OPTIMIZING SLEEP TO PERFORM, RECOVER AND THRIVE. Shona Halson, PhD Senior Physiologist Australian Institute of Sport

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1 OPTIMIZING SLEEP TO PERFORM, RECOVER AND THRIVE Shona Halson, PhD Senior Physiologist Australian Institute of Sport

2 Sleep

3 Elite Sport and Elite Military Vin Walsh, If one considers the challenges that elite sport performance presents the brain, it is difficult to think of any human activity that places more demands on the brain- with the possible exception of a combat solder Demands for self-control, skill-learning, long-term planning, resilience, judgement, defeat and injury Consequences of failure are immediate and often viewed and judged by many (in athletes) However, consequences of failure are VERY different Similarities include: variable sleep timing (not within own control), physical and mental stress Performance is the most important consideration

4 Sleep Basics

5 Neurocognitive Model of Insomnia

6 What is Good Sleep? Fall asleep within 30min Sleep through the night with brief awakenings Feel refreshed within 1 hour of awakening (5-7 days per week)

7 What is Insomnia? One of the following complaints at least three days a weeks for three months: 1) difficulty initiating sleep 2) difficulty maintaining sleep 3) waking earlier than desired

8 Prevalence of Insomnia 6-10% in general population Approximately 50% in military (Troxel et al, 2015) As high as 74% in other studies (Capaldi et al, 2015) Insomnia usually triggered by an acute event, which then leads to persistent maladaptive sleep patterns Causes: stress, noise, shiftwork, multiple deployments, trauma Outcomes: decreased readiness and performance, increased medical costs, increased accidents/errors, decreased immune function, increased risk of injury Quetiapine (anti-psychotic used off label for sleep) was reported as the second largest drug expenditure for the VA (Williams et al, 2014)

9 Why is sleep important?

10 What happens when we don t get enough sleep?

11 Consequences of Sleep Deprivation- Positive Mood Researchers have found that people who were more sleep deprived report feeling less friendly, elated, empathic, and report a generally lower positive mood. Sleep deprivation also seemed to reduce people s ability toreap theemotional benefits of a positive experience.

12 Consequences of Sleep Deprivation- Negative Mood When people are sleep deprived, they feel more irritable, angry and hostile. Sleep loss is also associated with greater depressive mood. Sleep deprivation seems to be associated with greater reactivity (more likely to react negatively when something doesn t go well for them). Sleep deprivation enhances negative mood due to increased amygdale activity (increased anger and rage) and a disconnection between the amygdale and the area of the brain that regulates its functions. In other words: increased negativemood, anddecreased ability to regulate that anger.

13 Effects of Sleep Deprivation on Emotional Intelligence Lower total EQ Lower intrapersonal functioning (self-regard, assertiveness, independence and self-actualisation) Lower interpersonal functioning (empathy and interpersonal relationships) Lower adaptability and impulse control Lower behavioural coping (positive thinking, action orientation,conscientiousness)

14 Consequences of Sleep Deprivation- Judgement & Impulse Control Increased risk taking Decreased self-control Increased impulsivity Increased invincibility Decreased self-confidence Decreased emotional intelligence Decreased constructive thinking skills

15 Sleep and Mental Health

16 Sleep and Depression Frequent or chronic sleep loss may induce neurobiological changes that accumulate overtime Sleep complaints have been identified as risk factors for psychiatric disorders Sleep disturbance traditionally viewed as a symptom of mood disorders Relationship is now know to be more complex and a bidirectional relationship exists Insufficient sleep may act as a causal factor that sensitises individuals to depression, contributes to its development, exacerbates the symptoms and reduces the efficacy of pharmacological treatment

17 Sleep and Depression

18 Sleep and Depression

19 Sleep and Anxiety Anxiety disorders typically result in sleep loss Anxiety is one of the most frequentlyreported neurobehavioral consequences of sleep deprivation

20 Sleep and TBI Sleep disturbances are very common following TBI The most common manifestations of sleep-wake disorders after TBI are excessive daytime sleepiness, increased sleep need, and insomnia. Less commonly, patients experience circadian rhythm disturbances and abnormal movements or behaviors during sleep, such as sleep talking, bruxism, and dream enactment Beyond symptomatic improvement, the potential benefits of treatment include improvement in functional outcomes and quality of life

Sleep and PTSD Insomnia and nightmares recognised as core symptoms of PTSD Other sleep disordersinclude sleep-disordered breathing (high prevalence) and

21 Sleep and PTSD Insomnia and nightmares recognised as core symptoms of PTSD Other sleep disordersinclude sleep-disordered breathing (high prevalence) and parasomnias Sleep disturbances are predisposing, precipitating and perpetuating factors (not simply secondary symptoms) Sleep is biologically relevant and modifiable

22 Sleep and PTSD

Sleep and Suicide Sleep disturbance associated with increased risk for suicidal ideation, suicide attempts and death by suicide Being awake at night has an increased association with alcohol and drug

23 Sleep and Suicide Sleep disturbance associated with increased risk for suicidal ideation, suicide attempts and death by suicide Being awake at night has an increased association with alcohol and drug use Reducedsocial support Intensifies sense of hopelessness, isolation and distress Decreased frontal lobe function (decreased problem solving abilities and increased impulsiveness) Increase allocation/utilization ofpsychosocial resources at night

24 Tx for Insomnia and Sleep Disturbance

All other unregulated compounds Three classes of prescription medication approved by US

25 Sleep Medication Four categories 1. Prescription required 2. Sedating medication used off-label 3. Other over the counter sleep aids 4. All other unregulated compounds Three classes of prescription medication approved by US FDA 1. Benzodiazepine Receptor Agonists (BZRA) (includes z drugs) 2. Melatonin Receptor Agonists 3. Histamine Receptor Antagonists

26 Sleep Medication- Do they work? 1. Prescription required * Very limited data on effectiveness 2. Sedating medication used off-label * Not proven in insomnia 3. Other the counter sleep aids * Very limited data on effectiveness 4. All other unregulated compounds * Very limited data on effectiveness Decreased perceived efficacy over time Most do not improve sleep maintenance

27 Sleep Medication- Is it safe? Decreased slow wave sleep- impaired physical recovery Residual daytime sedation Headaches, dizziness, nausea Impaired psychomotor skills (Increased risk of falls, accidents) Memory impairment Respiratory depression Dependency and tolerance Increased anxiety and depression Withdrawal- rebound insomnia (worse symptoms than prior to treatment) Increased risk of death (4 times mortality rate)

the non-drug treatments fail to have an effect Managing

28 Sleep Medication They may be considered: If symptoms are particularly severe To help ease short-term insomnia If the non-drug treatments fail to have an effect Managing jetlag Benefits must outweigh known risks in this population

29 Sleep Medication

30 Alcohol Sedating effects may promote sleep onset Net effect is deterioration in sleep quality Rapid tolerance toinitialeffect Exacerbates other sleep disorders such as OSA and parasomnias

Cognitive Behaviour Therapy for Insomnia CBT-I has been consistently shown to have greater efficacy when compared to medication The cognitive aspect of CBT-I teaches the individual to recognize and

31 Cognitive Behaviour Therapy for Insomnia CBT-I has been consistently shown to have greater efficacy when compared to medication The cognitive aspect of CBT-I teaches the individual to recognize and change beliefs that affect their ability to sleep (control or eliminate negative thoughts and worries) The behavioral aspect of CBT-I helps to develop good sleep habits and avoid behaviors that impair sleep Evidence that CBT-I is effective in military personnel (Taylor et al, 2017)

32 Cognitive Behaviour Therapy for Insomnia CBT-I is not widely used due to a lack of practitioners with expertise in this area Internet based CBT-I available Brief Behavioral Treatment for Insomnia(BBT-I)

33 Biofeedback

34 24 patients 20 min total throughout the day Dose-response relationship reported for both state anxiety and total sleep time Biofeedback and Sleep

35 Neurofeedback

36 Neurofeedback and Sleep- Insomnia EMG biofeedback was compared to SMR neurofeedback in patients with insomnia. SMR neurofeedback resulted in a greater increase in total sleep time when compared to EMG biofeedback.

37 Neurofeedback and Sleep-Athletes

38 What are athletes currently using?

39 Sleep Hygiene Education

Floatation tanks Water therapy- change body temperature Noise

40 Other Treatment Options Exercise Napping Mindfulness/relaxation/meditation/progressive muscle relaxation Floatation tanks Water therapy- change body temperature Noise and light reduction (eye masks and ear plugs) Light exposure and avoidance (manage jetlag)

41 Travel Plan

evaluation of recurrent unexplained nocturnal awakenings, which may be seen with

42 Measuring Sleep- Polysomnography (PSG) PSG can be useful if there is suspicion of a sleep related breathing disorder comorbid with insomnia PSG is also indicated for the evaluation of recurrent unexplained nocturnal awakenings, which may be seen with periodic limb movement disorder (PLMD) Allows the determination of sleep stages (Non- REM and REM)

43 Measuring Sleep- Activity Monitoring Wrist Activity Monitors Large sample sizes Non-invasive Causes the least amount of disruption Sleep Diaries Detailed information about sleep and wake patterns

44 Sleep in Australian Athletes 2636 nights of data (7 years) n = 2636 Mean ± SD Bedtime (hh:mm) 23:22 ± 01:25 Wake Up time (hh:mm) 07:00 ± 01:30 Time in Bed (h) 8:14 ± 1:22 Total Sleep Time (h) 6:31 ± 1:26 Sleep Efficiency % 85 ± 7 Wake in Sleep (min) 66 ± 30 Sleep Latency (min) 23 ± 34 Sleep Quality 2.65 ± 1.02

45 Sleep Duration Sargent, Lastella, Halson & Roach (2014)

46 Measuring Sleep- Activity Monitoring

47 Questionnaires Pittsburgh Sleep Quality Index (PSQI) The PSQI is an 18-item self-rated questionnaire used to assess overall sleep quality and sleep habits in the past month. Using different algorithms, items are combined to form 7 separate scales or components of sleep. These components are subjective sleep quality; sleep latency; sleep duration; habitual sleep efficiency; sleep disturbances; use of sleeping medication; and daytime dysfunction. Epworth Sleepiness Scale (ESS) Measure of daytime sleepiness Sleep Hygiene Index (SHI) Assessment of the practice of sleep hygiene behaviours

48 Sleep Diary

49 Sleep In the real world

50 Sleep In the real world

51 Technology & Social Media

52 Providing Feedback Stress and anxiety are related to sleep Care needs to be given to how and what information is provided

53 Assessment of Sleep Disorder Identification of existence of sleep concern Questions/discussions (identification of comorbidities) Questionnaires Sleep Diary Activity Monitoring or PSG

54 Treatment Options Education/ Feedback CBT-I or BBT-I Biofeedback or Neurofeedback Medication (short-term only)

55 Behaviour Change- Why can improving sleep be difficult?

56 How do we change behaviour? Have the fundamental knowledge Be able to translate that knowledge to convince the individual Know what drives the individual Does the individual want to: Feel better (physical + psychological) More time with children Save marriage Small, realistic, achievable This week I will be better than next week

57 Influencing Behaviour Change

to engage with change and if one of these is not in place change is

58 Influencing Behaviour Change 1. You have to be suffering enough or the reward has to be great enough to engage with change and if one of these is not in place change is unlikely 2. You have to be psychologically minded. How can you help the individual believe that change is possible?

59 Athlete Education

60 HOW TO GET A GOOD NIGHT SLEEP

61 Learnings from Elite Athletes: Monitoring- AIS AMS

63 AIS Research- Stay Healthy Genetics Immunology Psychology Mental health Resilience Travel Frequency Mode Training load Controlled environment Optimal Health Sleep Quality Duration Nutrition Energy availability Hygiene Behaviour Microbiome Gut health Medical Ferratin Vitamin D FBC

64 Recovery is KING

Learnings from Elite Athletes Persistence- not always a quick and

the individual: Sleep opportunities may be fixed- understand the

David Copperfield and I am not an expert Practice

65 Learnings from Elite Athletes Persistence- not always a quick and easy fix Repeat education regularly Be realistic or you will lose the individual: Sleep opportunities may be fixed- understand the limitations Need to focus on improving sleep when possible I am not David Copperfield and I am not an expert Practice non-pharmacological strategies now Look for treatments that are within our internal control

66 New ways of (simple) thinking

67 Simple Classical Conditioning Repeat three behaviors and associate with positive experiences

68 Thank you Web:

Improving Your Sleep Course. Session 1 Understanding Sleep and Assessing Your Difficulties

Improving Your Sleep Course. Session 1 Understanding Sleep and Assessing Your Difficulties Improving Your Sleep Course Session 1 Understanding Sleep and Assessing Your Difficulties Course Information Session Details Sessions Session 1 Session 2 Session 3 Session 4 Optional Review Session 5 Session