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Good Night, Sleep Tight: Understanding the Importance of Sleep

By Dr. Elliott Lee, Sleep Specialist at The Royal as presented at our monthly lecture series, Conversations at The Royal.

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Good Night, Sleep Tight: Understanding the Importance of Sleep

  1. 1. 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
  2. 2. Outline • Functions of sleep • Factors affecting sleep - Quantity - Quality - Timing • Is sleep an issue for you? • Obstructive sleep apnea, Narcolepsy • How to improve sleep
  3. 3. Arianna Huffington, Internet publishing pioneer President and Editor In Chief, Huffington Post Media Group
  4. 4.  Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%
  5. 5.  Approximately what percentage of our (adult) lives will be spent sleeping? A) 20% B) 25% C) 33% D) 40% E) 50%
  6. 6. 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)
  7. 7. Functions of Sleep  Body /brain repair - Increased resilience to stress/injury  Pain Reduction  Mood regulation  Diminished anxiety  Memory and learning  Immune competence
  8. 8. 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 ?
  9. 9. SLEEP HYPNOGRAM W N2 1 N1 N3 REM 1 2 3 4 Hours 5 6 7
  10. 10. Sleep factors impacting performance Sleep Quantity Sleep Quality Sleep Timing (Sleep Inertia)
  11. 11.  What is the commonest cause of excessive daytime sleepiness in the community?
  12. 12.  What is the commonest cause of excessive daytime sleepiness in the community? Chronic Insufficient Sleep
  13. 13. Sleep QUANTITY
  14. 14. 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.
  15. 15. 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?
  16. 16. 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 1Williamson AM and Feyer AM. Occup Environ Med 2000; 57; 649-55 2Koslowsky M and Babkoff H. Chronobiol Intl. 1992; 9(2); 132-6 3Reilly T and Edwards B. Physiology and Behaviour. 2007; 90; 274-84
  17. 17. Sleep Disorders Socioeconomic Consequences  More than 100,000 motor vehicle accidents annually are sleep-related (US).  “Toronto syndrome”
  18. 18. Psychomotor Vigilance Task (PVT) errors with cumulative sleep deprivation Dinges et al Sleep, 1997; 20(4), 267-77
  19. 19.  Challenger Disaster  3 Mile Island  Chernobyl  Exxon Valdez  Medical Errors  Transportation Industry
  20. 20. Daylight Savings and Traffic Accidents Coren S. N Engl J Med. 1996 Apr 4; 334(14): 924
  21. 21. 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?
  22. 22. Sleep Deprivation and Children  Not the same as adults  May be “hyperactive” - fidget - poor attention - cranky
  23. 23. Sleep QUALITY
  24. 24. 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
  25. 25. Sleep TIMING
  26. 26. Sleep Control Process S(leep) Process C(ircadian)
  27. 27. 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.
  28. 28. 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.
  29. 29. 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
  30. 30. Sleep and Light 11 PM 7 AM SLEEP SLEEP SLEEP
  31. 31. Sleep and Light 11 PM SLEEP SLEEP SLEEP 7 AM
  32. 32. Sleep and Melatonin 11 PM SLEEP SLEEP SLEEP 7 AM
  33. 33. 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
  34. 34.  Who is more likely to do rotating or evening shifts in Canada, men or women?
  35. 35.  Who is more likely to do rotating or evening shifts in Canada, men or women? WOMEN
  36. 36. Women are more likely to work rotating shifts or evening shifts Men Women Irregular 25% Other 13% Other 12% Evening 14% Irregular 35% Evening 10% Night 8% Night 8% Rotating 41% Rotating 34% Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005
  37. 37. 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. Megdal et al. Eur J Cancer. 2005; 41: 2023-32 Grundy A et al. Occup Environ Med. 2013; 70: 831-8 Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9
  38. 38. 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?
  39. 39. 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?
  40. 40. 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
  41. 41. 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
  42. 42. 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): 2Lugaresi et al. Sleep, 1980; 3(3-4): 221-4 1230-5
  43. 43. Fatal CV events and OSA Months Marin JM et al. Lancet, 2005
  44. 44. Nonfatal CV events and OSA Marin JM et al. Lancet, 2005
  45. 45. Motor vehicle accidents Hypertension OSA Consequences Impaired glucose control Irritability, mental illness e.g. depression Heart attack and stroke Memory problems
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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)
  51. 51. Narcolepsy Treatment SLEEPINESS: – Stimulants d-amphetamine (Dexedrine), methylphenidate (Ritalin) Novel - modafinil (Alertec / Provigil). - armodafinil CATAPLEXY: – Antidepressants – e.g. venlafaxine – Sodium oxybate (Xyrem)
  52. 52. All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from narcolepsy? A B C D E
  53. 53. All of the following famous people suffer from a sleep disorder. Which of these famous people suffers from narcolepsy? A B C D E
  54. 54. 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
  55. 55. 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.
  56. 56. Detriments to Sleep  Light (evening) - cell phones, computer  Stress (cortisol - steroid)  Caffeine  Nicotine  Alcohol  Marijuana  Drugs (Amphetamines, cocaine, opioids*)
  57. 57.  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)
  58. 58.  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)
  59. 59. 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.
  60. 60. 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
  61. 61. When the time to perform has come, the time to prepare has past. Bob Bowman, coach of Michael Phelps
  62. 62. Thank You! Questions?
  63. 63. Severe OSA, treated with CPAP 10 PM 12 AM 2 AM 4 AM 6 AM
  64. 64. Video courtesy of Joe Santos, IOSleep Med
  65. 65. Video courtesy of Dr. Viozzi, Mayo Clinic
  66. 66. Maxillomandibular Advancement 5 mm 5 mm +8 mm
  67. 67. Mandibular Repositioning Devices (MRDs) Klearway- Silencer- Great Lakes Orthodontics Johns Dental Labs

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By Dr. Elliott Lee, Sleep Specialist at The Royal as presented at our monthly lecture series, Conversations at The Royal.

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