Normal Sleep Pattern Common Sleep Disorders Medical Consequences
Overview
Why Sleep is Important? Normal Sleep Pattern Common Sleep Disorders Medical Consequences of Sleep Disorders Good Sleep hygiene Institute of Medicine Report
“An Unmet Public Health Problem”
“The cumulative effects of sleep loss and sleep disorders represent an under-recognized public health problem and have been associated with a wide range of health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. Almost 20 percent of all serious car crash injuries in the general population are associated with driver sleepiness. Hundreds of billions of dollars a year are spent on direct medical costs related to sleep disorders such as doctor visits, hospital services, prescriptions, and over-the- counter medications.” Higher Medical Costs
Undiagnosed or untreated sleep disorders sufferers utilize the healthcare system more frequently Untreated sleep apnea may cause $3.4 billion in additional medical costs People with insomnia use more health care resources than those without insomnia Why is Sleep Important?
Key to our health, performance, safety and quality of life As essential a component as good nutrition and exercise to optimal health As necessary as the water we drink, the air we breathe and the food we eat to function and live at our best. Sleep: Definition Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles, and reduced interactions with surroundings. It is distinguished from wakefulness by a decreased ability to react to stimuli, but is more easily reversed than the state of being comatose. Typically: postural recumbence, behavioral quiescence, closed eyes, etc. Why Sleep is Important? For all human functioning Cognitive & physical performance Its restorative powers Learning & memory consolidation Mood enhancement Protects the immune system New evidence shows a relationship to weight gain and aging We need consolidated, restorative sleep for:
Functioning in a safe, efficient and effective way Cognitive, social and physical performance Emotional enhancement and relating well with others Learning and memory consolidation Prevention of health problems and optimal health Hypnogram
Total Recording Time
Hours of Record
• Four to five sleep cycles a night • Cycling between NREM and REM sleep in about 90 - 120 minutes Children
Adult
Elderly Stages of Sleep in adult Sleep and Aging
Three elements of good quality sleep are:
Duration: The length of sleep should be sufficient for the sleeper to be rested and alert the following day. Continuity: Sleep periods should be seamless without fragmentation. Depth: Sleep should be deep enough to be restorative. Chronically Sleep Deprived...
The average American sleeps less than 7 hours
37% of adults say they are so tired during the day it interferes with daily activities
75% of adults experience at least one symptom of a sleep disorder a few nights a week or more
55% of adults nap at least once during the week
Source: NSF Sleep in America Polls Neuro & Psychi
Cardiovascular
Musculoskeletal
Immune
Metabolic Classification of sleep disorders- ICSD 3
International Classification of Sleep Disorder – Third Edition (ICSD -3) 2014 Common Sleep Problems
Chronic or short-term insomnia (more than 50% of all U.S. adults)
Snoring (90 million Americans snore, 37 million habitually)
Sleep Apnea (18 million Americans) 2-7x increased driving risk
Restless Legs Syndrome (12 million Americans) Insomnia
Defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment. These three components of insomnia - Persistent sleep difficulty - Adequate sleep opportunity - Associated daytime dysfunction Insomnia: Prevalence
Most common Sleep disorder - Occurring in 30 – 45% of adults More prevalent in women than in men - Approximately 2/3 are women Increases with age - Approximately 50% of the elderly population - About 65% of all insomnia prescriptions dispensed to patients over 55
Weyerer and Dilling, 1991 Wryer and Dilling, 1991 Insomnia Prevalence & Severity
Prevalence & severity increases with age
prevalence increases with age
Mild Moderate/severe
30 25 20 15 10 5 Prevalence (%) 0 15-19 20-29 30-39 40-49 50-59 60-69 70+ Age
Weyerer and Dilling,.1991 Insomnia
Three diagnostic categories for insomnia: - Chronic insomnia disorder - Short-term insomnia disorder - Other insomnia disorder
International Classification of Sleep Disorder – Third Edition (ICSD -3) 2014 Diagnostic Criteria of Chronic insomnia disorder Criteria A-F must be met A. The patient reports, or the patient's parent or caregiver observes, one or more of the following: 1. Difficulty initiating sleep. 2. Difficulty maintaining sleep. 3. Waking up earlier than desired. 4. Resistance to going to bed on appropriate schedule. 5. Difficulty sleeping without parent or caregiver intervention. B. The patient reports, or the patient's parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty: 1. Fatigue/malaise. 2. Attention, concentration, or memory impairment. 3. Impaired social, family, occupational, or academic performance. 4. Mood disturbance/irritability. 5. Daytime sleepiness. 6. Behavioral problems (e.g., hyperactivity, impulsivity, aggression). 7. Reduced motivation/energy/initiative. 8. Proneness for errors/accidents. 9. Concerns about or dissatisfaction with sleep. C. The reported sleep/wake complaints cannot be explained purely by inadequate opportunity (i.e., enough time is allotted for sleep) or inadequate circumstances (i.e., the environment is safe, dark, quiet, and comfortable) for sleep. D. The sleep disturbance and associated daytime symptoms occur at least three times per week. E. The sleep disturbance and associated daytime symptoms have been present for at least three months F. The sleep/wake difficulty is not better explained by another sleep disorder.
International Classification of Sleep Disorder – Third Edition (ICSD -3) 2014 Insomnia: Risk factor
3Ps Model
Predisposing factor Precipitating factor Perpetuating factor
International Classification of Sleep Disorder – Third Edition (ICSD -3) 2014 Insomnia
May be at increased risk for motor vehicle and work-site accidents as well as psychiatric and cardiovascular disorders. Insomnia often accompanies comorbid medical illnesses, mental disorders, and other sleep disorders. It may also arise in association with the use, abuse, or exposure to certain substances. Consequences of Insomnia
Worsens psychiatric disorders Prolongs medical illnesses Reduced quality of life Higher health care costs Insomnia: effective Treatment
Healthy sleep habits Behavioral therapy Prescription hypnotic medications Other therapies Central disorders of hypersomnolence
Narcolepsy Type 1 Narcolepsy Type 2 Idiopathic Hypersomnia Kleine-Levin Syndrome Hypersomnia Due to a Medical Disorder Hypersomnia Due to a Medication or Substance Hypersomnia Associated with a Psychiatric Disorder Insufficient Sleep Syndrome Hypersomnia, a complaint of excessive daytime sleep or sleepiness, affects 4% to 6% of the population. Methodological tools to explore sleep and wakefulness (interview, questionnaires, sleep diary, polysomnography Multiple Sleep Latency Test, Maintenance of Wakefulness Test) and psy-chomotor tests (for example, psychomotor vigilance task and Oxford Sleep Resistance or Osier Test) help distinguish between the causes of hypersomnia. It may Impair work performance and even be Involved In accidents at work or while driving.
Dialogues Clin Neurosci 2005 Dec; 7(4): 347–356. Circadian Rhythm Sleep-Wake Disorders
Criteria A-C must be met A. A chronic or recurrent pattern of sleep-wake rhythm disruption primarily due to alteration of the endogenous circadian timing system or misalignment between the endogenous circadian rhythm and the sleep-wake schedule desired or required by an individual’s physical environment or social/work schedules. B. The circadian rhythm disruption leads to insomnia symptoms, excessive sleepiness, or both. C. The sleep and wake disturbances cause clinically significant distress or impairment in mental, physical, social, occupational, educational, or other important areas of functioning. Circadian Rhythm Sleep-Wake Disorders
Delayed Sleep-Wake Phase Disorder Advanced Sleep-Wake Phase Disorder Irregular Sleep-Wake Rhythm Disorder Non-24-Hour Sleep-Wake Rhythm Disorder Shift Work Disorder Jet Lag Disorder Circadian Sleep-Wake Disorder Not Otherwise Specified (NOS) Circadian rhythm Circadian rhythm and Homeostasis
The lowest peak of alertness is at 2-6 am and 2- 6 pm. Regulation of melatonin production and receptor function
Dubocovich,2010 During the Sleep Cycle Circadian Rhythm sleep disorder
Symptoms of insomnia or hypersomnolence Persistent or recurrence pattern of sleep disturbance due to - Circadian timing system - Misalignment of circadian system and environment. Associated with impairment of function Circadian rhythm sleep-wake disorders Common Circadian Disruptions
Shift Work Jet Lag
Working evening, night, irregular Traveling across time zones or rotating shifts disrupts sleep
The Perils of Shift Work
Depression Digestive & Stress & anxiety gastrointestinal problems Divorce Cardiovascular disease Increased smoking Higher cholesterol More errors & Possible Carcinogen accidents
*World Health Organization (WHO) Report 2007. Treatment: Circadian Rhythm Disorders
Evaluate for an underlying cause Phototherapy Chronotherapy Sleep Hygiene Medication Hypnotic Melatonin Neurol Clin. 2012 Nov; 30(4): 1167–1191. doi: 10.1016/j.ncl.2012.08.011 Parasomnia
Parasomnias are a category of sleep disorders that involve abnormal and unnatural movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. Parasomnia
3 groups NREM related parasomnias REM related parasomnias Other parasomnias NREM-Related Parasomnias
Disorders of Arousal (From NREM Sleep) Confusional Arousals Sleepwalking Sleep Terrors Sleep Related Eating Disorder REM-Related Parasomnias
REM Sleep Behavior Disorder Recurrent Isolated Sleep Paralysis Nightmare Disorder Parasomnias
Parasomnias affect approximately 10% of Americans. They occur in people of all ages, but are more common in children. Children are particularly vulnerable because of brain immaturity. The good news is that they are usually not associated with negative health consequences and disappear as a child matures.
https://sleepfoundation.org/ask-the-expert/sleep-and-parasomnias/page/0/1 Parasomnias: Treatment
Good sleep habits include keeping a regular sleep schedule, managing stress, having a relaxing bedtime routine, and getting enough sleep. There are also drug therapies that are used to control symptoms. A person should seek treatment whenever there is risk for injury to oneself or another person from the parasomnia
https://sleepfoundation.org/ask-the-expert/sleep-and-parasomnias/page/0/1 Sleep related movement disorders Restless Legs Syndrome Periodic Limb Movement Disorder Sleep Related Leg Cramps Sleep Related Bruxism Sleep Related Rhythmic Movement Disorder Benign Sleep Myoclonus of Infancy Propriospinal Myoclonus at Sleep Onset Sleep Related Movement Disorder Due to a Medical Disorder Sleep Related Movement Disorder Due to a Medication or Substance Sleep Related Movement Disorder, Unspecified Restless Legs Syndrome/ Periodic Limb Movement Disorder Neurological movement disorders Involuntary urge to move due to unpleasant feelings in the legs during sleep or rest Jerking of legs and arms during sleep Increases with age Treatment Medications Healthy lifestyle Sleep hygiene
Sleep related breathing disorders
Obstructive sleep apnea disorders Central sleep apnea syndromes Sleep related hypoventilation disorders Sleep related hypoxemia disorder Isolated symptoms and normal variants Obstructive Sleep Apnea (OSA)
is a disorder characterized by intermittent upper-airway collapse, which impairs ventilation and disrupts sleep
Somers VK. et al. J Am Coll Cardiol 2008;52:686-717 Prevalence of OSA
The prevalence of OSA defined as an apnea- hypopnea index (AHI) ≥5 was a mean of 22% (range, 9-37%) in men and 17% (range, 4-50%) in women reported in a recent systemic review. The prevalence of OSA in adults in Asia was reported to be 3.7% to 97.3% in another systemic review. The prevalence in Thailand was reported to be 15.4% in men and 6.3% in women. In children, OSA affects about 1.2% to 5.7%, with the peak prevalence between 2 to 8 years old. Complex and Incompletely understood Multifactorial 1. upper airway narrowing 2. Reduced cross-sectional area of the upper airway lume due to either excessive bulk of soft tissues (tongue, sof palate, and lateral pharyngeal walls) or craniofacial anatomy, or both. 3. The activity of the pharyngeal dilating muscles become insufficient to prevent narrowing and/or closure of the upper airway. Decreased end-expiratory lung volume and falling ventilatory drive associated with hypocapnia also predispose to upper airway narrowing or closure. Some patients have unstable ventilatory control (high loop gain) with resulting periods of hypocapnia that may also contribute to upper airway narrowing.
Diagnostic Criteria of OSA (A and B) or C satisfy the criteria A. The presence of one or more of the following: 1. The patient complains of sleepiness, nonrestorative sleep, fatigue, or insomnia symptoms. 2. The patient wakes with breath holding, gasping, or choking. 3. The bed partner or other observer reports habitual snoring, breathing interruptions, or both during the patient’s sleep. 4. The patient has been diagnosed with hypertension, a mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus. B. Polysomnography (PSG) or OCST demonstrates: 1. Five or more predominantly obstructive respiratory events (obstructive and mixed apneas, hypopneas, or respiratory effort related arousals [RERAs]) per hour of sleep during a PSG or per hour of monitoring (OCST). OR C. PSG or OCST demonstrates: 1. Fifteen or more predominantly obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep during a PSG or per hour of monitoring (OCST).
International Classification of Sleep Disorder – Third Edition (ICSD -3) 2014 OSA: Polysomnography OSA Severity
Severity AHI or RDI (/hr) Mild 5 - < 15
Moderate 15 -30
Severe > 30 Intermediary Mechanisms Associated With Obstructive Sleep Apnea That Potentially Contribute to Risk of Cardiovascular Disease
Shamsuzzaman. et al. JAMA 2003;290:1906-1914. Anne BM, et al. The impact of sleep disorders on glucose metabolism: endocrine and molecular mechanisms. Diabetology & Metabolic Syndrome 2015;7:25 Sleep apnea hurts HEARTS by increasing the risk of:
H - heart failure E - elevated blood pressure A - atrial fibrillation (A-fib) R - resistant hypertension T - Type 2 diabetes S - stroke Sleep apnea afflicts nearly 30 million adults in the U.S. Source: AASM 2016
Severe, untreated sleep apnea more than doubles your risk of dying from heart disease. Source: Sleep and Breathing 2016
Middle-aged men with severe sleep apnea are 58% more likely to develop heart failure. Source: Circulation 2010
Between 30% and 40% of people with high blood pressure have sleep apnea. Source: ChronoPhysiology & Therapy 2011 The risk for Atrial fibrillation is 2 to 4 times higher in people who have sleep apnea. Source: Journal of Atrial Fibrillation 2016
Up to 85% of people with treatment-resistant hypertension have sleep apnea. Source: ChronoPhysiology & Therapy 2011
Sleep apnea afflicts about 7 in 10 people who have Type 2 diabetes. Source: Frontiers in Neurology 2012
People with severe, untreated sleep apnea are 2 times more likely to have a stroke. Source: International Journal of Cardiology 2013 PRINCIPLES OF GOOD SLEEP
Following the guidelines of Sleep Hygiene can help to prevent poor quality nocturnal sleep, short duration of sleep, fragmentation of sleep and serious sleep deprivation in adults.
http://worldsleepday.org/toolkit 10 COMMANDMENTS OF SLEEP HYGIENE FOR ADULTS
Fix a bedtime and an awakening time. If you are in the habit of taking nap, do not exceed 45 minutes of daytime sleep. Avoid caffeine 6 hours before bedtime. This includes coffee, tea and many sodas, as well as chocolate. Avoid excessive alcohol ingestion 4 hours before bedtime and do not smoke. Avoid heavy, spicy, or sugary foods 4 hours before bedtime. A light snack before bed is acceptable. Exercise regularly, but not right before bed. Use comfortable bedding. Find a comfortable temperature setting for sleeping and keep the room well ventilated. Block out all distracting noise and eliminate as much light as possible. Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. http://worldsleepday.org/toolkit Summary
Sleep is a basic biological need that is essential to our health, performance, safety & quality of life.
Sleep deprivation and sleep disorders have serious negative consequences.
Establishing healthy sleep practices prevent sleep problems & promote optimal sleep.