Why your doctor asks how you are sleeping

"How are you sleeping?"

You've probably heard many physicians ask you this question.

This question is part of the review of systems, the standard checklist a provider goes through while taking your history, and it’s not meant to be small talk. It is asked alongside questions like do you have chest pain, shortness of breath, unexpected weight loss or gain, and other important ones designed to take stock of your health.

I have asked this question countless times and the answer I’ve most often received is some version of "Fine, I guess." It’s a reasonable answer, though one that lacks specificity. What I’ve wanted to truly understand is how their sleep reflects their overall state of health.

How your sleep reflects your health is answered by a record of your sleep. There is a famous painting of what producing such a record used to take. In The Doctor, exhibited in 1891, a physician sits leaning forward, intently gazing at a sick child laid across a makeshift bed of two mismatched chairs. Dawn is flushing through the window behind him, and the child's parents are distraught in the background. There is no stethoscope or thermometer in sight. The only instrument in the room is the doctor's attention, and it has been running all night. Luke Fildes painted it after watching a doctor care for his own son, who died of typhoid fever.

Most physicians today cannot undertake this type of night vigil for their patients. But a record of what happens to their patients for a third of their everyday life can give meaningful clues to an individual’s health. A patient who cannot lie flat without getting breathless suggests an underlying heart condition. A patient waking four or five times a night to urinate may have an enlarged prostate, poorly controlled diabetes, heart failure, or may simply be taking a diuretic too late in the afternoon. A patient who falls asleep easily but awakens at 3am and cannot fall back asleep is experiencing something different from one who lies awake two hours before being able to fall asleep. While early waking has a relationship with depression, prolonged sleep onset may point more to anxiety or circadian timing. 

If a patient shares that their partner says they snore and sometimes has pauses in their breathing, obstructive sleep apnea is an immediate concern. Obstructive sleep apnea also raises the risk of hypertension, heart disease, and stroke. It is, however, close to invisible to many. By one estimate, 23.5 million Americans go undiagnosed. 

Complicating matters is that sleep can be the symptom or the cause. Poor sleep makes blood pressure harder to control, glucose harder to control, and mood disorders harder to treat. A patient with hypertension and untreated apnea sits inside a vicious cycle: the apnea worsens the pressure, the pressure gets medicated, and both the medication and the condition reshape the sleep.

And the test built to find the answers is challenging to scale. Sleep studies are expensive. A night in a sleep lab runs several hundred dollars or more, and access to care continues to be a challenge for many Americans.

The nights arrived

That changed in the last few years.

Sleep can now be measured continuously, in a person's own bed, by something they wear or by simply lying in their bed, across years rather than a single night. It can flag changes in sleep that lead an individual to seek more care. This is an exciting development for all of us looking to better manage our health. 

What the nights alone still can’t show

For most people that record arrives as a sleep score, and that is a good place to start. Compressing a night of physiology into something you can act on before your first coffee is technically hard, and the measurement underneath has become stronger.

The weak link shifted from measurement to interpretation. A score answers the question it was handed with the information it was given, but your doctor’s question goes beyond how did you sleep.

Say your deep sleep has been declining for a year. Is that ordinary aging? Is it too many glasses of wine in the evening? Or is it the beta blocker you started in March? Or a thyroid condition, or perimenopause?

Each scenario calls for a different response: do nothing, a change in habits, a conversation with a prescriber, a referral. No amount of additional precision in the sleep measurement will tell you which one you are looking at. That separation comes from context: your conditions, your medications, your labs, your health history. Give a good score that context and it stops describing your night and starts explaining it. But that context rarely sits in one place. It is scattered across every clinic, portal, and lab you have ever used, and the one thread running through all of it is you. 

Here is what explaining looks like. A woman in her forties comes to me tired, blaming work and her age. Fatigue is miserable to work up because nobody can date its onset. But with her nightly data, I see that her nights had been fragmenting since October, and her resting heart rate climbing with them, neither of which she could feel. She sleeps alone, so no one had told her she snored. Her chart shows eighteen pounds gained over two years and a blood pressure needing a second drug. None of that was a diagnosis – it was a reason to look. The sleep study I order is what confirms moderate apnea.

What the nightly record supplies is a date, and what her chart supplies is a reason to take that date seriously. She was going to be one of the 23.5 million until her nights gave us somewhere to start.

Our partnership with Eight Sleep

This is why I’m excited to share that HealthEx is partnering with Eight Sleep.

Eight Sleep has introduced Biological Age, developed in collaboration with Bryan Johnson's Immortals. It turns the physiological signals the Pod captures each night into a view of how a member's body is aging over time. Starting now, an initial group of members in the United States can also connect their medical records through HealthEx, securely and with their consent, adding conditions, medications, and lab results so the score reflects what is actually shaping those nights. This is just the beginning of what these two data modalities put together can unlock for members. The Pod and its scores are wellness tools, not diagnostic tests. They’re meant to give you and your doctor a better starting point for a conversation — not to replace one.

My hope for individuals

General sleep advice is to change habits. Keep a consistent bedtime, put the screens away an hour before, cut caffeine after lunch, skip the late glass of wine, keep the room cool and dark, and avoid daytime slumber.

A few patterns point away from habit and toward something worth investigating.

There is no onset you can name; it did not start with a move, a job, or a new baby. You have tried changing habits and nothing moved. The trouble is staying asleep or waking early rather than falling asleep. You sleep a full night and wake unrefreshed anyway. It began within a few weeks of a new prescription. Someone who sleeps near you has mentioned snoring, or pauses in your breathing.

I think about the patient managing high blood pressure who can finally see how a change in their medication shows up in their heart rate and their sleep, night after night, instead of wondering until the next appointment. I think about someone who has felt exhausted for months and, seeing their sleep data alongside a thyroid diagnosis, finally understands why, and walks into their doctor's office with something concrete to talk about. I think about the member who arrives at a visit with real data about how they've actually been sleeping, instead of a shrug and a guess.

The pattern, the timing, tied to the rest of your health. That is what turns eight unconscious hours into an answer for you and your doctor.

Learn more about our partnership with Eight Sleep here. The Pod is a wellness product, not a medical device, and is not intended to diagnose, treat, cure, or prevent any disease.