Good Night,

Sleep Tight:

Understanding the

Importance of Sleep

Conversations at the Royal

Elliott Lee MD, FRCP(C) D. ABPN Sleep Medicine, Addiction Psychiatry

D. Amer Board of Sleep Medicine

Assistant Professor, Royal Ottawa MHC December 19, 2013

• Functions of sleep

• Factors affecting sleep - Quantity - Quality - Timing

• Is sleep an issue for you?

• Obstructive sleep apnea, Narcolepsy

• How to improve sleep

Outline

Arianna Huffington, Internet publishing pioneer President and Editor In Chief, Huffington Post Media Group

Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%

Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%

Why Study Sleep? We spend 1/3 of our lives sleeping

Severe health consequences - DEATH!

Sleep deprivation costs

$150 BILLION/yr in lost

productivity (Nat’l Commission on Sleep Disorders, 2003)

Functions of Sleep Body /brain repair

- Increased resilience to stress/injury

Pain Reduction

Mood regulation

Diminished anxiety

Memory and learning

Immune competence

Sleep Characteristics by Stage NREM

- Stage N1 + N2 (light sleep) Motor skill learning? - Stage N3 slow wave (deep) Restorative function Memory

REM (rapid eye movement) - Dreaming (85%) - Memory ? - Mood regulation ?

SLEEP HYPNOGRAM

REM

N3

N2

N1

W

1

Hours

1 2 3 4 5 6 7

Sleep factors impacting performance

Sleep Quantity

Sleep Quality

Sleep Timing

(Sleep Inertia)

What is the commonest cause of excessive daytime sleepiness in the community?

Chronic Insufficient Sleep

What is the commonest cause of excessive daytime sleepiness in the community?

Sleep QUANTITY

Sleep Deprivation According to the most recent General Social Survey

done by Statistics Canada (2010), 46% percent of Canadians will cut back on sleep in order to add time to their days.

Sleep Deprivation There is a conflict between the biological imperative

for sleep and the social demand for performance. This poses a fundamental question: What happens to performance when the pressure for sleep is increased?

Sleep Quantity Too little – equivalent to functioning with 0.05 blood

alcohol level (<6 hours)1

<7 hours – decrements can be seen in performance

Cognitive function > speed > accuracy2,3

2Koslowsky M and Babkoff H. Chronobiol Intl. 1992; 9(2); 132-6 3Reilly T and Edwards B. Physiology and Behaviour. 2007; 90; 274-84

1Williamson AM and Feyer AM. Occup Environ Med 2000; 57; 649-55

Sleep Disorders - Socioeconomic Consequences More than 100,000 motor vehicle accidents annually

are sleep-related (US).

“Toronto syndrome”

Psychomotor Vigilance Task (PVT) errors with

cumulative sleep deprivation

Dinges et al Sleep, 1997; 20(4), 267-77

Challenger Disaster

3 Mile Island

Chernobyl

Exxon Valdez

Medical Errors

Transportation Industry

Daylight Savings and Traffic Accidents

Coren S. N Engl J Med. 1996 Apr 4; 334(14): 924

Sleep Deprivation and Wt gain? Women who sleep <5 hours per night, gained 2.5 lbs,

cf. to women sleeping 7 hours/night

Relative risk for obesity (BMI > 30 kg/m2) 5 hour sleepers = 1.15 cf. to 7+ hours

Studied >68 000 women (Nurses Health Study) for 16 years

Hormones? Basal metabolic rate?

Sleep Deprivation and Children Not the same as adults

May be “hyperactive” - fidget - poor attention - cranky

Sleep QUALITY

Sleep Quality Fragmented sleep

consequences are similar to sleep deprivation - ↓ concentration - ↓ attention - moodiness/irritability - ↓ reaction time - memory impairments

Causes of fragmented sleep: - Temperature - Light* - Noise - Pain - Anxiety/Stress - Sleep disorder - Snoring/Apnea - PLMs/RLS

Sleep TIMING

Sleep Control

Process S(leep)

Process C(ircadian)

Process S(leep) Homeostatic control

“The longer we’re awake, the more sleep debt we accumulate i.e. the sleepier we become”

The sleepier we are, the more deficits are seen

To date, there is no surrogate available for good quality sleep.

Process S(leep) Homeostatic control

“The longer we’re awake, the more sleep debt we accumulate i.e. the sleepier we become”

The sleepier we are, the more deficits are seen

To date, there is no surrogate available for good quality sleep.

Process C(ircadian) Sleep tendencies follow a circadian (daily) rhythm

This is controlled by a central “biological clock”

Several inputs also influence this clock, especially - Light - Melatonin

Sleep and Light

SLEEP

11 PM 7 AM

SLEEP SLEEP

Sleep and Light

SLEEP

11 PM 7 AM

SLEEP SLEEP

Sleep and Melatonin

SLEEP

11 PM 7 AM

SLEEP SLEEP

Consequences of Asynchronous Sleep

Impaired continuity of sleep

↓ alertness

↑cognitive errors

Like “hitting a tennis ball off the centre of the racquet” – sleep is not as efficient, and sleep architecture is disrupted

Jet lag, shift work

Who is more likely to do rotating or evening shifts in Canada, men or women?

WOMEN

Who is more likely to do rotating or evening shifts in Canada, men or women?

Women are more likely to work rotating shifts or evening shifts

Other 12%

Evening 14%

Night 8%

Rotating 41%

Irregular 25%

Women

Other 13%

Evening 10%

Night 8%

Rotating 34%

Irregular 35%

Men

Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005

Shift Work International Agency on Research and Cancer (IRAC)

classified shift work as a probable carcinogen in 2007.

40-50% increase in breast cancer risk with >20-30 years of shift work exposure.

Melatonin thought to play a key role; reduces estrogen levels and shown to have anticancer properties.

Grundy A et al. Occup Environ Med. 2013; 70: 831-8

Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9

Megdal et al. Eur J Cancer. 2005; 41: 2023-32

Is sleep an issue for you? Do you feel satisfied with the quality of your

sleep?

Do you frequently fall asleep if given a sleep opportunity (a sleep opportunity is defined as a quiet, dark environment for at least 10 minutes)?

Do you usually need an alarm clock to wake you?

Do you tend to catch up on sleep during the weekends?

Once awake, do you feel tired most mornings?

Do you frequently take naps during the day?

Is sleep an issue for you? When you can get it, do you consistently sleep

more than 9.5 hours per night?

Do you feel lethargic or slow throughout the day?

Do you sleep longer during times of depression, anxiety and stress?

Do you snore?

Do your legs bother you at bedtime, interfering with your sleep?

What Happens at the Sleep Lab… ROMHC: 5 bed clinical lab, 4 bed research lab STEPS: 1) → Referral 2) → Consultation with a Sleep Specialist 3) → Overnight Sleep Study 4) → Data is Analyzed by RPSGTs 5) → Results Appt with a Sleep Specialist

How Do We Measure Sleep in the Laboratory?

Electrophysiology

EEG – brainwaves (Central & Occipital Leads)

EOG – eye movements

EMG – muscle tone

EKG – heart

Breathing:

1)Airflow

& 2) Effort: Thoracic & Abdominal

Blood oxygen saturation (SaO2)

Audio-visual recording

Obstructive Sleep Apnea (OSA) Definition:

The presence of abnormal breathing disruptions/cessations (apneas) during sleep

Sleep is disrupted temporarily, usually without recall. As a result, sleep deprivation and/or excessive daytime sleepiness occur, usually with snoring at night

Up to 25% of men and 9% of women are thought to be affected, with 90% of patients likely undiagnosed1

50% of snorers are thought to have OSA2

Strongly associated with cardiac disease

1Young et al. N Eng J Med, 1993; 328(17): 1230-5 2Lugaresi et al. Sleep, 1980; 3(3-4): 221-4

Months

Marin JM et al. Lancet, 2005

Fatal CV events and OSA

Nonfatal CV events and OSA Marin JM et al. Lancet, 2005

OSA Consequences

Memory problems Irritability, mental illness e.g. depression

Motor vehicle accidents Hypertension

Heart attack and stroke Impaired

glucose

control

Treatments for OSA **Weight loss - ↓ BMI = ↓ RDI Avoid alcohol consumption and sedative medications “Snoreball” technique / positional therapy Upper airway surgery

Tonsillectomy (pediatrics) Uvulopalatopharyngoplasty (UPPP) Maxillomandibular Advancement (MMA) Tracheostomy

Provent Oral Appliances - Mandibular Repositioning Devices

(MRDs), Tongue Retention Devices (TRDs) **CPAP – Continuous Positive Airway Pressure

OSA and Attractiveness? Treatment of OSA with

CPAP has been shown to improve attractiveness

Perceived to be - More alert - More youthful - Less forehead creases

Chervin R et al. J Clin Sleep Med, 2013; 9(9): 845-52

All of the following famous people suffer from a

sleep disorder. Which of these famous people

suffers from obstructive sleep apnea? (Choose

all that apply):

A B C D E

All of the following famous people suffer from a

sleep disorder. Which of these famous people

suffers from obstructive sleep apnea? (Choose

all that apply):

A E B C D

Narcolepsy A pathologic disorder of sleepiness during the day –

key symptom – sleepiness

May have insomnia at nighttime

Affects about 1/2000 people

Very underdiagnosed; difficult to recognize

80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness

Related to cerebrospinal fluid deficiency of hypocretin (orexin)

Narcolepsy Treatment

SLEEPINESS:

– Stimulants d-amphetamine (Dexedrine), methylphenidate (Ritalin) Novel - modafinil (Alertec / Provigil). - armodafinil

CATAPLEXY:

– Antidepressants – e.g. venlafaxine

– Sodium oxybate (Xyrem)

All of the following famous people suffer from a

sleep disorder. Which of these famous people

suffers from narcolepsy?

A B C D E

All of the following famous people suffer from a

sleep disorder. Which of these famous people

suffers from narcolepsy?

E A B C D

How to Improve Sleep Get adequate quantity of sleep (7.5-8.5 hrs)

Regular sleep/wake times – timing/routine important

Develop a relaxing pre sleep ritual - relaxation exercises can be helpful - avoid stressful/stimulating activities prior to sleep

Avoiding prolonged naps* in the day

Bed – only for sleep (and romance!)

Avoid clock watching

Rule out sleep disorder, psychiatric disorder

How to Improve Sleep Sleep Environment

- Avoid environmental disturbances - Partner/Children - Roommate - External noises – phones, texting, external (white noise generator may drown out) - Avoid bright light in evenings - Temperature – slightly cooler (<21-22oC) is better. drop in temperature facilitates sleep onset - Bed should be comfortable – consider memory foam mattresses/pillows; queen or king size beds

Quiet. Dark. Cool. Comfortable.

Detriments to Sleep Light (evening)

- cell phones, computer

Stress (cortisol - steroid)

Caffeine

Nicotine

Alcohol

Marijuana

Drugs (Amphetamines, cocaine, opioids*)

Which of the following substances has the highest amount of caffeine? A) Red Bull, 250 mL B) Coca Cola, 1 L C) Starbucks Coffee, Grande (360 mL) D) Green Tea, 300 mL E) Caffeine pill, (200 mg tab)

Which of the following substances has the highest amount of caffeine? A) Red Bull, 250 mL B) Coca Cola, 1 L C) Starbucks Coffee, Grande (360 mL) D) Green Tea, 300 mL E) Caffeine pill, (200 mg tab)

Caffeine – a Canadian Love Affair

Starbucks coffee(20 oz) 400 mg

Second Cup coffee (20 oz) 400 mg

Tim Horton’s coffee (20 oz) 270 mg

Instant coffee (8 oz)* 95 mg

Tea (leaf or bag, 8 oz) 50 mg

Mountain Dew (12 oz) 55 mg

Coca Cola (12 oz) 45 mg

Red Bull (250 ml) 80 mg Sources: National Coffee Association, National Soft Drink Association, Tea Council of the USA, and information

provided by food, beverage, and pharmaceutical companies and J.J. Barone, H.R. Roberts (1996) "Caffeine

Consumption." Food Chemistry and Toxicology, vol. 34, pp. 119-129.

Summary Sleep is important to consider for performance

Good sleep can improve performance - Cognition/memory - Accuracy - Speed - Health/Decrease sick days (immune competence) - Improve mood, anxiety, resilience

Sleep variables to consider: Quantity, Quality, Timing

Rule out sleep disorder

Details are important; BALANCE – key to success

When the time to perform has come, the time to prepare has past. Bob Bowman, coach of Michael Phelps

Thank You! Questions?

Severe OSA, treated with CPAP

12 AM 10 PM 2 AM 4 AM 6 AM

Video courtesy of Joe Santos, IOSleep Med

Video courtesy of Dr. Viozzi, Mayo Clinic

Maxillomandibular Advancement

5 mm

5 mm

+8 mm

Mandibular Repositioning Devices (MRDs)

Silencer-

Johns Dental

Labs

Klearway-

Great Lakes Orthodontics