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Rest up

Sleep doctor takes the Z out of snooze


NIGHTY-NIGHT: Krulin helps patients get rest.
  • NIGHTY-NIGHT: Krulin helps patients get rest.

Dr. Gregory Krulin has had his day in the sun, that is, in an Arkansas Times Best Doctors issue. It was 1996, and he was quoted in a story about the burden health maintenance organizations had brought to the field of psychiatry.

That was then. Krulin is again in the Arkansas Times' spotlight — but now as a sleep doctor.

It makes sense. As a graduate student at the University of Arkansas at Fayetteville, Krulin did research in hibernation physiology. Then he decided he wanted to be a medical doctor, and he went to the University of Arkansas for Medical Sciences. He began his career as a psychiatrist in 1978.

In the 1990s, Krulin began doing both psychiatry and sleep medicine. There was commonality: Anxiety, depression, post-traumatic stress disorder — all disturb and are exacerbated by sleep loss.

The field of psychiatry began to change, too, as psychiatrists moved into medication management and away from therapy. “I'm blessed with really liking people,” Krulin said. “I want to understand the dynamics” of why a person is suffering from insomnia.” So he left psychiatry, went to “sleep school” at Stanford University in California and returned to work with sleep doctor Bob Galbraith in Little Rock at what is now the Arkansas Sleep Institute.

There are 60 sleep disorder diagnoses, but the most prevalent, Krulin said, is insomnia. Then comes sleep apnea (which disturbs sleep), restless leg syndrome (which prevents sleep) and narcolepsy (too much sleep).

Anxiety and depression are the culprits in insomnia, and sometimes re-learning how to sleep is hard work. Our sleep clock, the suprachiasmatic nucleus, is located where the optic nerves meet somewhere behind our noses and is smaller than the head of a pin. When it gets out of whack it can take a while to reset. Krulin said he sees patients who, for example, may sleep one day and stay up for two. It's hard work, Krulin said, to reset the clock. The patient has to learn to wind down; medication is a quick fix but an addictive one. (We asked Krulin how to kick our sleep med jones; eat four light meals and get a really good workout every day, he advised.)

Most sleep problems can be helped, Krulin said. Which is a good thing, because some 20 percent to 40 percent of the American population has insomnia, getting two bad nights of sleep a week.

Sleep apnea — when the muscles of the tongue and throat relax so much they block off oxygen, kicking off the brain's wake-up warning (apnea means “without breath”) — is a common sleep problem, especially for overweight men over 40.

The treatment is the CPAP (continuous positive air pressure) mask to be worn while sleeping. It forces oxygen in so the brain won't have to wake up and get you breathing again. So what if it makes you looks like something from outer space? Krulin asks. An older female patient of his told him she worried she scare her grandchildren if she wore the CPAP. “Tell them you're Top Gun,” Krulin instructs. Don't worry about it. Apnea patients who use the CPAP (some 95 percent get good results) feel good, feel younger and, most importantly, halt the apnea cycle that can spiral into such disturbed sleep that the lack of oxygen begins to damage the organs.

The drugs Mirapex and Requip were introduced in 2006 to treat restless leg syndrome, a condition in which the legs burn or itch. Moving them provides relief, but keeps sufferers awake.

Stimulants like Ritalin and Provigil and antidepressants are used to treat narcolepsy,

an unusual sleep disorder occurring in 1 in 2,000 people. People who suffer from narcolepsy fall into a state of cataplexy — the muscles become partially paralyzed, droop, but awareness is unaffected. The condition is caused by a deficit in the brain chemicals that control wakefulness. Strong emotions — laughter, fear, even orgasm — can trigger the sleep-like state. Narcolepsy can be caused by genetics or traumatic brain injury; one of Krulin's patients became narcoleptic after her car was run over by an 18-wheeler.

Krulin likes to talk to the “bed partner” to get a fuller picture of his patients' sleep behavior, and the sleep laboratory at St. Vincent Medical Center Infirmary provides even more details on patients, such as what position a patient is in when his sleep apnea is worst, how severe is the disturbance, how quickly they fall asleep.

A result of chronic sleep deprivation is that a sufferer may lose awareness that he is, in fact, sleep deprived. Krulin provides patients and “bed partners” a check sheet of cognitive impairment that can be caused by chronic sleep deprivation:

Does the patient have trouble understanding directions? Remembering information? Poor judgment? Is the patient quick to anger or depressed? Does he doze off while watching TV or sitting in meetings?

He also uses the Epworth sleepiness scale, which asks the patient to rate, from 0 to 3, the likeliness that he'll fall asleep after lunch, in a theater, in conversation, or as a passenger in a car for more than an hour.

He also weighs his patients, since weight can be linked to apnea.

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