Dr. Alex Iranzo: “Over the last 15 years we have realized that what is important for a good life is to have healthy sleep, a balanced diet, moderate exercise and good mental health”

Sleep is one of the three basic cornerstones to a healthy life, along with diet and exercise.  Moreover, as Dr. Alex Iranzo explains, it is the one that requires the least effort of all three because it is achieved spontaneously.  However, studies show that we are sleeping less and less nowadays, and people have more minor problems with sleeping, or sleeping well.  And poor sleep quality predisposes people to developing a whole host of health problems: heart attacks, strokes, diabetes, hypertension, anxiety, depression, and even some cancers. We talk about all this with neurologist Alex Iranzo, one of the leading figures in the study of sleep at the Hospital Clínic.

What is normal sleep, if indeed normal sleep exists?

Yes, normal sleep does exist: our brain is made to be biologically active, and one of the functions of nature is to make us sleep and we sleep to rest.  This is why we have well-constructed sleep that consists of three stages: shallow sleep, deep sleep and REM sleep, which alternate in three or four cycles over the course of a night.  During the first part of the night, most time is spent in deep sleep, and more time is spent in REM sleep towards the end of the night, which is when we tend to dream. And then there is shallow sleep, which is constant throughout the night.

However, this varies over the years, and depending on one’s sex…

Sleep varies depending on one’s age, just like the other biological functions: hormones, weight, etc. A child aged three or four needs a lot of deep sleep because it is during this stage that the growth hormone is secreted.  Then, when they get older, from the age of 18 or 19, they no longer need it because they have finished growing and the REM sleep stabilizes.  The body and the brain mature over the course of our life, but an adult's normal sleep pattern appears between the ages of 14 and 20.

So, do men and women also sleep differently?

Very slightly. Women need a little more deep sleep and that means they have more stable sleep.  They also tend to suffer more insomnia.  Men, on the other hand, have a greater tendency to develop sleep disorders such as apnoea.

You said that sleep was one of the three basic cornerstones to a healthy life:  exercise, diet and sleep.

Yes, and mental health too. They are the four pillars everyone talks about these days, but they have been there all our lives.   It is over the last 10 to 15 years that we have realized that what is important for a good life is to have healthy sleep, a balanced diet and moderate exercise. And then it is also important to have good mental health, which means developing our qualities and trying not to get depressed or be anxious.

What would good sleep habits consist of, more or less?

First of all, we need to have a regular schedule, always going to sleep at more or less the same time.   This doesn’t mean that it has to be exactly at 11.23 and 40 seconds, but going to bed between 10 and 11 pm and getting up between 7 and 8 am. That’s the way to ensure we get enough sleep.  

But there are many people who are sleep deprived.

There are studies in the United States that say that in the 1980s people slept an average of 7.5 to 8 hours and now, 40 years later, they only sleep 6 hours. These hours of sleep have been lost basically because of the demands of life:  stress, anxiety, worries… That's why we wake up at 4 am remembering a problem, and we can’t stop thinking about it. What’s more, it doesn’t happen at 2 or 3 am, but at 4 or 5 am, when we have no more deep sleep and it’s shallower.  So, if we wake up, we remain restless and it’s harder to get back to sleep.

And what can we do to sleep better?

In addition to having regular sleep habits, we should avoid doing anything silly. For example, we shouldn’t drink alcohol because, although alcohol makes us sleepy, it also fragments our sleep a lot and it becomes shallower; we don’t have deep sleep.  Sometimes, people think that exercising in the evening is a good way to sleep better, but this is wrong: our body will be tired but our brain won't, and if it's going at 300 an hour, it won’t be easy to get to sleep.

And what if we have insomnia?

Then we must follow a few golden rules:  the bed should only be associated with sleep.  Other activities such as reading, watching television or listening to the radio should not be done in bed. It is also a good idea to avoid looking at our watch and to stay away from screens, because by lighting up they activate the brain.  To avoid feeling anxious, it is recommended to make a list of any problems or pending tasks we have about three hours before going to sleep and not to think about them again until the following morning.

There are quite a few clichés linked to the world of sleep. For example, I'm not sleeping right now, but I'll catch up on sleep at the weekend.  Is that true? Can we catch up on lost sleep?

No, it is lost. If we take advantage of it being the weekend and have a two-hour nap or sleep until 11 am because during the week we only sleep five hours a night, we won’t make up for this lack of sleep by sleeping more.  We have lost it forever.

And are naps good or bad?

Restorative naps, good and natural ones, last 20 minutes or 30 at the most. If we need to sleep for longer, it means we are not sleeping enough at night or that our sleep is of poor quality.

And, if we sleep little and badly, what kind of sleep disorders can develop? And what is the risk of contracting diseases?

In the short term, not sleeping at night means that we don’t perform well the next day.  This happens to doctors, when they do very long on-call shifts, they get the next day off because they are not in a position to continue working. This is a short-term result: we do our work worse than we would if we had rested properly.  Then, in the long term, sleeping little and badly, with fragmented sleep, predisposes us to cardiovascular problems, heart attacks, strokes, diabetes, hypertension and also, on a psychiatric level, to more irritability, more anxiety, more depression and less desire to be sexually active.  Some cancers have even been associated with this.

And Alzheimer’s disease too.

Yes. It is a disease in which neurons die, especially those that regulate memory.  But in addition to dying, they stop eliminating a toxic substance called beta-amyloid, which destroys neurons.  This toxic substance is eliminated when we sleep and, if we sleep little, we have few hours to eliminate this toxin.  So, if we are predisposed to Alzheimer’s disease and sleep little or badly, this makes us more likely to develop the disease.

We still know very little about sleep.

Compared to years ago, we know far more, but there is still a lot to discover. In 2014, at the Hospital Clínic we discovered a new sleep disorder:  anti-IgLON5. Patients came to see us because they had apnoea, because they couldn't sleep, because they were making strange movements whilst they were sleeping, they were making punching movements, etc.  And we saw that they had an antibody against the neurons and, in addition to having problems with sleeping at night, they had neurological issues such as balance and congenital disorders.

How are sleep disorders dealt with at the Hospital Clínic?

We have performed a very important task on a scientific scale in studying how a sleep disorder called REM Sleep Behaviour Disorder develops. This mainly occurs in people over the age of 60 who, during the REM sleep phase, instead of dreaming and experiencing the normal temporary paralysis, make involuntary movements.  So, they have nightmares in which they’re being attacked or they’re arguing and they shout or make punching movements and even fall to the ground. It is as if they are having an extremely vivid dream, but it is a sleep disorder. Initially, it may appear like it’s just a sleep problem but, after 15 years, 90% of sufferers develop dementia with Lewy bodies or Parkinson’s disease.

In other words, this sleep disorder is the beginning of a neurodegenerative disease.

We have been describing this for around 15 years and we have seen that when we carry out a lumbar puncture, a skin biopsy or a saliva gland biopsy, the neurons contain a protein called alpha-synuclein, which is the protein associated with Parkinson’s disease.  In other words: they already have the seed. And now there are drugs against this protein, which attempt to neutralize it. So, at the Hospital Clínic we are looking for a neuroprotector to eliminate these proteins, and patients who have this sleep disorder will then be left with just this, with a simple sleep disorder, and will not develop Parkinson’s disease or dementia.

Would these two be the most important breakthroughs for sleep that have been made at this hospital?

We also saw that some of our patients with REM sleep behaviour disorder were former footballers.  And we were awarded a Health Research Fund (FIS) grant to study the possible long-term consequences of contact sports and sleep disorders. It is possible that after 40 years  they may develop a neurological disease such as dementia or Parkinson’s disease. We have the support of FC Barcelona and we are starting to study other sports such as rugby, American football, ice hockey, boxing and the marital arts.