key for a good sleep practitioner. Further I think you really need to have a good sense of sleep pain relationships. Question 7 You are founding Co-Editor and Editor-in-Chief for the Journal of Sleep Medicine Reviews, and also serve as editors on other numerous renowned journals such as Behavioral Sleep Medicine, Journal of the American Geriatrics Society and Sleep Medicine. Based on your extensive experience of dealing with journals, could you please give some advice for the development of Heart and Mind? Prof. Vitiello The best advice I can have for journals is to survive long enough so that you start getting impact ratings by the various companies like Clarivate, Scopus, as such attract submissions, which can then raise impact factors. Being listed in PubMed is another major step in a journal's growth and health. This all takes considerable time. Heart and Mind is still young in its life. It's still very much a starting journal but that's changing slowly and appropriately. Second is the development of a strong and diverse editorial board and the editorial board members either submitting some of their own work or encouraging colleagues to submit. As this process continues over time you again start to have papers come in that are increasing quality. Again, as the journal's reputation grows, typically exemplified by increasing impact factors, authors recognize it as a place to put papers now. Many top tier journals with high impact factors started from the bottom. They were not always been powerhouses but they grew into the powerhouses. The third one is to take actions step by step. It's long, slow and difficult but it's the only way. There is no silver bullet because the process is iterative. Increasing journal impact is a step-wise process; it will not be a grand leap. So just keep at it. Be steady, keep at it and follow through so that if you're talking to an author and they're interested, don't drop them, respond to them promptly. That's all the "secrets" I have. EDITOR'S NOTE With a love for science, he has spent most of his life studying sleep and aging, expecting to improve the quality of sleep and cognitive function of all mankind. During the interview, he summarized his own research with satisfaction and kept abreast of the latest research progress. As a sleep expert, he also has his own tricks for insomnia and shared them without reservation. Here seven key points summarized from his words: The changes that we typically thought of as occurring with aging which you would expect to continue across the life span occurred earlier in the life span between ages 20–60, if you get out to 60+, and you stay healthy your sleep doesn't change very much. CBTI works very well and improves sleep in older adults. Sleep is much more important than we give it credit for, and disturbed sleep is not necessarily simply secondary to diseases but is often contributory to diseases. Sleep may indeed have a key role in the development of Alzheimer's disease, which is the most common form of dementia. Deep breathing causes increased parasympathetic nervous system activity, which predisposes to relaxation and can aid in falling asleep quickly. GH secretion has always been linked with sleep. Interestingly, GHRH treatment while not impacting sleep improves cognitive function in normal healthy older adults and delays cognitive decline in older adults with MCI, a preclinical form of Alzheimer's disease. Getting regular and sufficient sleep is a key to staying healthy with advancing age, and should be a life-long goal, not an after-the-fact response to poor sleep and health in later life. Michael V. Vitiello, Ph.D, Department of Psychiatry and Behavioral Sciences, University of Washington, USA. [email protected]. Financial support and sponsorship Nil. Conflicts of interest Prof. Michael V. Vitiello is an Editorial Board Member of the Heart and Mind journal. Prof. Meiyan Liu is the Executive Editor in Chief of the Heart and Mind journal. Doris Yang is an editorial staff of the Heart and Mind journal. The article was subject to the journal's standard procedures, with peer review handled independently of Prof. Michael V. Vitiello and the research groups. There are no conflicts of interest.