Tackling the Problems of Inadequate Sleep and Sleep Disorders Allan I. Pack, M.B.Ch.B., Ph.D., FRCP John Miclot Professor of Medicine Director, Center for Sleep and Circadian Neurobiology Chief, Division of Sleep Medicine/Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
Outline of Talk Basic biology of sleep/circadian rhythm Sleep loss and its impact Inadequate sleep is common Common sleep disorders Sleep problems in workplace
Enhancing Sleep Is this the next large culture change (similar to stopping smoking)? Arianna Huffington The Sleep Revolution
Sleep??..Who Needs Sleep?!?
Two Process Model of Sleep Regulation (Borbély)
Features of Biological Clock DNA Light/Dark Retino-hypothalamic tract Clock Molecules Clock is produced by molecular feedback and oscillations Main mechanism to entrain clock Suprachiasmatic nucleus (SCN) of hypothalamus
Consequences of Interaction Between Sleep and Circadian Systems Alertness in morning following major sleep episode Become sleepy after lunch (1:00-3:00 PM) (siesta time) Alertness then returns even if individual does not sleep Early evening becomes forbidden time for sleep Sleepy again in late evening Sleep efficiency impaired if try to sleep at alert clock times CLOCK SETS TIME WINDOW FOR SLEEP
Morningness-Eveningness A Great Variation Between People in Timing of Sleep Bout LARK Early to bed Not party person?biological advantage OWL Late person Difficult to get to early morning meetings THIS IS GENETIC RECENT STUDIES HAVE IDENTIFIED VARIANTS IN CLOCK GENES
Ability to Sleep is Impaired if Individual Sleeps at Inappropriate Circadian Time This is key concept Implications Shift work Difficulty sustaining sleep when sleeping after night-shift Jet-lag Particularly severe with largest time differences, e.g., 12 hours Readjustment of master clock takes place slowly about 1 hour/day
Time of Occurrence of Fall-Asleep Crashes in Individuals Age 16-25 Years 250 (Pack et al, Accid. Anal. Prev. 27:769, 1995) Number of Crashes 200 150 100 50 0 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 Time of Day IS DRIVEN BY SLEEP/CIRCADIAN BIOLOGY
Time of Occurrence of Fall-Asleep Crashes in Individuals Over 65 Years (Pack et al, Accid. Anal. Prev. 27:769, 1995) Number of Crashes 40 35 30 25 20 15 10 5 0 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 Time of Day OLDER INDIVIDUALS NO LONGER DRIVE AT NIGHT
Two Process Model of Sleep Regulation (Borbély)
Basic Facts About Sleep Drive for sleep is coupled to duration of wakefulness Humans are programmed to stay awake for 16 hours without impairment Beyond 16 hours, impairment gets progressively worse - sleepiness Sleep drive is homeostatic Sleep drive thought to be coupled to accumulation of sleep-promoting molecules
There are Different Sleep Stages in Mammals Non-Rapid-Eye Movement Sleep (NREM) Stage 1 Stage 2 Stage 3 Slow-wave (delta) sleep Stage 4 Rapid-Eye Movement Sleep (REM) Flurries of activity Autonomic instability Muscle atonia paralyzed Dreams
Major Types of Sleep Loss Acute sleep loss Humans are programmed to be able to stay awake for 16 hours without impairment Longer hours awake the worse the performance Chronic insufficient sleep Inadequate sleep day after day Often involves catch-up sleep at weekends CDC now monitoring sleep duration across the country Can be acute on chronic sleep loss (combination)
Chronic Sleep Restriction Sleep and Performance The less sleep you get, the more impaired you are Deficits due to sleep loss are cumulative After 2 weeks, you don t adjust -- you get worse Van Dongen et al., 2004
Chronic Sleep Restriction Sleep and Performance But you don t realize that you are getting worse. Van Dongen et al., 2004
Consequences of Sleep Loss (Sleepiness) on Cognitive Function* WAKE STATE BECOMES UNSTABLE Involuntary microsleeps occur Attention-intensive performance is unstable Errors of omission (lapses) increase Errors of commission (wrong responses) increase *From Goel N, et al, Semin Neurol 29:320, 2009
Consequences of Sleep Loss (Sleepiness) on Cognitive Function* COGNITIVE SLOWING OCCURS Response time slows Longer to complete tasks If timed task, increased errors *From Goel N, et al, Semin Neurol 29:320, 2009
Inadequate Sleep Also Has Cardio-Metabolic Consequences Leads to insulin resistance (pre-diabetes) Increases appetite (changes in leptin, ghrelin levels) Increases obesity Has cardiovascular consequences
How Much Sleep Do You Need? (Watson N, et al, J Clin Sleep Med 11:931, 2015) Consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on recommended amount of sleep for a healthy adult 7-9 hours per day 6 hours of daily sleep is inadequate
Sleeping Less Than 6 Hours is Common in USA (Data from CDC, 2013)
Sleep Durations Vary Across the United States From Liu et al, CDC Morbidy and Morality Report, 2016
Sleep Problems in the Workplace Chronic insufficient sleep Shift-work sleep disorders Insomnia Obstructive sleep apnea
Inadequate Sleep and Sleep Disorders in the Workplace Affect productivity Increase errors Increase health care costs In safety-sensitive organizations impair safety
The Cost of Sleep Lost In a typical good sleeper, the cost of lost productivity was approximately $1,293 per employee per year Insomnia: $3,156 ( 144%) Insufficient Sleep: $2,796 ( 116%) At-risk: $2,319 ( 79%) Significant productivity lost due to Time management Mental and interpersonal demands Output demands Physical job demands
How to Address This? At the individual level At the group level At the system level
What Employers Can Do Awareness/Education Understand your population & work schedules Provide opportunities to educate on tips for better sleep/time management Address the 24/7/365 culture without sacrificing productivity Take advantage of the wearable device trend Assessment & Program Support Partner w/3 rd party vendors to assess & gather sleep data Digital/Telehealth coaching support
How to Measure Sleep To measure sleep habits, you do not need a full sleep study
Measuring Sleep Habits Validated questionnaires Assess sleep timing, duration, and quality Risk for sleep disorders Ways that sleep interferes with functioning Prospective sleep diaries Sleep continuity and quality Computed variables Other daily factors Objective sleep measurement Several technologies available based on needs Actigraphy is most common
What is Actigraphy? Wrist-worn device Records continuously for 24 hours Quantifies activity and light exposure Minute-by-minute agreement with polysomnography ~90% Relatively low cost and scalable
Addressing Common Sleep Disorders
Shift Work and Insomnia Shift-work sleep disorder Difficult to sleep at incorrect circadian time Insomnia Chronic difficulty initiating and sustaining sleep
Can Sleep Problems Be Fixed? Let s take an example: Cognitive Behavioral Therapy for Insomnia (CBTI) A non-medication approach Involves re-programming your sleep schedule Usually takes 4-8 weeks Extremely effective and well-studied New IT systems for support of CBTI Can be delivered by telemedicine and in groups
Does It Work? Data Across 59 Studies 0% -10% -20% Sleep Onset Latency WASO Awakenings Total Sleep Time -12.6% -15.3% -9.5% -8.2% -1.2% -30% -40% -29.8% Treatment Control -50% -43.1% -46.4% Morin, et al., 1994
Obstructive Sleep Apnea What is Sleep Apnea? AWAKE ASLEEP
We Have a Growing Problem Percent who are obese 30 25 20 15 10 5 0 As obesity becomes more common, so does sleep apnea Source: Centers for Disease Control Prevalence of moderate-to-severe apnea Men Women 1994 (Young et al) (state employees) 4% 2% 2007-2010 (Peppard et al) 30-49 years 10% 3% 50-70 years 17% 9%
Is Sleep Apnea Treatable? Continuous Positive Airway Pressure (CPAP) http://www.sleepwise.com.au/images/d912193040.gif http://www.resmed.com/uk/images/cpap_treatment.jpg
Effects of CPAP on Sleep and Oxygen Levels Without CPAP Sleep fragmentation No N3, REM Low oxygen saturation With CPAP Sleep consolidation REM rebound Slow wave sleep achieved Oxygen saturation restored
Consequences of Obstructive Sleep Apnea Sleep fragmentation excessive sleepiness Increased risk of crashes, errors Cyclical falls in oxygen systemic disease Hypertension Cardiovascular disease (stroke, MI) Atrial fibrillation Abnormal glucose control
In Addition to Eliminating Breathing Pauses During Sleep and Improving Oxygen Level, What are the Benefits of CPAP? CPAP lowers: health care costs disability claims 3 1, 2,3 absenteeism 3 workplace turnover 4 crash risk 6 blood pressure 7,8 CPAP improves quality of life 5 alertness 6 performance on driving simulator 6 1 Albarrak, Sleep, 2005 2 Ronald, Sleep Res Online, 1998 3 Hoffman, JOEM, 2010 4 Osterberg, Schneider Trucking, Sleep Apnea Trucking Conference, 2010 5 Sanner, Eur Respir J, 2000 6 Tregear, Sleep, 2010 7 Haentjens, Archives Int Med, 2007 8 Bazzano, Hypertension, 2007
How Do We Know Patients Are Using CPAP? MONITORING SYSTEMS SD cards Remote/wireless (Blue Tooth) Specialized websites REPORTED DATA Hours of use Pressure level Residual Apnea- Hypopnea Index (AHI) Mask leak Issues can be addressed in real time PERMITS CHRONIC CARE MANAGEMENT
UPenn Program with AmeriGas Large truck company with propane trucks Do telemedicine evaluation of drivers in different states Do home sleep studies (keep costs down) CPAP provided Remote monitoring of CPAP use
UPenn Program with AmeriGas Have care management team troubleshoot problems with CPAP remotely Achieve 100% compliance
Impact on Transportation Major crashes indicate impact of insufficient sleep, diurnal time and sleep apnea
Metro North Train Crash
Metro North Rail Crash Driver of train did not adjust speed. Speeding at 82 MPH in a 30 MPH curve Driver stated he was stupefied Train derailed 4 dead, 82 injured Driver has now been diagnosed with severe obstructive sleep apnea All Metro North drivers will now be screened for sleep apnea
Tracy Morgan (A Famous American Comedian)
Tracy Morgan Crash
Tracy Morgan Crash Driver of Wal-Mart truck struck the rear of limo Tracy Morgan was in Driver had been awake for more than 24 hours Had been driving for 9 hours, 37 minutes Was speeding at 65 MPH through work area (45 MPH limit) Comedian killed Tracy Morgan seriously injured
Train Crash at O Hare Airport
O Hare Rail Crash Driver fell asleep train went up escalator Occurred at 2:52 AM circadian low No deaths or serious injuries 32 minor injuries
Conclusions There is a distinct biology to sleep Education about sleep/circadian biology is lacking Inadequate sleep is a very common problem in our society There are a number of specific sleep disorders that are very common and easily treatable Insufficient sleep and sleep disorders are an issue in the workplace Requires approaches at multiple levels