Unlock Sleep’s Role In Alzheimer’s Prevention

Audrey Wells, MD

It’s my pleasure to be here. It’s great to see you.

Heather Sandison, ND

You as well, always. Let’s dive straight into the connection between sleep disturbances and Alzheimer’s disease.

Audrey Wells, MD

Yes. This is something that’s been the subject of research, and I’m diving back into recent studies. What I can tell you is that sleep deprivation looks problematic for brain functioning and the clearance of waste products that accumulate in the brain. Specifically, where Alzheimer’s disease is concerned, if you are sleep deprived, even for one night, beta-amyloid protein has been detected in the CSF of young, healthy subjects. I liken this to a breast analogy. One of the things that the brain does is go through and do a rinse every night during a particular sleep stage. If that’s not happening because of sleep deprivation, then those little metabolites—those little molecules of rust—are left there. If they accumulate over time, they start gumming up your inner network. Beta-amyloid protein is increased. Tau protein has been demonstrated to increase. Then there’s also the neural filament, A-protein which is higher in sleep deprivation as well. The connection between sleep deprivation or sleep loss and Alzheimer’s is strengthened with every research study that’s come out.

Heather Sandison, ND

You said just one night of sleep deprivation. Do people need to be worried? Like if they fly? Or is this something that is a problem if it accumulates over time?

Audrey Wells, MD

Yes. Let me clarify. One night of full sleep deprivation produced measurable amounts of beta-amyloid in the CSF. Now, what does that mean? It means that the beta-amyloid was not cleared because of the night of sleep deprivation. The idea is that over time, the chronic sleep loss that so many Americans are subject to is probably accumulating some degree of waste in the CSF and the brain. There’s not a causal relationship demonstrated yet, but there’s a lot of circumstantial evidence. There’s this intuitive idea that the cleaning mechanism that the brain goes through is dependent on healthy sleep.

Heather Sandison, ND

How do people know if they’re getting good sleep? Can they measure this?

Audrey Wells, MD

This is a great question because that’s something that a lot of people are fuzzy about. The way I like to take encapsulate is for good sleep. You need enough sleep. That’s the quantity of sleep you need—high-quality sleep. The third thing is consistent sleep timing. For most people, that’s going to be a window that’s fixed in 24 hours. Most people go to bed around 10 p.m. and wake up at 6 a.m., just as an example. Quality, quantity, and timing are the three components of healthy sleep.

Heather Sandison, ND

What about someone who thinks they’re getting good sleep but wakes up feeling tired?

Audrey Wells, MD

Yes, that speaks to the quality piece, and there can be some different reasons for that. Quality sleep means that you’re having enough of the different sleep stages and that your sleep is relatively stable, such that your brain can naturally cycle through those different sleep stages. I’ll name a couple that people have heard about because these wearable trackers tend to define them. There’s a slow wave or deep sleep. That’s also called non-REM-three sleep. There’s lighter sleep, which is a combination of non-REM one and non-REM two. then in the last half of the night, REM sleep, rapid eye movement, sleep or dreams, sleep is most prominent. If there’s a question about sleep quality, I like to look at different things like light exposure, physical activity, and medications. All of those things can affect sleep quality. But always in my mind, as a sleep medicine physician, an undiagnosed sleep disorder is a possibility as well.

Heather Sandison, ND

I’m sure you see tons of people who complain about not being able to get to sleep or stay asleep. They’ve heard it all before. Get to sleep at the same time, do the sleep hygiene practices, and make sure that you’re giving yourself enough time in bed. They’re doing all that. But when they try, they can’t sleep. What do you tell them?

Audrey Wells, MD

I love that you bring this up because it’s one of the things that is a thorn in my side. I think that sleep hygiene tips are important, and you’re going to have to forgive me. They’re so tired. Everybody has Googled the things. You try to implement healthy things. It’s a lot of good common sense, which is great. But I think something that the listeners and the viewers need to know is that because sleep is a state of unconsciousness, it’s effectively a blind spot in your health. Without some testing to shed some light on what’s going on, you simply don’t know. It may surprise you to know that just feeling tired during the day is a symptom. That’s a symptom that something is amiss. If you’re already doing all the sleep hygiene techniques and it’s not getting better in your mind, the next step is a sleep study because, over 65, people have a sleep diagnosis that’s going to be uncovered with that sleep study.

Heather Sandison, ND

Does that mean you have to go into the hospital either overnight, or are there alternatives to that these days?

Audrey Wells, MD

Yes. In the past, I think anybody you talked to who had a sleep study was very happy to tell you how horrible it was to be in a hospital or even an outpatient setting. There’s wire everywhere. You know, it’s a very strange experience nowadays, especially since the pandemic home sleep apnea testing is enjoying a big boom. But just to be cautious, the home sleep apnea tests only measure for sleep apnea. They do not measure sleep. Okay. that’s important. Home sleep apnea tests do not measure sleep. If you’re somebody who has a hard time getting to sleep or staying asleep, that could affect the test so much that you get a false negative result.

Heather Sandison, ND

Okay. Then that’s when you’d want to do a more stringent study of the gold standard in a hospital or an overnight sleep study in a facility.

Audrey Wells, MD

You’re exactly right. That overnight sleep study in a sleep lab, whether it be in the hospital itself or an outpatient setting, is going to be much more accurate at determining what’s going on. Because when I’m looking at that type of test, which includes EEG signals from your scalp, I can factor out all of the wakes you’ve had and just look at the sleep periods. Even if you don’t get a good night’s sleep, and, spoiler alert, you probably won’t even if you don’t get a good night’s sleep, that information is still valuable, and it’s worth it to consider one night of inconvenience to find out what’s going on so that every other night after that, for years of your life, you can get healthy sleep.

Heather Sandison, ND

I see so many of my patients that, as they age, it gets harder and harder to do something like that. It’s not just a minor inconvenience. It’s now a bigger one because maybe they rely on their adult children to get to doctor appointments day by day. The thought of asking them to go and pick them up and drop them off for this overnight sleep study feels like an additional burden. I want to emphasize doing this earlier in life when it’s a little bit easier to manage the logistics of getting in to do that. It’s like, if youth are at all concerned about their sleep, get yes. Get an Oura Ring. I think you and I both have them. We love the Oura Ring, but they’re not going to give you great insights into your sleep. Although the technology is getting better for the wearables at home and the sleep studies that you can do at home, it’s still not the same as what you can do in a sleep lab. You’re the expert. You speak to this. But I just want to emphasize, like, get it sooner. Don’t wait if you think you have an issue.

Audrey Wells, MD

Yes. One of the things about testing your sleep is that it is a high-value test. Your brain is your most important asset. I invite somebody to argue with me about this. I cannot give up my brain, and sleep is for your brain. When you go to get a sleep study, yes, I’ve had four of them. I know how horrible it feels. But you do it to confirm that everything’s operating well. It’s just one night, and you can make arrangements to treat yourself nice the next day with maybe a nap or something. I want to tell you, too, that these wearable devices are my favorites. I do. Because they elevate sleep into our conversations. The problem is for the Oura Ring and others specifically; it’ll say something like, were there any oxygen fluctuations during the night? For me, I will get one from time to time when I put the Oura Ring head to head with a home sleep apnea test or an in-lab sleep study. This is a very blunt tool, and it will not detect those fluctuations that are going to be concerning for conditions like obstructive sleep apnea. I would hope nobody is resting their actions on what their Oura Ring is telling them that this is not sensitive enough at all to say that you don’t have a sleep disorder.

Heather Sandison, ND

Yes, we want to get those more intensive tests and work with a sleep medicine doctor if there’s any concern. In neurodegenerative diseases, there is a very clear connection between REM sleep disorder and Parkinson’s, or multiple symptom atrophy. There’s also this very clear connection between sleep apnea and dementia. Can you talk about what’s going on there?

Audrey Wells, MD

Sleep apnea is one of the most common sleep diagnoses. It’s consistent with airway obstruction. Most commonly, there are other types of sleep apnea, but obstructive sleep apnea is by far the most common type. What’s happening is that when you go to sleep, all of the muscles in your body relax. That’s normal. That includes muscles in the back of your throat. Now, for someone who has sleep apnea, the muscle relaxation in the back of the throat means that the airway collapses to the point where you’re not able to get enough oxygen or air into your lungs to get oxygen into your bloodstream, which is going to your heart, your brain, your digestive system, etc. You need that oxygen and more than a sleep disorder. 

Obstructive sleep apnea is a breathing disorder, and I just want to point out that if we experience something similar during the daytime when we stop breathing effectively, our oxygen levels go down. Your brain had to be interrupted by what you were doing, and then you gasped. You would go to the emergency room if that was happening multiple times, and you would get that treated immediately. But because we’re asleep, it’s not accessible to us. It’s that unconscious blind spot that I was talking about before. Obstructive sleep apnea means you’re blocking your airway multiple times an hour throughout the night, and then your brain, when it detects that low oxygen level, is in an emergency. It sounds like an alarm, so you can open up your airway and take some recovery breaths. that disrupts the sleep quality sometimes to the point of full awakening, but most often, not most often, the person who’s affected isn’t aware how often that’s happening. That’s obstructive sleep apnea, in a nutshell. It’s a breathing disorder.

Heather Sandison, ND

How does this put people at risk for Alzheimer’s?

Audrey Wells, MD

When you stop breathing, your oxygen levels go down. The brain needs a steady supply of oxygen and a reliable supply of sleep. Obstructive sleep apnea interrupts both. The brain is hobbling along, trying to recover from a night that should have been rejuvenating. Night after night, month after month, and year after year, you are suffering the effects. that accelerates aging. It accelerates inflammation. That’s where you get the beta-amyloid accumulation, the tau protein, and the neurodevelopment. All of this stuff grows over time into dementia.

Heather Sandison, ND

Then I hope that you never have patients say that you are a sleep medicine expert. But I certainly have patients who come in and say, I’m not going to do a sleep study because they’re just going to give me a CPAP. I know that that’s way too uncomfortable, and I’m never going to wear it, so don’t even bother. Why do you tell people who are worried about the treatment options that they won’t be able to tolerate them?

Audrey Wells, MD

I’m glad that you brought this up because it’s a question I get all the time. Usually, what’s going on is that the spouse is sitting like this because they finally dragged their snoring partner into the sleep specialist’s office. I think that what I like to appeal to people is that we’re going to get information. We’re going to get information about what’s going on with your sleep so that you can make some informed decisions. It’s not up to me to make decisions. It’s up to you to make decisions. Instead of sticking your head in the sand and leaving this blind spot untended, what we can do is take a look and see how this is affecting your health. 

With that information, we can work out what the next steps might be, and CPAP is one option. It happens to be the gold standard for treating sleep apnea, but I certainly don’t recommend it for every single person who walks through the door. There are other options. There is a mouthpiece. There are different types of surgical procedures, either to debunk the airway or to place a stimulant stimulator that moves the tongue. Different options are tailored to each individual. Their sleep apnea severity, their preferences, and a lot of other factors. It’s not that a CPAP is waiting for you the morning that you wake up from the sleep study. We make some decisions. But first, we need information. I appeal to people to move forward with getting that information so that they have an informed choice to make.

Heather Sandison, ND

Then, if someone feels like they’ve tried the CPAP or they’ve tried one of these treatments and they’ve struggled, what can they then do? Do they go back to their sleep medicine doctor? often, you’ll probably appreciate this. They have to wait for months to get in and then they’re not using the CPAP because they can’t get it to work, the mask doesn’t fit, or whatever. They’ve got something that’s standing in the way of their being able to get the benefit of the treatment. How do you suggest that they navigate that?

Audrey Wells, MD

I sympathize, first of all, because, in our current medical delivery system, we are not doing this well. I fully recognize that when people are having trouble with their CPAP, they are vulnerable to abandoning care because they can’t get the help that they need or the support that they need to finally make it through and get the healthy sleep that they deserve. Yes, it takes many months to see a sleep specialist. Usually, there are only about 7500 of us in the whole country. If a person’s having trouble, the first thing I recommend is to be noisy about your trouble. Understand what it is that’s not working for you. It may be the mask. It may be the pressure. It may be the way you’re thinking about this new medical machine that is now living on your bedside table. All of these are valid complaints, and you need to be the squeaky wheel. 

Now, see your sleep medicine physician to get adjustments, and talk about alternatives; if you’re at that point, that’s all great. I also offer online education and group coaching for people struggling with masks, pressure settings, etc. Some people like to go on a weight-loss journey, which may or may not be effective at curing sleep apnea. But it’s always good for your overall health. Certainly, what you put in your mouth has a huge effect on how you sleep and your long-term health. Those are some options. But I would just encourage people who are at that point of knowing they have sleep apnea and struggling to work as much as they can to advocate for themselves and move forward until they can get treated because it’s so worth it.

Heather Sandison, ND

We were discussing briefly diet and fasting in particular, and their relationship with the quality of sleep. Can you dive into what you’ve learned about the connection between how we eat and how we sleep?

Audrey Wells, MD

I love this conversation, and I’m going to try to keep my comments limited because this is a special interest of mine. It’s fascinating. We were meant to have periods of eating and then longer periods of fasting over years and years. We developed it this way. Our hormonal regulation is optimized if we are not eating 3 hours before bedtime, and not eating throughout the entire night until the next day. Wakefulness and eating are paired activities in our brain and body. Sleep and digestion, or sleep and antibodies, are building up in our tissues, which are paired at night. If you’re eating late, that can reduce your melatonin secretion, affect your growth hormone production, and affect your sleep stages, not the least of which is having acid reflux in the middle of the night. All of these things need to be working in quality, quantity, and timing again with your food because we’re influenced by what we eat and when we eat. I suggest to people that whether they’re on a weight loss journey or not, whether they’re trying to improve their diet or not, stop eating 3 hours before you go to sleep and, consider, an eating window during your day and not just grazing through the whole day. That’s not good for you, either. The timing is important there.

Heather Sandison, ND

When I first started practicing, we were running a lot of cleanse programs, and it was so surprising to me, even still, I just delight in it when someone says, I changed my diet, I got into ketosis, or I changed how I eat, and I cleaned it up, and I’m only having whole foods. I did this cleanse, and my sleep made the biggest difference. It’s just a night and day between the crappy sleep they were getting before and how great they feel when they wake up in the morning now. This, of course, trickles into our day. I mean, there’s no way to disconnect them. People have a better mood and better energy. Everything is easier. But we’re getting a good night’s sleep.

Audrey Wells, MD

My heart sings to hear you say that. I mean, all we need to do as human beings is eat, sleep, and move just like food and sleep.

Heather Sandison, ND

Maybe connect.

Audrey Wells, MD

Connect. It’s true. Just like with food, sleep is supposed to be a wholesome, natural experience and a natural pleasure. It’s not something that’s supposed to be laced with medication and anxiety-ridden. I like to help people get back to a natural, wholesome, pleasurable sleep. Doesn’t that sound so nice?

Heather Sandison, ND

I mean, it is so nice. I appreciate it when I get it. A lot of our audience is caring for someone with dementia. Often, as people progress through the stages of dementia, their sleep can be disrupted. then the caregiver’s sleep is disrupted. Often, someone who’s caring for someone with dementia feels like they’re back to raising an infant. They say their entire day is filled with being present. One-on-one with the person they’re caring for. The only time they have to themselves is when that person is asleep. They start to limit their sleep. There are many, many ways that sleep is negatively affected for caregivers. How do you think they can start optimizing their sleep to protect their brain health as they age?

Audrey Wells, MD

This is critical to anybody who is in a caregiver position because it’s the equivalent of putting your oxygen mask on before assisting others. Sleep is not only critical to your functioning but also to problem-solving, mental flexibility, and mood. If sleep is an issue in your role as a caregiver, I would recommend that you start to protect your sleep as a non-negotiable period and look for ways to get respite if you’re not able to do that fully. Tag other family members to take over some of the work of hiring it out, if that’s available to you. Having somebody else step in to relieve you so that you can take care of yourself and rest is a huge game changer. This is a situation that tends to have some duration to it. This is going to go on for several years. The endurance that you’re going to need means that you need to prepare ahead of time and get that support, not only for your loved one but for yourself because that must be in place for your health.

Heather Sandison, ND

Interestingly, you said it not only for your loved one but for yourself, and I would flip it around. This isn’t just for you as a caregiver. You are going to be a better care partner if you are rested. I hear so many, especially the people who are showing up and listening to this summit, about the Reverse Alzheimer’s. They’re here because they are at the cutting edge. They want to do everything they can for their loved ones, and they are tireless and relentless in their care. It’s amazing and inspiring. Yet my message is always, as you said, put your oxygen mask on first, not just for you but because of you. I feel like it’s even better motivation for them. If we say it’s for the person you’re caring for, you’re going to show up in a better mood. You’re going to be more creative. Like you said, you’re going to have more capacity to solve problems, and that is going to make everything easier for both of you. So please, prioritize your sleep and make sure that you’re getting the support you need, whether it’s from people in your community. There’s a long list of support sources, even government support sources. Please reach out and do that before you think you need it. Get it ahead of time so that you’re not late. No one gets into crisis mode and is pushed into a corner without options. Start doing that before you think you need it.

Audrey Wells, MD

I endorse that. Caregivers are givers by nature, and I see that. It’s just that when you go to sleep at night, I like to say you do a U-turn. Why? Oh, U-turn. That inner search for what you need is also part of caregiving and being vocal about what you need. Yes, I endorse what you said. It’s part of being a great caregiver.

Heather Sandison, ND

Dr. Wells, I want everyone to know where they can find out more about you. You mentioned your coaching courses, I think. Don’t you have one called Make Friends with Your Spouse now?

Audrey Wells, MD

That was an iteration. Yes, people wanted more personalization. I have the Ultimate CPAP Mask Course. I have 21+ CPAP Alternatives. How to Finally Sleep Better and Feel More Awake. These are online courses with videos and group coaching experiences that I do. I love it. It’s fun for me to connect with people in a way that I never had the opportunity to do behind the walls of my sleep clinic. I’m bringing healthy sleep to the folks who want it. I’m very happy to share my website, which is www.supersleepmd.com.

Heather Sandison, ND

You can get access to a sleep medicine specialist without losing months and months of weight or having to go back to the sleep lab. Take advantage of that. Dr. Wells, it’s always a pleasure to connect with you. This is, I think, one of the most informative and action-packed interviews we’ve done. I’m just so delighted and feel it’s such a privilege to have you here. Thank you for sharing all of your insights and wisdom.

Audrey Wells, MD

It was my pleasure. It’s great to see you.