Sleep: Myths and Facts

Jess: Good evening, everyone. Thank you for attending the webinar tonight. It's on sleep, myths and facts, and our presenter tonight is Dr. Simon Frenkel, who has kindly joined us tonight.

Acknowledgement of country. In the spirit of reconciliation, MS Plus acknowledges the traditional custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

So, this is a bit about Simon, Dr. Frenkel, who is our presenter tonight. Simon is a respiratory and sleep disorders physician from Lung and Sleep Victoria and with over 10 years’ experience consulting throughout Melbourne at Western Health and through private practice. Expertise in all aspects of sleep medicine with a particular interest in non-respiratory sleep disorders, so insomnia sleepiness, circadian rhythm disturbances and restless leg syndrome uses multidisciplinary models of care to optimise health outcomes for his patients, actively involved in sleep education.

Dr. Frenkel has presented at numerous state and national scientific meetings, along with providing education to GPs and the general community. And he's also presently the co-chair of the Sleep Physicians Council of Australasia and the Sleep Association.

So, thank you so much for joining us tonight.

Simon: Okay, thank you very much for the introduction and to the team at both MS Plus and MS Australia for putting this together. As already mentioned, I'm a sleep physician with a particular interest in all aspects of sleep medicine. And, I guess, presenting this talk is important for me because it represents the intersection of a number of very important aspects of my life, one of which is my professional practice as a sleep physician, the other being that MS being a prevalent condition within our community most of us will know someone or be closely associated with someone with MS and, on a personal level, that's certainly the case with me.

So, this is an important intersection. What I'm hoping to do today is, I guess, give a bit of an overview about what sleep is, what normal sleep is, how we can measure sleep, the type of things that can happen when sleep goes wrong, and then finally the end touching on, on sort of the tricky element of sleep and MS.

So what is sleep was the question that first came to my mind when I opened the textbook of sleep medicine and the first sentence in the book was by a Scottish physician, the surgeon and philosopher by the name of Robert McNish, who said, as you can see, quoted there that, Sleep is the intermediate state of between wakefulness and death, with wakefulness being regarded as the active state of all of the animal and intellectual functions, and death as that of their total suspension. So helpful, but not particularly, and he was also the author of a possibly more interesting book, The Anatomy of Drunkenness. So, what actually is sleep? And really it can be defined across multiple domains. So, there is the personal experience of what we all experience as sleep, as being a state.

Some degree of unaware of your external environment to an observer, we might be lying there quiet with our eyes closed and unresponsive. As a sleep physician, we would define sleep neurologically on the basis of characteristic wave forms on an EEG recording that allow us to work out whether people are awake or asleep and if they are asleep.

The depth of sleep, whether it's REM or the various stages of non-REM sleep. But most importantly, it serves a functional purpose. We sleep for a reason. And again, that's something that's spread across multiple domains. There's Increasing evidence that there is a very important housekeeping role of, of sleep that you know, while our brain and muscles are asleep, there are various active physiological processes going on that basically allow things to return to a normal state of affairs for, you know, the baseline functioning for the beginning of the next day.

It's also becoming increasingly evident that the various elements of sleep are important for memory processing and dreaming, in fact does appear to be although we don't exactly know why people dream, it does seem to serve a purpose with regards to memory processing and consolidation.

On the right hand side of the slide, you can see what's depicted there is the three pillars of health, those being physical activity of some description, a healthy diet and sleep. So, we need sleep working well for the other bits to function and for the roof not to cave in. So, the perennial question that I get is how much sleep do I need?

And it's actually a bit of a tricky answer, but what I'm going to do now is throw it out to the listeners or the watchers for a poll to see what you reckon and we can take it from there. So hopefully you'll get the option to vote.

Jess: It was 58 percent of people had said seven to eight. We had a few that said it depends and maybe one or two people had said, six to seven hours or that eight to nine hours.

Simon: Excellent.

Jess: Okay.

Simon: So, you never quite know where these things are going to go, but that's probably what I would have predicted. And the good news is that you're all right to an extent. Generally, when I do multiple choice questions, if you get a vague one, like it depends, I'll usually go for that.

But yes, the most, the most common response would be the seven to eight hours. And one of the reasons as to why that is, is actually a historical reason from that had its origin in Melbourne. So anyone listening from Melbourne the monument here is known as the Eight Hour Day Memorial, and it's on the corner of Russell Street and Victoria Street across the road from what you just saw used to be the Trades Hall Council. And so this monument was erected, I think, in the early 1900s, but it recognises a workers movement from the mid 1800s, where a bunch of, I think they were stonemasons, downed tools and marched on state parliament demanding fair rights for workers and an eight hour day of work and after several weeks of protest they were granted their wishes and the law was enacted and Victoria was actually the first place in the world to legislate an eight hour working day.

And so, what you can see on the top of that monument is the numbers 8 8 8, which represent eight hours work, eight hours recreation and eight hours rest. And so, at least some of the myth of needing eight hours sleep comes from comes from this movement in Victoria from the 1800s. A number of years ago, probably about 10 years ago now there was an international body that was established to review available scientific literature and to come up with some sort of a magic number about The number of hours of sleep that is required and the document they produced, having analysed about 5000 scientific papers, had a headline statement that the average adult needs a minimum of 7 hours of sleep on a regular basis for optimal functioning.

Which was fantastic on face value, but as with all of these things, the devil was in the detail, and there was quite a bit of fine print and a number of caveats. And what this slide shows is that sleep requirements across the lifespan change. They generally get increased. Less as we get older. And although for the average healthy adult seven hours is a rough estimate you know, seven to nine hours is generally considered to be okay with, you know, a bit less than that and a bit more than that possibly being okay when you read the literature and, and, and none of this, you know, really applies or it's unknown how it applies to people with chronic illnesses.

So, although it's helpful to talk in generalities about how much sleep someone needs at an individual level that is sometimes hard to determine. And so we get into these you know, sort of circular discussions about the amount of sleep that someone needs is really the amount that allows them to undertake their daily functions without Undue limitation.

But using that sort of seven to nine hour estimate is not a bad way to start. And in fact, sleep requirements vary quite considerably. across the population. So there are, you know, very famous long sleepers. So we've got LeBron James, probably one of the best basketball players ever to have played, will consistently sleep 15 hours a night.

Mariah Carey, probably more of my wife's cup of tea than mine, also 15 hours a night. Thomas Edison was famously has said that there's no real reason why men should go to bed at all. So, he was reportedly a short sleeper, but in fact had a bed in his laboratory and would catnap frequently during the day.

So, he probably slept a bit more than he recognised. And then there are an example down the bottom there of You know, the reasons why insufficient sleep can cause significant you know, mental instability and poor decision making.

Alright, so how do we measure sleep? There's a number of different ways of doing it, and in my patients, depending on what the particular complaint is, we might use one or sometimes a combination of these modalities of measurement. So, on the left hand side, there's a sleep diary, which allows people to, contemporaneously record after they've woken in the morning the number of hours that they've slept during the night and any time that they've been awake.

And so, it gives us an indication of what someone's subjective experience of sleep is and is often a good way of initially assessing insomnia, for example. In the middle panel are the various sleep trackers that are on the market now, and there are multiple varieties of these that at a population level are reasonable at measuring probably sleep duration more accurately than sleep depth and so what they're able to do is give us a very low fidelity recording of, of some element of sleep but over an extended period of time albeit a little probably inaccurately with regards to depth of sleep when compared with the panel on the right, which is the, you know, a hundred wires that get hooked up when we bring someone into a sleep laboratory and measure their sleep more accurately in that regard.

And so, there's various ways that we can, you know, that we can sequence these types of measurements depending on the individual. So, what are the types of things that people can experience when sleep goes wrong? Again, it's multifaceted. So, the most common things in the wider community are things like snoring and sleep apnoea.

So, partners reporting, disruptive snoring, possibly people stopping breathing when they're asleep. Insomnia will often be manifest as either a difficulty getting to sleep or if someone wakes during the night, difficulties getting back to sleep, or perhaps waking. Earlier in the morning than desired.

There can be various forms of sleep disturbance through the night. And often when sleep is disturbed, there are impacts with regards to daytime function, with sleepiness, tiredness and fatigue being different manifestations of that. We see a number of people with restless legs syndrome uncomfortable sensations in the legs, usually worse in the evening that necessitate people moving the legs around to, to settle down those sensations and sometimes needing medication to control it.

Various types of sleepwalking, sleep talking, sleep eating, acting out dreams. So, things that go bump during the night and problems with the internal clock. So, with sleep timing, so people falling asleep. You know, later than desired and waking later than desired or falling asleep too early or a bit of a mixture of the two.

So, there's a number of different ways that sleep disorders can manifest. So, who can help? When, when they do there are a number of healthcare professionals whose domain includes management of sleep disorders. So, the medical practitioner side of things GPs are often the first port of call sleep specialists like myself. So, more tricky sleep issues.

There are some neurologists who have an interest in sleep, probably an increasing number, but many neurologists, if they think there is a primary sleep disorder, will refer along to a sleep specialist and There are certainly a number of people who I co-manage with neurologists who have underlying neurological issues, you know, MS or Parkinson's disease, where there'll be significant sleep components who will co-manage patients in that regard.

But there are other allied health professionals, both general psychologists and clinical psychologists, but also clinical psychologists who have done additional training in sleep medicine who can deliver sleep specific forms of therapy. therapy such as a particular version of a cognitive behavioural therapy that has been designed for insomnia, for example, and that's best delivered by a sleep psychologist and other members of multidisciplinary teams.

So, there are increasing number of nurses, for example, particularly in rural and regional areas who can deliver this type of intervention and sleep coaches as well. There's an increasing online presence for sleep information and sleep therapy and I've got a slide at the end that lists some of them, but just making sure that you get that from reliable sources.

So the Sleep Health Foundation is a nonprofit. Australian based advocacy, advocacy group for sleep issues. And they've got some good facts sheets about various sleep disorders. And there are some online modules available for people who are interested in treatment for insomnia There's one in particular called This Way Up, which is is based out of Sydney Union of New South Wales and St.

Vincent's Hospital there that have got a very good insomnia program some of which is actually open access and free and other aspects that you need to pay for. There is another one called Sleepio that used to be available in Australia, but for some reason the moment isn't, but that was also a good online module to deliver those types of interventions.

So, I'm seeing that factors which can affect sleep or that can affect sleep. So, I'm not sure we should have a poll on. I think the grammar might be wrong there, but apologies for that. Maybe factors that can affect sleep. Anyway, the various things that can affect sleep. And as you can see it's pretty complicated and a number of the arrows that I've got there go both ways.

That these particular issues can affect sleep but if sleep isn't good, it can have you know, the countermeasure effect on, on, on that issue. So, you know, the things that we ingest, caffeine, alcohol, recreational drugs, can all often negatively affect sleep you know, particularly alcohol, which although it gives the perception of deeper sleep, it often results in significantly poorer quality sleep and more frequent wakening during the night.

Various prescriptions medication can impact on sleep and wake regulation both by making people more sleepy or in some people causing insomnia. Anxieties and stress can obviously impact sleep, but when sleep isn't working that well, it can you know, amplify those problems as well and more broadly in the mental health realm you know, mood disorders as well are very tightly you know, related with sleep in a bidirectional way.

Shift work about 20 percent of our workforce are shift workers and many of them have issues with sleep regulation. Obviously, there are a number of sleep disorders that by virtue of the fact their sleep disorders you know, will impact on sleep. And then, yeah, the elephant in the room, which is which is MS.

And I'll talk about that briefly at the end. I've deliberately there put a sort of a unidirectional. Arrow in that MS can certainly affect sleep, but I think as to whether sleep can impact MS outcomes, I think that that is less convincingly defined at the moment.

So, we know that sleep issues are considerably more common in people with MS than in the general population and there are some surveys that have indicated that about two thirds of people with MS at some stage or some extent will experience issues with poor quality sleep and there will be knock on effects with regards to Rudy's quality of life as a result of that.

So, MS can impact on sleep, you know, in a number of different ways. So, if there are particular MS symptoms, be it pain or continent symptoms or issues with temperature regulation, they can all most certainly impact on sleep. Any related mood or anxiety issues could do the same. Depending on how the Ms affects an individual and where individual plaques are sitting.

The machinery for driving and regulating sleep and wakefulness is housed in, in the part of the brain known as the brainstem or the, or the upper part of the brainstem. And any, any lesions in those areas of the brain have got. The potential to affect sleep either by causing insomnia or excessive sleepiness or, or, or other impacts and obviously medication can have an effect as well.

Sleep can impact on MS with regards to fatigue. So, if sleep, if there are problems with sleep, then that can either cause problems with fatigue or perhaps compound preexisting problems with fatigue, which is obviously a big issue in MS. We know that pain perception when sleep is problematic can also be altered.

But as I alluded to earlier, the, the impact of poor sleep on MS outcomes is, is hard to, to really nut out. And I don't know that we've really got definitive answers. Answers about that at the moment. And I guess the final thing to remember in this regard is that not everything necessarily relates to MS.

So, it sometimes might just be that you've got someone with MS, but they just have snoring and sleep apnoea because they've got big tonsils and a blocked nose. So, not everything needs to be tied back into the MS all the time. And just I guess to wind up I was Asked to just touch briefly on sleep and menopause and you know this is a well recognised and emerging area of of sleep disturbance primarily because it's thought that about 50 percent of women will experience some issue with their sleep in perimenopause and as with all this stuff it's very multifactorial so it might be issues with temperature regulation and hot flashes and vasomotor type symptoms that are primarily related to a reduction in estrogen levels.

And estrogen is important among other things in terms of keeping the body temperature low. There can be anxiety related to, you know, becoming menopausal and having menopausal type symptoms that can impact on sleep. And again, you know, the insomnia might not be due to any of this at all.

Sleep apnoea can be more common in perimenopausal women thought at least partly due to the impacts of a reduction in progesterone levels which results in more relaxation and more collapsibility of the upper airway, which can predispose people to snoring and sleep apnoea. Restless legs is also thought to be more common, possibly due to changes in iron metabolism.

And there may also just be issues that are completely unrelated to gender. So, as I alluded to earlier, we do require a little less sleep as we get older. And what happens to many people, particularly in the advanced stage, is sleep times shift earlier. So, people will fall asleep much earlier in the evening, but wake up much earlier in the morning.

Hormone replacement therapy does have some role in this in both sleep apnoea and insomnia. But, you know, it's a complicated discussion with primary care physicians or specialists about the, you know, the risk benefit balance of going down that pathway. So just to wind up there, these are a few of the resources that I thought, if you're interested in having a bit of a dive into some sleep stuff as I learned from my kids the good websites are the orgs and the govs and the edus because they're great.

Bye. coming from approved organisations rather than dot coms, which could be coming from anywhere. So, I've got the Sleep Health Foundation, which is the, the Australian advocacy group and some very good fact sheets there about various sleep disorders. There's the U. S. equivalent, which is the National Sleep Foundation.

Some information there about Cognitive Behavioural Therapy as a non medication based treatment for insomnia. And just another plug for that, this way up website. So, they do both insomnia, but there's also a mental health, depression, anxiety component to it as well. It's a very, very good website. So, I guess in conclusion sleep is one of the important pillars of our health and we need to make sure that we're doing whatever we can to optimise people's sleep quality and quantity but there's no magic number of hours that an individual needs or not that's easy to define anyway.

Sleep issues are more common in people with MS, but they're not always caused by the MS. So, I would urge, people with any specific complaints about sleep to, address those with, whichever healthcare practitioner they feel most engaged with and there will be a pathway to get that sorted out.

And I think that that's all I had to say. So, I've got a complicated Salvador Dali print there just to confuse things. But I'm happy to answer some questions if there are any.

Jodi: I had a question. Thank you. Simon. I didn't know about the 8 8 8, so I'm very I was very pleased to know about that little information.

Thank you for that. Always good to learn something like that. There's a lot of now there's a rise of people who've got sleep coaches and sleep psychologists and particularly in the sleep coach space there's a lot of people who you can sign up with who help you sleeping. Is that because, do you think that's because sleeping has become a bigger problem?

So generally, in society do you think it's a bigger problem or is it just becoming a little bit more of a or is it just a little bit more of an opportunity or, you know, there's so much more about sleeping now.

Simon: Yes, I think it's probably a bit of both. I think that there's certainly been more of an appreciation, and I think the Sleep Health, the Sleep Health Foundation has got to be thanked for that, for bringing sleep into the, you know, public domain in terms of something to talk about.

So I think it's partly due to, you know, greater recognition by general public, by healthcare practitioners about the importance of sleep. And I, I think that some people you know, have understandably seen that as a an unmet need. And so. You know, for sleep psychologists, for example you know, they're, they're, there aren't many of them around.

And, and so access to these types of people is, is difficult. And I did actually speak just the other week to a sleep coach, because I was sort of, I was a little bit sceptical about. Yes. Snake oil merchants. And, and she was actually very well credentialed. She'd done a number of face to face and online credential courses to actually learn the art of sort of delivering that that type of intervention.

And so, I think if people, I don't think there's any particular problem with going down that pathway. But. I guess buyer beware and just, do your research, see, see what someone's background is and where they're, where they've come from. But there are certainly some good practitioners out there who perhaps don't have university degrees necessarily, but have done a lot of education around it and who could be trusted.

Jodi: Yes, we often think we can fix things on our own or on Instagram. And it's and I'm learning more that's having someone, having someone to guide you through that can be really helpful. Yeah, for sure.

Jess: Simon, there was a question that came through about whether we can catch up on sleep, if that is something that people can actually do.

Simon: That's a tricky one. So, sleep loss is it's a very big issue throughout the population. So, everyone's got busy lives and the first thing that gets chipped away is sleep. And so most people are thought to have some degree of chronic sleep deprivation. We know that in the acute models of sleep deprivation, that if you deprive someone of sleep for a short period of time, that they will have recovery sleeps and they will catch that sleep up.

What's less well defined is in people who perhaps miss out on a little bit of sleep over a long period of time, whether that can be recovered and what the impacts of that, that's much less well defined. But we do know that there appear to be adverse health, metabolic cardiac, neurological outcomes in people who chronically don't sleep enough.

So, it's a matter of being able to try and prioritise sleep. But in terms of the models of chronic sleep loss it's not clear. clear how much if it's a one for one transaction where if you miss out on an hour of sleep, is an hour of recovery sleep going to pay that back enough in the short term?

Yes, in the long term, much less well defined.

Jess: Great. Thank you. And we also actually had a question come through regarding, dealing with sort of sensory symptoms, waking people while they're sleeping, so pins and needles or even, you know, feet feeling really numb and cold and tingling, I guess, do you have sort of tips around how people can manage that and the impact on their sleep?

Simon: Yes, that, that's complicated because that this is where the whole issue with MS being so diverse in terms of how it can impact people individually. And You know, me seeing someone with MS who is describing these symptoms, my, my initial approach is, well, are we dealing with someone who has got, you know, for example, sensory neurological problems related to their MS per se, or have we got someone with, primary restless leg syndrome?

Where, whether or not they had MS, they've got restless legs, and we need to be treating that in its own right. And so, as a clinician, me trying to tease that apart is important and not always straightforward. So, from my perspective, it's a matter of, being able to examine someone and seeing whether there's anything abnormal on examination.

If there's a neurologist involved, sometimes speaking to them about what the neurological manifestations of that person's MS are. But if I do think that it's restless leg syndrome, iron is extremely important and so making sure that someone has got very good iron storage levels is critical.

Some people with mild to restless legs will find that physical activity, particularly in the evenings, can help calm them down. Or if they're getting these symptoms during the night, having a bit of a walk around, but if the symptoms are problematic and not responding to those more conservative you know, measures, then a medication based approach is, is where we head.

Jess: Great, thank you. And another question, we've actually had several questions about this, is not so much the lack of sleep, but oversleeping. Is there an impact from having too much sleep, someone saying they're sleeping eight to nine hours every night and they still feel like napping during the day, is there a possibility that they're getting too much sleep?

Simon: Yes, so it's not, it's not in, in a healthy person, it's not possible to get too much sleep. So, your body will generally only allow the sleep that's required, and you'll wake, naturally and spontaneously after that time. If someone is allowing sufficient. Space and time and opportunity for sleep and despite sleeping that time they are unable to maintain wakefulness in situations during the day where they're otherwise wanting to be awake or in people who are needing to, in addition to their nighttime sleep, have planned scheduled naps during the day, then those types of manifestations are often an indication that there's something going on.

So, if you're not able to stay awake in scenarios where you want to, or if you're needing to have additional and extended sleeps during the day then that could be an indication that, that there, that someone has got excessive sleepiness and that itself would merit evaluation. So yes, I guess the simple answer is it's not possible to oversleep, but if someone is needing a lot of sleep or unable to function properly during the day because of sleepiness, then that should be investigated.

Jess: Great. Thank you.

Simon: Actually, I've just remembered somehow there was a slide that I've just, I've just realised I skipped past. I forgot time at the end. I had a slide about healthy sleep tips as well. But if you've got more questions, I'm happy to deal with those first.

Jess: Yes, sure. One of the other questions that we had was regarding, I guess, getting off long term use of you know, sleep medication to assist in establishing a new sleep pattern. So how someone might go about that?

Simon: Yes, so it's a common problem because we know that, in terms of the way that insomnia has been conceptualised and studied and treated over the years. We know that about 70 percent of people with insomnia will have either a significant improvement in their insomnia or remission of their insomnia with cognitive behavioural therapy.

So, with a non-medication based approach, as I mentioned earlier, delivered either online or face to face with sleep type psychologist so that we can avoid medication. But medication is used in a lot of people because it's just easier and for some people it's the only choice that we've got. And, about 30 percent of people who do cognitive behavioural therapy will have residual insomnia and will need medication.

So, there is a role for medication, but there are a group of people who get stuck on medication that is either ineffective or unhelpful or causing side effects. And so, in people on sleep type medication, sleeping tablets, temazepam or Stilmox or, you know, whatever the flavour of the month is.

There are ways of stopping it but in people who have been on it for a long time, it's best done as part of a a planned and structured approach because what often happens if they say I'm not going to take it tonight is that they will get rebound insomnia. And so, by engaging with some sort of a clinician, sleep coach, sleep psychologist, sleep physician and having a strategy in place about, okay, this is what we anticipate when we maybe not try and stop it.

Maybe it's just trying to reduce the dose initially or look at alternate day dosing. There are various ways of sort of tapering it off but having non medication-based strategies to deal with the insomnia that is likely to occur when, when, when you do sort of try and stop it. So, it's almost like sort of quitting smoking in a way that you wouldn't tell someone to go and just go cold turkey.

You want to have it a, you know, a planned approach that will optimize the chance of that intervention working. And for insomnia, it'd be having strategies, non-medication strategies in place to to help with the tapering and hopefully, you know, cessation of the sleeping tablet medication.

Jess: Great, thank you.

And I guess the last sort of question that we've also had a few comments around is, I guess stimulants like coffee, is there a latest time in the day you should be having this? Can that have an impact on things like frequent waking at night? What's your view on that?

Simon: Coffee is great.

And it's a completely. legitimate stimulant. So, it is okay to drink, whether it's coffee or tea. I mean, remember there's, there's caffeine in, in, in tea as well, a bit less than coffee, but there's still caffeine in tea or in, you know, various sort of soft drinks and other things like that.

Generally, so the recommendation is less than five cups of coffee a day, which is a lot. Once you're beyond that, you can start getting, toxicity. from the caffeine, palpitations, anxiety, nausea. So generally, first half of the day, so in patients who I see who are experiencing problems with insomnia, I'll say look, after lunch or early afternoon, cut the caffeine.

It's rarely the only thing that's causing people's sleep problems, but you're just wanting everything that you can have on your side to optimise the chances of good quality sleep at night. So, yeah, I actually sort of set a cutoff as early afternoon.

Jess: Great. Thank you, Simon. I will make you the presenter again so you can share that slide that you were talking about.

No, that's all right.

Simon: It just gets back to sort of just, yes, sort of what you're asking about, just some basic sleep tips. Okay, here we go. Yes, so this is basically sort of what we call sleep hygiene, essentially. So, it's basically just, good habits around sleep and those habits are having a regular routine.

So, you've got, the master clock sits in a part of your brain called the suprachiasmatic nucleus. But that clock talks to the individual clocks that literally exist in every one of the trillion cells in your body. And so by having a regular sleep, wake rhythm it gets all those clocks essentially beating in unity and by having a regular sleep time that is ideally started by having a reasonably regular wake time in the morning it gets all of those biological systems nicely in sync.

Ideally wanting to minimise daytime naps. So, if you do need to nap during the day, it's best to do that as a power nap. So 15, no more than 20 minutes. And setting an alarm because what happens if you sleep longer than that is that you wake up with a lot of that inertia that you have when you get up first thing in the morning.

Because you've been into the deeper stages of sleep. And it also in people with insomnia it's taking away from some of that high sleep drive that we want people to be experiencing when they're going to sleep at night. So, you don't want, if avoidable extended daytime naps. And those, those power naps can have an alerting effect of anything up to four to six hours after a power nap.

Maintaining activity during the day is important. It will also you know, minimise the risk of having unexpected naps. Talked about caffeine already. Minimising alcohol and large meals before bed. You want a bedroom environment that is conducive to sleep. So comfortable, quiet. In my shift workers, some of them even use, blackout material to keep it dark during the day.

You want nice ambient temperatures. Generally, they recommend somewhere between 13, 23 degrees. Anything beyond those extremes people will struggle to sleep. And usually something in the middle is about right. And restricting. Basically, all you're doing in bed is sleeping is good sleep hygiene.

And the light exposure is important because light is the primary controller of our biological rhythms and timing. And light in the morning sets the clock for the day and the light in the evening will keep people awake and on the top picture there the perennial handheld devices are all very bright with blue enriched light, which is actually the stronger wavelength in terms of controlling rhythm.

So, we try and. minimise the usage of that in the evenings and particularly in bed. In people where we're really wanting to restrict light exposure, I've got a picture of Bono there to remind me that yellow or orange glasses will prevent that blue light from getting in. So often people using those types of glasses of an evening or nighttime to minimise evening light exposure.

There are devices in people where we're wanting to give them light at particular times that we can provide them with light therapy devices that will deliver the right wavelength light. But just keeping in mind that the bottom photo there is that the cheapest intervention is actually the natural light.

And yes, to allow our clocks to be controlled by the cycle of the sun. So yes, I think that was the only slide I missed. Hopefully I didn't miss too much more.

Jess: Excellent. Thank you for that, Simon. That was really, really great.

Simon: No problems.

Jodi: Thank you. Thank you again, Simon. Thank you for that. That was a fantastic overview of sleep and reminds us all of the importance of sleep and particularly in people with MS.

I think that sleep is It can be really challenging, but it's so important because, you know, it's an uphill battle against fatigue a lot as well too, so getting that right sleep and I think hearing from sleep physicians just really cements it and hopefully encourages people to have a conversation with their neurologist as well too, to say, I'm not sleeping, it might not just be MS, it might be something else.

It might be sleep apnoea, and often then, the neurologist is going to forget to ask if you snore, but it's really important to tell people that fact so that so that they can involve this whole team that we're developing around helping people sleep. So, think that's great to be able to prompt the conversation as well too.

Simon: Exactly right.

Jess: Right. Thank you both. So that sort of concludes the webinar for tonight. So, this is just a slide showing, the other services and supports that you can get through MS Plus. And we have resources, so including this webinar will be uploaded on our website on the Resource Hub.

We've got some great sleep resources there and this will be one of them and you can always get in touch with us at Plus Connect with the details there and if you want to stay online and just answer a short survey and just give some feedback about the session, that would be great.

So, thank you everyone and have a great night.

Simon: Thank you.