Sleep Science: better sleep for you and your patients CHUNBAI ZHANG, MD MPH UW MEDICINE VALLEY MEDICAL CENTER

Sleep Science: better sleep for you and your patients CHUNBAI ZHANG, MD MPH UW MEDICINE VALLEY MEDICAL CENTER

Disclosure: Financial - none Non-Financial - none

Selected Topics Sleep epidemiology Sleep Architecture and Staging Sleep deficiency Sleep and diseases Insomnia CBT-insomnia Medications Questions

What is poor sleep? How much sleep do we need? duration ( quantity ) and depth ( quality ) Sleep debt (repayment) insufficient sleep syndrome: chronic sleep deprivation

National Sleep Foundation 2013 Recommended Sleep Duration

Change of sleep architecture as human age: SWS = N3 deep sleep Stage 2 = N2 Stage 1 = N1 WASO = wake after sleep onset Sleep latency = time needed to fall asleep Ohayon MM et al 2004

Analysis of the American Time Use Survey (ATUS) Duration of sleep varies with gender Duration of sleep varies with weekdays and weekends Duration of sleep varies with age Basner et al 2007

Kirsch et al 2016 Sleep stages and architecture: W (wake) R (REM sleep) N (Non-REM sleep): N1, N2, N3 * periodicity: 90 minutes

PSG (stages): NREM vs REM Kirsch et al 2016

Sleep and other Diseases Sleep & DM II Sleep & CVD Sleep & Depression Sleep & Chronic Pain Sleep & Performance (drivers)

Disordered sleep and DMII Meta-analysis (10 studies): Quantity and quality of sleep predicts risk of DMII. (Cappucio et. Al. 2010) Compared with 8 hours/day of sleep, both short ( 5 to 6 hours/day) and long (>8 to 9 hours/day) duration of sleep were significantly associated with an increased risk of type 2 diabetes (RR 1.28 and 1.48, respectively). (Cappucio et. Al. 2010) European Prospective Investigation into Cancer & Nutrition (EPIC) study > 23,000 participants across Europe, short sleep duration (<6 hours/day compared with 7 to <8 hours/day) was associated with an increased risk of chronic disease, including type 2 diabetes (RR 1.44, 95% CI 1.10-1.89) (von Ruesten et al 2012) Mechanism unclear (confounder: obesity), possible via Melatonin

Source: Spiegel et. Al. 2004 Mean Leptin and Ghrelin Level in healthy adults after sleep restrictions Green: Leptin Purple: Gehrlin

Disordered sleep (OSA) and HTN Severity of OSA (AHI) is positively associated with high blood pressure Peppard et al 2000

Sleep and Depression Depression: decrease in REM latency and Stage 3 (slow wave) sleep (Thase 2006) flat circadian rhythm (vs. diurnal pattern) (Souêtre et al 1989) Treatment of depression returns to the circadian diurnal pattern Return of circadian diurnal pattern in treated Seasonal Affective Disorder (SAD) with light therapy (Johansson et al 2003)

Sleep and Chronic Pain Healthy adults: extended sleep decreases sensitivity for pain Roehrs et al 2012

Sleep and Performance Boston Celtics New Rules for practice: 1. No morning practice 2. 2 a.m. rule If players cannot get to the hotel by 2 a.m. then they stay put at the same place to get 8 hours of sleep. 3. Increased reaction time 4. Decreased irritability at the game Boston Globe 2007

Sleep quality # number of arousals (or awakenings) from sleep the percentage, duration, and type of sleep stages

Sleep in a typical college student Note: 1. Delayed sleep phase 2. Napping in afternoons Wyatt 2016

Behavioral Therapy Source: NSF 2016 1. Sleep hygiene 2. Stimulus control 3. Relaxation 4. Sleep restriction therapy 5. Cognitive therapy 6. Cognitive behavioral therapy (CBT i) 8 sessions outcome similar to medications available online face to face with slightly better outcome

Healthy Sleep Hygiene 1. Stick to the same schedule even on the weekends. 2. Practice a relaxing bedtime ritual. 3. avoid naps especially in the afternoon. (pros and cons of power naps ) 4. Exercise Daily: Exercise at any time of day, but not at the expense of your sleep. 5. Room Conditions: A. Temp: F 60-67 degrees B. Free of noise and light C. bed partner's snoring? blackout curtains, eye shades, ear plugs, "white noise" machines, humidifiers, fans? 6. Sleep on a comfortable mattress and pillows. Free of allergens Source: NSF 2016

What to do at night time? 1. Use or avoid bright light to help manage circadian rhythms 2. Avoid alcohol, cigarettes, heavy meals in the evenings 3. Wind down 4. Don t stay in bed if you can t sleep (bed: sleep or sex) 5. Sleep diary/log Sleep specialist Source: NSF 2016

Caffeine: how much is too much? 1. Tea/coffee/soft drinks/cocoa/chocolates/some drugs/ 2. Mechanism: block sleep-inducing chemicals & increase adrenaline 3. 8 oz of coffee x 3 per day = moderate amount or 250 mg 4. 8 oz of coffee x 6 or more = excessive amount 5. Loading effect: 15 minutes 6. Half life: 6 hours 7. Withdrawal: headache, fatigue, muscle pain 8. Suppresses appetite (avoid in children) 9. 2001 Sleep in America poll: 43% of American very likely to use caffeine to stop excessive daytime sleepiness (EDS) Source: Belenky: NSF 2016

Sleep log (not to be done during sleep time)

Camey CE et al. 2012 Sleep diary Questions 1-10 are to be completed within 1 hour of getting out of bed in the morning. Questions 11-15 are to be completed before bed.

Medications for Insomnia Melatonin or Melatonin Receptor Agonist (Romelteon) Diphenhydramine (no good evidence) Dietary supplements (valerian; chamomile, kava, and wuling): no evidence they work. Some may cause liver damage Benzodiazepine: triazolam, estazolam, lorazepam, temazepam, flurazepam, and quazepam (in order of increasing half-life) Non-Benzodiazepine hypnotics: Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta) in order of increasing half-life Antidepressant if associated with depression: Trazadone (short term usage)

Medications for Insomnia Try CBT- i (insomnia) first Try combined therapy of CBT-i with medications Once cured, discontinue medication, but continue CBT-i long term usage NOT recommended contraindications: pregnancy, alcoholics, elderly, drivers, renal failure Ask What kind of Insomnia? : sleep onset vs. sleep maintenance

Summary: Sleep deficiency is prevalent Sleep architecture changes with age Too little or too much sleep are both bad Poor sleep is associated with many metabolic, psychiatric diseases Disordered sleep affects performance Treatment of insomnia relies more on CBT than medications More research is needed in the field of sleep

Questions:

References: National Sleep Foundation www.sleepfoundation.org UptoDate 2016 last accessed August 25, 2016 Ohayon MM et al. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. (2004) Basner et al. American Time Use Survey: Sleep Time and Its Relationship to Waking Activities. (2007) Spiegel et al. Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. (2004) Peppard et al. Prospective study of the association between sleep-disordered breathing and hypertension. (2000) Roehr et al. Pain Sensitivity and Recovery From Mild Chronic Sleep Loss. (2012)