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Kelly Glazer Baron, PhD, MPH, CBSM August 9, 2019 OVERVIEW

1. What is sleep and why is it important 2. What is sleep health 3. Common sleep disorders: and 4. Behavioral - what we do 5. What you can do to improve your sleep 6. Resources 1. WHAT IS SLEEP?

• Sleep is a Goreversible to sleep andbehavioral wake up state of perceptual disengagement from and Tune the world out relative insensitivity to the environment, usually characterized by typical behavioral concomitantsLie down with eyes closed

Circadian and Homeostatic Regulation of Sleep

Melatonin

Adapted from Edgar et al. J Neurosci. 1993 SLEEP ACROSS THE LIFESPAN

So, how much sleep do you really need?

(and how much are we really getting?) SIGNS OF INSUFFICIENT SLEEP

• Need to be awakened in morning • Sleep 2+ hours on weekends or vacations than weekdays • Fall asleep in school or other inappropriate times • Behavior/mood differ following nights of increased sleep Please take the Epworth Sleepiness Scale test

Chance of dozing Situation (0-3) Sitting and reading 0 1 2 3 Watching television 0 1 2 3 Sitting inactive in a public place— 0 1 2 3 for example, a theater or meeting As a passenger in a car for an hour without a 0 1 2 3 break Lying down to rest in the afternoon 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch 0 1 2 3 In a car, while stopped in traffic 0 1 2 3 Total Score SLEEP DURATION TRENDS

• About 1/3rd of adults sleep less than 6 hours per night

• Rates of short sleep duration may be increasing over time SHORT SLEEP DURATION AND HEALTH

CHD Symptomatic Diabetes Relative Risk Relative Relative Risk Relative

Reported Sleep Duration (hours)

Ayas.NT et al. Arch Intern Med. 2003;163:205-209 SLEEP DURATION AND BODY MASS INDEX

Wisconsin Sleep Cohort Study, Taheri et al, 2004 Nurses Health Study, Patel et al., 2006 SLEEP DURATION AND METABOLIC PROFILES

4 Hours in 8 Hours in Bed 12 Hours in Bed 3h48' of Sleep 6h52' of Sleep 8h52' of Sleep 15 CORTISOL 10 (µg/dL) 5 0

40 HOMA (INSULIN (mU/L) * 20 GLUCOSE(mmol/L) / 22.5) 0 9 13 17 21 1 5 9 9 13 17 21 1 5 9 9 13 17 21 1 5 9 Clock Time Clock Time Clock Time

HOMA = homeostasis model assessment Spiegel K, et al. J Clin Endocrinol Metab 2004;89:5762-5771. SLEEP CURTAILMENT AND ENERGY BALANCE

5 h of sleep, 5 d – 5% increase in energy expenditure – Smaller breakfast – Greater intake after dinner (+42%)

Nedeltcheva et al, 2009; Markwald et al., 2013; St-Onge et al., 2011

WHAT IS HEALTHY SLEEP? RU SATED??

Regularity Do you go to bed within 1 hour every day?

Satisfaction Do you go to bed within 1h every day?

Alertness Do you stay awake all day without dozing?

Timing Are you asleep (or in bed) between 2 and 4 am?

Efficiency Do you spend less than 30 min awake at night?

Duration Do you sleep between 7 and 9 hours per day?

Buysse 2014 COMMON SLEEP PROBLEMS SLEEP PROBLEMS IN PRIMARY CARE

N=1934

34 37 33 34 28

Responders (%) Responders 14

Alattar M, et al. J Am Board Fam Med. 2007;20:365-374. CHRONIC INSOMNIA DISORDER • Difficulty initiating, maintaining sleep, or waking up too early, or • Resisting going to bed on schedule, or • Difficulty sleeping w/o parent/caregiver

• Adequate opportunity for sleep • At least 1 daytime consequence • At least 3 nights per week • At least 3 months (Acute insomnia: < 3 months)

ICSD-3, AASM, 2014 HOW INSOMNIA DEVELOPS

Spielman & Glovinsky, in Hauri, 1991 PERPETUATING FACTORS IN INSOMNIA

• too much time in bed • “catch sleep if it occurs” Behavioral • sleep later when possible • after poor night’s sleep

• caffeine & stimulants for sleepiness Pharmacologic • alcohol self-medicating for sleep • random/habitual use of hypnotics

Cognitive • expectations of poor sleep • unreasonable concerns over next-day consequences Spielman, Clinical Psychology Review, 1986 Wyatt & Crisostomo, in Sleep Medicine, 2008 IMPACT OF INSOMNIA

• Poor quality of life • Loss of productivity • Increased risk of cardiovascular disease, dementia WHICH IS THIS? HOW SLEEP APNEA HAPPENS Narrow upper airway

Relaxation of upper airway during sleep

Obstruction during sleep

Decreased airflow,

Decreased blood oxygen, arousal CONSEQUENCES OF OSA

• Sleepiness • Cardiovascular disease • Depression • Accidents 27

WHAT YOU CAN DO TO IMPROVE YOUR SLEEP IF YOU: 1. Don’t get enough sleep 2. Can’t sleep 3. Are concerned about a sleep problem HOW TO GET ENOUGH SLEEP

• #1- make sleep a priority • Have a good environment • Practice good sleep habits • Seek treatment for sleep disorders and underlying medical and psychiatric disorders that may impact sleep HOW TO MAKE TIME FOR SLEEP

• Set a goal to get into bed at the same time • Set an alarm clock and get out of bed at the same time • Avoid bright light in the evening and seek bright light in the morning • Get back on track after occasional relapses • Keep a sleep diary to track your progress IF YOU CAN’T SLEEP MANAGEMENT OF CHRONIC INSOMNIA DISORDER IN ADULTS: A CLINICAL PRACTICE GUIDELINE FROM THE AMERICAN COLLEGE OF PHYSICIANS COMPONENTS OF CBT-I

• Brief (4-6 sessions), time limited (weekly, bi-weekly) • Specialized (not all therapists are trained to do it) • Multicomponent – Sleep Restriction/ Sleep Compression – Stimulus Control – Education – Cognitive Restructuring – Relaxation Training 33 COGNITIVE RESTRUCTURING

• Identify, evaluate, and replace dysfunctional beliefs • Targets – Unrealistic sleep expectations – Misconceptions about insomnia – Catastrophic thinking (losing job, health) – Helplessness/hopelessness – Performance anxiety ., 2011

BRIEF BEHAVIORAL THERAPY FOR INSOMNIA (BBTI) 1. Reduce the time spent in bed to match hours asleep 2. Get up at the same time every day 3. Do not go to bed until sleepy 4. Don’t stay in bed unless you are asleep

Troxel 2009 SLEEP HYGIENE INSTRUCTIONS

1. Sleep only as much as you need to feel refreshed 2. Get up the same time per day 7 days/wk 3. Exercise regularly 4. Make sure your bedroom is a comfortable 5. Don’t go to bed hungry 6. Avoid excessive liquids at night 7. Cut down on caffeine and alcohol 8. Smoking may disturb sleep 9. Don’t take problems to bed 10.Don’t try to fall asleep 11.Turn the clock, so you don’t see it 12.Avoid BEDROOM ENVIRONMENT

• Cool temperature, warm • Comfortable bed • Dark shades • Quiet environment ** Interruptions by bed partners (people/pets) EXERCISE IS GOOD FOR SLEEP

• Increases deep sleep, sleep quality, vigor • Improves insomnia, sleep apnea, restless legs Reid, Baron, Lu, Naylor, Wolfe and Zee (2010) Sleep Medicine IF YOU HAVE CONCERNS

• Discuss with your primary physician • Consider a sleep medicine evaluation if you think you have a sleep disorder • Manage stress, keep up good health habits • Take care of your chronic conditions, pain etc. • Complete a sleep diary/log to evaluate your own sleep pattern 40

BEHAVIORAL SLEEP MEDICINE AT UUSWC:

• CBT for insomnia • PAP non-compliance • disorder • Circadian rhythm disorders, • Non-pharmcologic treatment for • Coping with PATIENT RESOURCES SLEEP: A MODIFIABLE RISK FACTOR FOR DISEASE

• Sleep is a critical component to health • Sleep problems are common Nutrition and addressable Exercise • Seek help if you are having sleep issues! Health

Sleep