Need for Sleep. Overview. Sleep Disturbances, Comorbidities, Quality of Life & Healthy Sleep. PhD, RN, CHTP, AHN-BC, FAAN

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1 1 Sleep Disturbances, Comorbidities, Quality of Life & Healthy Sleep Presented By: Carol Baldwin PhD, RN, CHTP, AHN-BC, FAAN SOUTHWEST BORDERLANDS SCHOLAR DIRECTOR, CENTER FOR WORLD HEALTH PROMOTION AND DISEASE PREVENTION 2 Overview Need for Sleep Insomnia Obstructive Sleep Apnea Short/Insufficient Sleep RLS Excessive Daytime Sleepiness Sleep Tips References 3 Need for Sleep Sleep, that knits up the ravell d sleeve of care William Shakespeare Benefits recognized since time of Hippocrates, yet sleep disorders are: Public health problem Under-diagnosed Basis for jokes

4 Difficulty Initiating or Maintaining Sleep Difficulty falling asleep Difficulty staying asleep Early morning wakening with difficulty resuming sleep Acute Short duration Chronic More than one month

2 4 Difficulty Initiating or Maintaining Sleep Difficulty falling asleep Difficulty staying asleep Early morning wakening with difficulty resuming sleep Acute Short duration Chronic More than one month Insomnia 5 Insomnia: Classification Primary (according to the DSM IV): Symptoms for at least 1 month Cause distress, or reduce ability to function successfully Symptoms cannot be associated with a medical condition, medication side effects, or substance abuse Secondary: Comorbid with Medical condition Medications, alcohol Psychiatric disorder (depression, mania, anxiety, PTSD) (Epstein & Bootzin, 2002) 6 Insomnia: Epidemiology Primary = 9 12% (community studies) Secondary = 70% of insomnia problems in the general population More common in women Insomnia contributes to Substance abuse Poorer health-related QOL Functional impairment & healthcare utilization Economic impact Direct costs = $ $15.4 billion/year Indirect costs accidents, reduced productivity (Epstein & Bootzin, 2002)

7 Diagnosing Insomnia Usually self-reported; PCPs don t generally ask Sleep Diary Bed, wake times, night awakenings, habits, stress Can uncover factors related to insomnia Actigraphy Compare with

3 7 Diagnosing Insomnia Usually self-reported; PCPs don t generally ask Sleep Diary Bed, wake times, night awakenings, habits, stress Can uncover factors related to insomnia Actigraphy Compare with diary Shows graphed activity/quiet times over one to several days Insomnia: Treatment Behavioral management Stimulus control (2-Ss, bed when sleepy) Relaxation techniques Sleep restriction (mild deprivation) Medications First, see your health care provider e.g., Lunesta, Rozarem (Epstein & Bootzin, 2002) 9 Obstructive Sleep Apnea (OSA) The object that presented itself to the eyes of the astonished clerk was A wonderfully fat boy standing upright with his eyes closed in sleep and seemed, to the clerk s imagination, to snore feebly. Charles Dickens

10 OSA: Diagnosis Bed-partner reports Loud snoring Apnea/gasping Brief awakenings Physiology Upper airway narrows/closes Intermittent hypoxia Sympathetic activation Sleep fragmentation DX:

4 10 OSA: Diagnosis Bed-partner reports Loud snoring Apnea/gasping Brief awakenings Physiology Upper airway narrows/closes Intermittent hypoxia Sympathetic activation Sleep fragmentation DX: Polysomnography (Baldwin & Quan, 2002) 11 OSA: Epidemiology 2-4% in working men & women 2:1 male:female ratio Rates increase in women after menopause 20% in 65 and older Overweight/Obesity Heritable factors Head/neck anomalies (Baldwin & Quan, 2002) 12 OSA: QOL/Morbidity and Mortality Poorer Quality of Life Physical Psychological Social (bed partner may sleep in another room) Morbidity & Mortality CVD Type 2 diabetes Cognitive deficits Mood/personality changes Impotence/reduced libido Sleep Heart Health

5 13 OSA: Public Health and Safety Public health problem OSA severity related to magnitude of medical costs Untreated OSA ~$3.4 billion in added medical costs VA pts with OSA 6X more likely to have coronary angiography Male snorers at 2-fold risk for occupational accidents; accidents increase by 50% in men with OSA OSA prevalence expected to increase in young adults due to obesity epidemic (Touchette E, et al., 2008) Public safety risk OSA patients 3X more likely to be in auto accidents Drowsy driving akin to driving drunk/on drugs (Baldwin & Quan, 2002) 14 Maintaining ideal weight Diet Aerobic exercise Antioxidant-rich foods Sleeping position Continuous Positive Airway Pressure device (CPAP) Dental devices Surgery OSA: Treatment (Baldwin & Quan, 2002) 15 Short Sleep: Pop Quiz On average, how many hours of sleep do you get per night (estimate if shift worker)? When you restrict your sleep to 5 or 6 hours per night (exams, children, grant-writing, etc.): What do you eat? Do you eat more or less when you restrict sleep? What do you drink? Do you take time to exercise? How do you feel the next day?

16 Short/Insufficient Sleep High costs (NCSD) $150 billion/year Higher stress Reduced productivity Public tragedies Chernobyl Exxon Valdez High-risk Caregivers of family/friends with chronic illness

, 2006) 17 Short/Insufficient Sleep: Risks SHHS short sleep time findings: Hypertension (Gottlieb et al., 2006) Type 2 diabetes & impaired glucose tolerance (Gottlieb et al.

6 16 Short/Insufficient Sleep High costs (NCSD) $150 billion/year Higher stress Reduced productivity Public tragedies Chernobyl Exxon Valdez High-risk Caregivers of family/friends with chronic illness Working double shifts Multi-responsibilities (e.g., working single parents) Students/Teachers (Scott LD, et al., 2006) 17 Short/Insufficient Sleep: Risks SHHS short sleep time findings: Hypertension (Gottlieb et al., 2006) Type 2 diabetes & impaired glucose tolerance (Gottlieb et al., 2005) work/traffic-related accidents Health care workers (Scott et al., 2006) Fatigue = vigilance = patient safety burnout 18 Stanford Report 2004 General population ages over 4 years Compared 8 hr sleepers to 5 hour sleepers Short sleep time ghrelin (eat more) leptin (don t feel full) BMI ( obesity) Sleep, Hormones, Obesity (Taheri S, et al., 2004)

19 Sleep-related Vehicular Accidents AKA Drowsy Driving National Highway Traffic Safety

5 billion economic costs National Sleep Foundation 51% adults admitted Drowsy Driving 71% for ages

org) 20 Restless Legs Syndrome (RLS) Uncomfortable sensations in the lower limbs Worse in the evening

, walking) Epidemiology Ranges from 5 15%, increases with age More common in women Associated with

7 19 Sleep-related Vehicular Accidents AKA Drowsy Driving National Highway Traffic Safety Administration 100,000 police-reported crashes related to fatigue 1,550 deaths 71,000 injuries $12.5 billion economic costs National Sleep Foundation 51% adults admitted Drowsy Driving 71% for ages ( 20 Restless Legs Syndrome (RLS) Uncomfortable sensations in the lower limbs Worse in the evening or night Worse during periods of rest/inactivity Partially/totally relieved by movement (e.g., walking) Epidemiology Ranges from 5 15%, increases with age More common in women Associated with depression (dopamine system) (Hening W, et al., 2007) Causes Uncertain: Possible bases are CNS/PNS,vascular, genetic, metabolic Metabolic basis may be related to iron deficiency anemia Genetic basis supported by positive family history Diagnosis and Treatment Sleep specialist 21 Excessive Daytime Sleepiness (EDS) Associated with OSA Insomnia Insufficient sleep RLS Other conditions CVD Diabetes Depression

22 EDS and Fatigue Behavioral features of sleep disorders, esp. OSA Can occur while talking, driving, or eating Assessment Subjective: paper & pencil tests, e.g., Epworth Sleepiness Scale (propensity to doze -?

8 22 EDS and Fatigue Behavioral features of sleep disorders, esp. OSA Can occur while talking, driving, or eating Assessment Subjective: paper & pencil tests, e.g., Epworth Sleepiness Scale (propensity to doze -? gender bias) Objective: obtained in sleep lab, e.g., Multiple sleep latency test (MSLT)-time to sleep Maintenance of wakefulness test (MWT)-stay awake Gender Differences Men more likely to report EDS Women more likely to report fatigue (could miss OSA) (Baldwin & Quan, 2002) 23 Sleep Do s & Don ts 24 Alcohol Disrupts sleep Rebound insomnia Caffeine Stimulant Sleep Don t: Alcohol/Caffeine Difficulty falling asleep Diuretic Frequent trips to BR

25 Sleep Don t: Heavy Meal at Bedtime Large meal/spicy food Can cause

OK!! Banana serotonin Warm milk tryptophan Yoghurt 26 Sleep Don t: Tobacco

Nicotine increase in cigarettes by10 30% Targeting youth & minorities

unable to sleep in15-30 minutes Get up Sleep Don t: Toss and Turn Return

9 25 Sleep Don t: Heavy Meal at Bedtime Large meal/spicy food Can cause discomfort Weight gain Fluid intake Frequent trips to BR Light snack at HS OK!! Banana serotonin Warm milk tryptophan Yoghurt 26 Sleep Don t: Tobacco Cut back, or stop use Nicotine Stimulant Difficulty falling asleep Nicotine increase in cigarettes by10 30% Targeting youth & minorities David Brown Washington Post Staff Writer Thursday, August 31, If unable to sleep in15-30 minutes Get up Sleep Don t: Toss and Turn Return to bed only when sleepy Set alarm, put clock out of site Checking time can contribute to insomnia

28 Go to sleep and awaken at the same time Weekdays

encourages better sleep 29 Sleep Do: Comfortable

better than hot Lighting Dark as possible Noise Less

Stress-free zone Bedroom for the 2 S s Avoid TV,

30 Sleep Do: Exercise Regular exercise improves

10 28 Go to sleep and awaken at the same time Weekdays Weekends Sleep Do: Regular Schedule Sleep-wake cycle encourages better sleep 29 Sleep Do: Comfortable Environment Sleep Environment Temperature Cool better than hot Lighting Dark as possible Noise Less = better sleep Comfort Good mattress/pillow Stress-free zone Bedroom for the 2 S s Avoid TV, reviewing IRA, fretting, etc. 30 Sleep Do: Exercise Regular exercise improves sleep Morning, afternoon, or at least 3 hours before bedtime Supports deeper, more restful sleep

31 Relax before Bedtime Warm bath Relaxation techniques Calming music

, Chamomile (unless allergic to aster family) 32 Questions & Resources

11 31 Relax before Bedtime Warm bath Relaxation techniques Calming music Aromatherapy Lavender specifically Lavendula angustifolia Mandarin Herbal tea Sleep Do: Relaxing Routine e.g., Chamomile (unless allergic to aster family) 32 Questions & Resources National Sleep Foundation (Se habla Español) For more information: 33 Credits Sponsors ASU Center for World Health Promotion and Disease Prevention

12 34 References: B - E Baldwin, C. M., Bell, I. R., Guerra, S., & Quan, S. F. (2005). Obstructive sleep apnea and ischemic heart disease in Southwestern U.S. veterans: Implications for clinical practice. Sleep Breathing, 9, Baldwin, C. M., Bell, I. R., Guerra, S., & Quan S. F. (2004). Associations between chemical odor intolerance and sleep disturbances in community-living adults. Sleep Medicine, 5, Baldwin, C. M., Bootzin, R. R., Schwenke, D. C., &Quan, S. F. (2005). Antioxidant nutrient intake and supplements as potential moderators of cognitive decline and cardiovascular disease in obstructive sleep apnea. Sleep Medicine Reviews, 9, Baldwin, C. M., Griffith, K. A., Nieto, F. J., O Connor, G. T., Walsleben, J. A., & Redline, S. (2001). The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep, 24, Baldwin, C. M., Kapur, V. K., Holberg, C. J., Rosen, C., & Nieto, F. J. (2004). Associations between gender and measures of daytime somnolence in the Sleep Heart Health Study. Sleep, 27, Baldwin, C. M., & Quan, S. F. (2003). Sleep-disordered breathing. Nursing Clinics of North America, 37, Dallman, M. F., Pecoraro, N., Akana,S. F., et al. (2003). Chronic stress and obesity: A new view of comfort food. PNAS, 200, Epstein, D. R., & Bootzin, R. R. (2003). Insomnia. Nursing Clinics of North America, 37, References: G - S Gottlieb, D. J., Punjabi, N. M., Newman, A. B., Resnick, H. E., Redline, S., Baldwin, C. M., & Nieto, F. J. (2005). Association of sleep time with diabetes mellitus and impaired glucose tolerance. Archives of Internal Medicine, 165, Gottlieb, D. J., Redline, S., Nieto, F. J., Baldwin, C. M., Newman, A. B., Resnick, H. E., & Punjabi, N. M. (2006). Association of usual sleep duration with hypertension: The Sleep Heart Health Study. Sleep, 29, Hening, W., Allen, R. P., Tenzer, P., & Winkelman, J. W. (2007). Restless legs syndrome: Demographics, Presentation, and differential diagnosis. Geriatrics, 62, Quan, S. F., O'Connor, G. T., Quan, J. S., Redline, S., Resnick, H. E., Shahar, E., Siscovick, D., & Sherrill,D. L. (2007). Association of physical activity with sleep disordered breathing--the Sleep Heart Health Study. Sleep Breathing, 11, Quan, S. F., Wright, R., Baldwin, C. M., et al. (2006). Obstructive sleep apnea-hypopnea and neurocognitive functioning in the Sleep Heart Health Study. Sleep Medicine, 7, Ritchie, S. A., & Connell, J. M. C. (2007). The link between abdominal obesity, metabolic syndrome and cardiovascular disease. Nutrition and Metabolism in Cardiovascular Disease, 17, Scott, L. D., Rogers, A. E., Hwang, W. T., & Zhang, Y. (2006). Effects of critical care nurses work hours on vigilance and patients safety. American Journal of Critical Care, 15, Shahar, E., Redline, S., Young, T., Boland, L. L., Baldwin, C. M., Nieto, F. J., O Connor, G. T., Rapoport, D. M., & Robbins, J. A. (2003). Hormone replacement therapy and sleep-disordered breathing. American Journal of Respiratory and Critical Care Medicine, 167, References: S - W Singh, M., Drake, C. L., Roehrs, T., Hudgel, D. W., & Roth, T. (2005). The association between obesity and short sleep duration: A populationbased study. Journal of Clinical Sleep Medicine, 4, Taheri, S., Lin, L., Austin, D., Young, T., & Mignot, E. (2004). Short sleep duration is associated with reduced leptin, elevated ghrelin, and increased body mass index. PLoS Medicine, 1, Touchette, E., Petit, D., Tremblay, R. E., Boivin, M., Falissard, B., Genolini, C., & Montplaisir, J. Y. (2008). Associations between sleep duration patterns and overweight/obesity at age 6. Sleep, 31, Trenkwalder, Cl, Hening, W. A., Montagna, P., et al. (2008). Treatment of restless legs syndrome: An evidence-based review and implications for clinical practice. Movement Disorders, 23, Vgontzas, A. N., Bixler, E. O., & Chrousos, G. P. (2005). Sleep apnea is a manifestation of the metabolic syndrome. Sleep Medicine Reviews, 9, Vgontzas, A. N., Lin, H-M., Papaliaga, M., et al. (2008). Short sleep duration and obesity: The role of emotional stress and sleep disturbances. International Journal of Obesity, 32, Winkelman, J. W., Redline, S., Baldwin, C. M., Resnick, H. E., Newman, A. B., & Gottlieb, D. J. (2009). Polysomnographic and health-related quality of life correlates of restless legs syndrome in the Sleep Heart Health Study. Sleep, 32,

WHY CAN T I SLEEP? Deepti Chandran, MD

WHY CAN T I SLEEP? Deepti Chandran, MD Sleep and Aging How does sleep change as we age? Do we need less sleep as we get older? Can a person expect to experience more sleep problems or have a sleep disorder