Sleep and Stroke: WTF? You're Asleep Already?

"Are you asleep?"

I whisper the words, but loud enough for him to hear it. I don't get a response--not a foot twitch, not a hand movement, not a face gesture. I get nothing. He lies down and then, somehow, he is instantly asleep. Lucky him. But to this stroke survivor, not so fast. I often get up, in the middle of the night, because I can't fall asleep and don't want to lie there endlessly for more than two hours which is my limit, waiting for sleep to overtake me. 

It's unfortunate for me that I'm so active in the middle of the night. I get up and do something else, like go downstairs to my office to write, or flip through my kids' pictures--again, or listen to the night sounds of the ocean crashing against the surf. Oh, boy. I have to get up early. The vampire, aka phlebotomist, is coming at 8. *sigh* The time is now 1 AM.

First, background is needed. The National Institutes of Health say that until the 1950s, most people thought of sleep as a short, daily hibernation from our hectic lives. What we know now, over fifty years  years later, is that our brains are busy during sleep, affecting our physical and mental functioning in a slew of ways. Sleep comes in stages: 

Stage 1 is denoted by  light sleep where we drift in and out of sleep and can be awakened easily;
 
Stage 2 sleep is characterized by eye movements stopping and brain waves become slower;
 
Stage 3 happens when slow brain waves begin to appear, combined with smaller, faster waves;
 
Stage 4 is the deepest sleep when there is no eye movement or muscle activity;
Rapid Eye Movement (REM) sleep, occurring about 70 to 90 minutes after we fall asleep, is when our breathing becomes irregular and shallow, eyes move quickly, limb muscles become temporarily paralyzed, heart rate increases, and blood pressure rises.

On average, the Cleveland Clinic says a complete sleep cycle takes an average of 90 to 110 minutes.
 
As the night goes on, REM sleep increases in length while deep sleep decreases. The amount of sleep each person needs depends on age and condition. Infants usually require about 16 hours a day, teenagers about 9 hours, adults usually about 7 to 8 hours though some people need as few as 5 hours or as many as 10 hours of sleep. In the first 3 months of pregnancy, women often need several more hours of sleep than is their typical pattern. If you're sleep-deprived, the body requires you  to make it up later when you have the opportunity. You can't go without sleep for two days because sleep will catch up with you. It's a fact. Don't even argue it. You'll lose.

And most sleep studies conclude that sleep deprivation is dangerous. Sleep-deprived folks when tested perform as badly or worse than those who are intoxicated. Sleep deprivation also intensifies alcohol's effects on the body. Since drowsiness is the brain's final step before falling asleep, driving while drowsy--intoxicated or not--can lead to tragedy. Coffee, tea, or other stimulants doesn't cut it with severe sleep deprivation. The National Sleep Foundation has a rule: if you can't stop yawning and have trouble keeping your eyes focused, or if you can't remember driving over the space of three minutes, you are probably too fatigued to drive safely.

Anyway, it's the same thing one or two times every week that I can't sleep, but I'm certainly not alone. Sleep problems are usual for stroke survivors. Having a sleeping problem can be make you irritable and cantankerous, like saying "fuck" when uttering that word is uncalled for. 

Sleep problems can also increase your risk for another stroke because two-thirds of stroke survivors have sleep-disordered breathing (SDB), the most common being sleep apnea. With SDB, the side effects may increase your blood pressure and cause blood clots. Signs include, despite yawning repeatedly, the inability to fall asleep or remain asleep throughout the night which, in turn, causes excessive sleepiness, attention problems, depression, irritability, and headaches during the day. SDB is a vicious cycle of events.

Treatments are tricky. Aside from sleeping on your stomach (some people say that helps with the snoring), the most successful treatment is Continuous Positive Airway Pressure (CPAP), which is a compact machine no larger than a few reams of paper, blowing heated, humidified air through a short tube to a mask which fits tightly around your nose and mouth to prevent humid air from leaking out. Albeit not good for curly air that might to turn to frizzy hair, it might help. The National Stroke Association said sleep studies using CPAP revealed that better thinking abilities and having higher energy levels were the result.

A variety of medications prescribed in the rehabilitation process can change the quantity, quality, and pattern of sleep. Medications prescribed for sleep may interact with sleep processes by increasing or decreasing the amount of time spent in sleep. The intake of medication and its timing can also influence sleep quality in a negative way and should be monitored carefully. 

Inherent factors to the hospital or rehabilitation environment may, in themselves, contribute to produce sleep disturbances in some patients, like co-habitation with other patients, pain, anxiety, noise, lights, and the strict schedules for a routinized day. Then when the stay comes to an end, patients must integrate their lifestyle to accommodate the home environments. Any factor alone isn't a walk in the park, by no means. 

When the patient returns home, resuming sleep patterns may not happen if these conditions are present:
* Consuming big meals late at night
* Ingesting alcohol, caffeine, and nicotine in irregular patterns
* Performing extreme exercise  
* Maintaining obesity which is linked to sleep disordered breathing
* Taking naps within three hours of bedtime
* Incurring emotional upheaval 

An average of 30% of stroke survivors have “circadian disturbances” or sleep-wake cycle disorders (SWDs) where your sleep regimen is no longer set by day or night. But in my mind, no matter what acronym one calls it, many stroke survivors are left with, in conjunction with other sleep disorders, the big "i"--insomnia, the inability to fall asleep. An insomniac is usually defined by the following criteria: 
* Dissatisfaction with sleep quantity or quality
* Difficulty initiating and/or maintaining sleep
* Recurring sleep difficulties at least 3 nights a week
*Significant impairment in social, inter-personal, or other areas of daytime interactions

Insomnia is considered chronic when it has lasted for more than 6 months. Mine had lasted for 4-1/2 years.

Sleep is still in the partial mystery category. While researchers and doctors know something about sleep, like the regulation of the body's temperature, the conservation of energy, and immunity to disease, they don't know everything. 

When it comes to rehabilitation, pioneers in sleep disorders, Canadian researchers Marie-Christine Ouellet and Simon Beaulieu-Bonneau, said even though problems with sleep are often regarded as minor problems, the lack of sleep is developing into a serious problem. It can retard rehabilitation and make a difference for patients in their outcomes. With the efforts involved in rehabilitation, it is important to deem sleep disorders as possible roadblocks to the entire rehabilitation process. 

Indeed, it was a roadblock for me. I don't think I was in a state of mind to receive therapy as soon as I did. So should there be time allowed before the stroke patient is ready for therapy, or should therapy start right away even though the patient's not ready to receive it? I don't know the answer. Nobody does. And hospitals don't have the money for psychologists to pave the way for therapy.

It's 2:30 AM now as I write this post. Sleep is the furthest thing from my mind.

How to Change Your Own Mind, Literally

"You can't be too skinny or too rich," said my old college buddy back in the 60s. But now you know the truth. Skinniness sometimes is related to anorexia or bulimia. And you've heard stories about the deaths of lottery winners who blew their money on drugs or died from being poisoned. My friend got it wrong. She should have said, "You can't be too brainy."
 

The brain controls everything, like our emotional outbursts to pain, our nervous eating, our ability to pee regularly, our resistance to confront people, our neurotic tastes. But what was thought prior to the 1970s--that the brain was fixed and couldn't be changed after early childhood--was wrong. The brain can process new experiences, like having a stroke, by creating neural pathways to accommodate them. Welcome to neuroplasticity, the game changer.

There are four key truths about neuroplasticity:

Neuroplasticity is ongoing throughout life and involves brain cells and neurons.
 
Neuroplasticity can happen for two distinct reasons--as a result of learning, experience, and memory or as a result of brain damage.
 
Neuroplasticity can vary by age, and while plasticity occurs throughout life, certain types of changes are more predominant.
 
Neuroplasticity and environment, both together, play an essential role in the process.

In the first few years of life, the brain is growing rapidly. The average adult brain grows slower because as we process new experiences, some connections are strengthened while others are merely replaced by the process known as synaptic pruning. By developing new connections and pruning less important ones, or synapses we don't need at all, the brain is able to change either size or shape, and maybe both.

The human brain is made up of around 100 billion neurons. Early research was comfortable in the fact that neurogenesis, or the creation of brand-new neurons, was over after birth. Before the 1970s, most researchers believed that the brain and nerves could not regenerate themselves to replace damaged ones. Most stroke patients and individuals with brain trauma were convinced that brain damage from accidents or disease was there to stay. Areas of the brain that were dedicated to control the movement of arms and legs, for example, were expected to stay just that way from trauma following brain injury. The brain was not capable of relearning lost functions, most researchers said, because the brain was deplete of plasticity.

In the 1970s, in experiments with rats, researchers found a region of the

animals' brain--the hippocampus--where new nerve cells were miraculously generated. The hippocampus region is where memories of new things and places are established, and the scientists found two cavities in the hippocampus where the new cells were generated. These cells, called stem cells, traveled to different parts of the brain and took on the functions of that specific area of the brain.

So neurologists a few years later were excited and actively worked with

human patients who had brain injuries, and they were enacting experiments in animal models to determine whether the brain could be re-mapped following injury. Neurologists along with researchers knew what part of the brain controlled the activity of various body parts. A major part of this effort was determining what types of physical therapies were suitable in retraining those parts. Neuroplasticity was indeed coming to the forefront and was seen in animal experiments where a number of physiological changes were observed--changes in the size and shape of brain regions, increases in the molecules that assist and  transmit signals through the brain, and the generation of new neurons.

Michael Merzenich is a neuroscientist who is known for being a frontrunner in the field of neuroplasticity. For over thirty years, he has made some remarkable finds. For example, in a post-doctoral experiment in the 70s, he cut the peripheral nerve of monkeys' brains and sewed the ends together again. The result was that those brains was nearly normal, prompting Merzenich to conclude, "If the brain map could normalize its structure in response to abnormal input, the prevailing view that we are born with a hardwired system had to be wrong. The brain had to be plastic."

Today, it is documented that the brain possesses the capacity to redo neural pathways, regenerate new connections and, in some instances, create new neurons. NICHD-funded researchers have concluded that the brain is receptive to neuroplasticity. The magnetic resonance imaging (MRI) can also tell where the  neuroplastic events occur. In a recent stroke patients' study, the MRI detected where neurons sprung new connections that extend into the area surrounding the affected site.

So the question is, if disabled or not, what can YOU do about enacting neuroplasticity on your own brain, i.e. be more brainy?

1. Plenty of studies have linked meditation and yoga to changes in the density of gray matter or cortical thickness. In 2000, Sara Lazar from Harvard , and Richard Davidson, a neuroscientist at the University of Wisconsin, teamed up with the Dalai Lama on what results would be incurred on the brain. The results suggested changes in different levels of activity associated with such qualities as anxiety, depression, attention, fear, anger, and the capability of the body to heal itself. (Yes, there are modified meditation exercises for the disabled. Call around).

2. In another study, mice who were coerced to run on treadmills showed signs of molecular changes in many portions of their brains when viewed under a microscope, while mice who had the comfortable wheel-runner had changes in only one area. Chauying J. Jen, a professor of physiology and an author of the study, said, "Our results support the notion that different forms of exercise induce neuroplasticity changes in different brain regions." (So when it comes to humans at the gym, sometimes pain IS gain).

3. Hyperbaric oxygen therapy, or HBOT, is an simple treatment with catastrophic results. Patients inhale oxygen while inside a mildly pressurized chamber. The oxygen dissolves  into the blood, plasma,  and tissues. HBOT enables oxygen to go into areas with restricted blood-flow caused by injury or disease, thus stimulating the body’s natural healing process. Oxygen is a basic part of our physiology. Among other things, we require oxygen to heal from injuries and illness. During a normal day, the average adult inhales approximately six pounds of oxygen, of which about 2 pounds are automatically dissolved into the blood. While inside the chamber, patients inhale oxygen in its purest form at ten times the normal rate. (Some people said it's phenomemenal, even for stroke survivors. Start with the Washington Hyperbaric Therapy Center, (425) 644-7999, to learn more). 

4. Lumosity.com says it targets core cognitive processes that underlie performance in many different areas, and these processes include attention, flexibilty, memory, and focus. You can subscribe to Lumosity and play 5 games at a time to build up your endurance or, if money's an issue, you can play some games for free. It has a Brain Profile Index where you can compare scores over a period of time. (Lumosity, which was a gift from my son, is a staple for me now).

But sometimes, nothing helps but patience and hope. I've got both of them... literally.