WHO technical meeting on sleep and health Bonn Germany, 22-24 January 2004 World Health Organization Regional Office for Europe European Centre for Environment and Health Bonn Office ABSTRACT Twenty-one world experts on sleep medicine and epidemiologists met to review the effects on health of disturbed sleep. Invited experts reviewed the state of the art in sleep parameters, sleep medicine and, long-term effects on health of disturbed sleep in order to define a position on the secondary and long- term effects of noise on sleep for adults, children and other risk groups. This report gives definitions of normal sleep, of indicators of disturbance (arousals, awakenings, sleep deficiency and fragmentation); it describes the main sleep pathologies and disorders and recommends that when evaluating the health impact of chronic long-term sleep disturbance caused by noise exposure, a useful model is the health impact of chronic insomnia. Keywords SLEEP ENVIRONMENTAL HEALTH NOISE Address requests about publications of the WHO Regional Office to: • by e-mail [email protected] (for copies of publications) [email protected] (for permission to reproduce them) [email protected] (for permission to translate them) • by post Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark © World Health Organization 2004 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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TABLE OF CONTENTS Introduction..................................................................................................................2 Scope of the meeting...........................................................................................................3 Summary of the meeting discussion..................................................................................4 Working Groups .................................................................................................................13 Conclusions and recommendations.................................................................................14 Annex 1 – Technical papers ......................................................................................23 Adult’s sleep physiology, sleep quality and indicators of disturbed sleep. Short-term effects on health of disturbed sleep in adults - Alain Muzet ....................................24 Sleep characteristics and sleep deprivation in infants, children and adolescents - Kahn A, Franco......................................................................................................38 Sleep disorders in adults ; biological mechanisms through which sleep disorders affect the health of adults. Identification of environmental factors leading to clinical sleep disorders - Michel Billiard..............................................................................62 Sleep disorders in children, mechanisms through which sleep disorders affect the health of children – A. Wiater .................................................................................82 Medium and long term effects of sleep disturbance (by disorders and/or by stressors) on the health of adults - Sona Nevsimalova.........................................107 Medium and long term effects of disturbed sleep on the health of children - Oliviero Bruni ....................................................................................................................126 Sleep - gender, age, stress, work hours, Torbjörn Åkerstedt................................156 Annex 2 –Participants List .......................................................................................181 Introduction We spend almost a third of our life sleeping. Good quality sleep is essential for good health and well-being. However, lifestyle and environmental factors are increasingly causing difficulties in sleeping. Sleep disturbance is frequently considered the most serious consequence of environmental noise. The WHO European Centre for Environment and Health expanded its work on sleep disturbance (focusing on the health consequences of poor sleep as well as on noise disturbance itself) in order to define a position on the secondary and long-term effects of noise on sleep for adults, children and other risk groups. 21 international specialists on sleep, including psychiatrists and psychologists, gathered in Bonn from 22 to 24 January 2004. This document describes the meeting discussion and presents the conclusions and recommendations. Dr Christopher Drake reviewed the conclusions and recommendations. A note on sleep Sleep is a basic human need and is essential for good health, good quality of life and performing well during the day. Several indicators can be used to describe sleep disturbance or sleep disorders. These indicators are: 1) Sleep latency 2) Number and duration of nocturnal awakenings; 3) The total sleep time 4) Modifications in amount and proper rhythms of particular sleep stages such as slow wave sleep (SWS, or stages 3 and 4); 5) Rapid Eye Movement sleep (REM sleep), together with modifications in the autonomic functions (heart rate, blood pressure, vasoconstriction and respiratory rate); 6) Repetitive nights of sleep disruption among one week or one month. Self-reported sleep can also be used as an indicator: it is considered the least reliable objectively but perceived as the most important by the individual. Health effects of not sleeping The main effects of sleep deprivation include physical effects (sleepiness, fatigue, hypertension) cognitive impairment (deterioration of performance, attention and motivation; diminishment of mental concentration and intellectual capacity and increase of the likelihood of accidents at work and during driving) and mental health complications. Inadequate rest impairs the ability to think, to handle stress, to maintain a healthy immune system, and to moderate emotions. Maintained total sleep deprivation is fatal in some animal species. The day after a night of abnormal or poor sleep is, whatever the cause, a disturbed day. People can fall asleep at work, at school or when driving; feel tired; have concentration and vigilance detriments; have memory blanks; irritability; frustration; and have a higher probability of accidents or injury (WHO, 1998). 2 Scope of the meeting The main purpose of this meeting was to identify the current links between sleep disturbance (under all its modalities) and health status of adults, children and risk groups (shift workers, elderly, insomniacs), both on a long term and short term basis. The following figure illustrates the reasoning and logic behind the meeting preparation and the starting point for the writing of the meeting background papers. 3 Sle ep/clinical Disorders - Sleep apnoea, - Chronic Insomnia - … Effects on health 4 • Short term - Increased risk of accidents Symptoms or indicators of “disturbed sleep” - Blood pressure (disturbances) 1S - Stress hormones 2 - Inability to fall asleep - … - Successive awakenings - No-refreshing sleep 1 • - -…. Medium term 1ML - Cardiovascular - Cognitive Time performance - … • 5 Long term - Mental .. - Cardiovascular Stre ssors - Immune system - Environment, - Psychological - Life style - …. Figure 1 – Scope of the meeting Main themes for the technical papers of the meeting Results (1) - Most unknown ; (2) - Little known ; (3) Important body of knowledge ; (4) Important body of knowledge ; (5) Important body of knowledge With three groups of population in mind (adults, children and specific risk groups) the meeting reviewed: 3 1.Sleep physiology: what is a “normal” sleep? What are the various types of sleep disturbances? What kind of indicators are used to describe each of these types of disturbances? (Awakenings, arousals, body movements, changes of sleep stages, cortisol secretion etc.); 2. Are there specific sleep disturbances that are of special relevance for some “risk groups”, and why? (This will cover children, elderly, shift workers, etc.). 3. The various health end points than can be linked to sleep disturbances. Summary of the meeting discussion Dr G. Klein welcomed the participants on behalf of Dr. M. Danzon, Regional Director of the WHO Regional Office for Europe.