Sleep Deprivation: Can it kill us?

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Sleep Deprivation Can it kill us?

• TWUC
• Betsy R. Sears MSM, MT(ASCP) EVP, Sales
  Support ExamOne

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Sleep deprivation

• One of most pervasive health problems in U.S.
• Estimated 1.5 hours less/night than a century
  ago
• 2002 Sleep in America poll 5,000 adults 1/3
  need 8 hours but dont get
• Studies on lt 6 to 7 hours sleep increased
  mortality risk
• Can affect health
  
  safety
  performance
  
  pocketbook
• Experts say brainpower

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Outline

• Sleep - why we need it
• Reasons we dont sleep
• Consequences of sleep deprivation
• Studies statistics
• Success for sleep

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Sleep

• Naturally recurring state characterized by
  reduced or absent consciousness, relatively
  suspended sensory activity, and inactivity of
  nearly all voluntary muscles
• Heightened anabolic state, accentuating growth
  and rejuvenation of the immune, nervous, skeletal
  and muscular systems (all animals)
• Melatonin triggers functions clears cells of
  toxins, slows respiratory system
• Purpose only partially clear
• 2007 American Academy of Sleep Medicine (AASM)
  stages REM Non-REM (N1, N2, N3)
• Stages assessed by polysomnography EEG, EOG, EMG

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Sleep stages

• NREM sleep
• N1 drowsy sleep twitching lost muscle tone
  (falling!) 4-5
• N2 muscle activity and conscious awareness
  disappears
  eye movement stops
  45-55 adult sleep
• N3 (deep sleep) no eye or muscle activity
  children - night
  terrors, sleepwalking, bedwetting 6 15
• REM sleep
• REM and brain waves at waking levels most
  memorable dreams HR BP male
  erection body temperature fluctuates muscles
  relax (3 to 5 cycles each night) paralysis
  protective 20-25 adult sleep infants 90
• N1 N2 N3 N1 REM

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Sleep cycles
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Sleep why we need it

• After 50 years research, William Dement "As far
  as I know, the only reason we need to sleep that
  is really, really solid is because we get
  sleepy.
• Animals tell us . . . even the sharks
• Restoration wound healing
  
  immune system
  
  somatic growth
• Ontogenesis REM necessary for brain development
• Memory processing working memory keeps
  information active for further processing
  supports higher level cognitive function (38
  drop in sleep test 26 min/night/4 days)
• Preservation and Protective adaptive function
  protect in 24 hr/day

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Optimum amount of sleep

• Varies by age and individual genetics size and
  shape adequate if no daytime sleepiness or
  dysfunction
• Controlled by circadian clock, sleep - wake
  homeostasis, willed behavior
• Circadian clock works in tandem with adenosine
  (neurotransmitter) high
  levels cause sleepiness melatonin released and
  decrease in body temperature
• Homeostasis need for sleep as function since
  time last sleep cycle
• Optimal sleep not meaningful unless timed with
  circadian rhythms
• University of CA, S.F. 3 of population
  requires 6 hrs or less (DEC2 mutation)
• Univ of San Diego 1 M adults, longer life
  6-7 hrs sleep/night
• Other studies - gt 8 hrs/night associated with
  mortality (depression)

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Biological clock
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Reasons we dont sleep 100 M of us

• Insomnia - 70 M
• Sleep apnea or other disorders 18M
• Eating/drinking habits
• Restless leg syndrome 12 M
• Depression 90
• Noisy bedtime setting
• Shift working 22M
• Frequent flyers
• Medical illness causing pain

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Insomnia

• Acute - Difficulty getting to or staying asleep
  1 night to few weeks
• Chronic 3 nights a week for a month or longer
• National Sleep Foundation (NSF) most common of
  all sleep problems Americans overall 58
  
  Elderly 68
  
  Males 31
  
  
  Females 48
• Primary - alcohol, anxiety, coffee, stress
• Secondary physical condition
  (depression,
  asthma, cancer)
• Treatment nothing, change in sleep habits,
  pills, treat health conditions, behavioral
  therapy Gayle Greene

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Insomnia
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Sleep Apnea

• Risks if untreated
• Stroke 4x more likely
• Heart disease 4x more likely
• 3 risk of heart attack and stroke
• 50 have hypertension
• 38,000 deaths/yr

• Prevalence
• 18 million in the U.S.
• Children 1-2
• Male 4-9
• Female 2-4 (menopause)
• Elderly 20
• 2-4 of Americans go undiagnosed (5-10M)

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Consequences of sleep deprivation

• 85 sleep disorders recognized by American Sleep
  Disorders Association (ASDA)
• 2 hours sleep loss 2 or 3 12 oz. beers
• Missed 1 night irritable and clumsy easily
  tired
  2 nights
  concentration mistakes normal tasks
  
  3 nights hallucinate lose grasp on reality
• Few hours sleep each night sleep debt 1997
  study showed persons sleep 4-5 hours/night needs
  2 full nights to recover performance, alertness
• Morbidity/mortality

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Physical effects of sleep deprivation
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Sleep deprivation consequences short term

• Decreased performance alertness
• Memory cognitive awareness
• Physical appearance
• Wound healing

• Stress relationships
• Immune system
• Poor quality of life
• Occupational injury
• Automobile injury

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Occupational injury

• gt 10 people die/day due to injuries on the job
  (sleepiness, drugs, alcohol)
• Non-fatal accidents cost 100 billion/year lost
  wages and productivity, administrative expenses,
  health care, and other costs
• 2009 National Sleep Foundation 85 police
  officers, 80 regional pilots, 48 air traffic
  controllers have nodded off on the job in past
  year 41 medical workers made fatigue related
  errors
• 1999 American Airlines crash in Little Rock
• 2003 Staten Island Ferry crash
• 2009 crash regional jet in Buffalo NY 50 people
  killed
• Exxon Valdez grounding, 3 Mile Island Chernobyl
  nuclear accident
• 2004 study Harvard Medical School medical
  residents made 2x as many mistakes with lt 4
  hrs/sleep as compared to gt 7 hrs/sleep

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Drowsy driving

• National Center for Sleep Disorder Research
  (NCSDR) National Highway Traffic Safety
  Administration (NHTSA) report that
• Most car crashes do not involve alcohol
• Fall asleep crashes more serious higher speed,
  delayed response
• North Carolina drowsy driving crashes resulted
  in more injury than other non-alcohol related
  crashes Mortality 1.4 vs. 0.5

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Automobile injury

• According to National Highway Traffic Safety
  Administration (NHTSA) drowsy driving causes
  
  approximately
  100,000 crashes a year (AASM 250K-1 in 5)
  approximately 71,000 people
  injured
  1,500 deaths
  
  12.5 billion in
  property losses lost productivity
• NSF in last year 51 say sleepy 17 have
  fallen asleep
• Sleep deprivation like driving drunk (blood
  alcohol 0.8)
• Federal government's "Healthy People" initiative
  aims to reduce the rate of car crashes due to
  sleepiness per 100 million miles traveled from
  2.7 to 2.1 by 2020 Texting?
• Rumble strips there for a reason! Stop
  immediately, get equivalent of 2 cups of coffee,
  take 20 minute nap 12am 6am risky times

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Sleep deprivation consequences long term

• High blood pressure
• Heart attack
• Heart failure
• Stroke
• Obesity (diabetes)
• Cancer
• Psychiatric problems, including depression and
  other mood disorders

• Attention Deficit Disorder (ADD)
• Mental impairment
• Fetal and childhood growth retardation
• Injury from accidents
• Disruption of bed partner's sleep quality
• Poor quality of life

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Obesity and Sleep Deprivation

• 1/3 Americans obese - calories,
  physical activity, interaction between genes and
  environment and cultural influences
• Sleeping less is there a connection?
• Research (2001) Staying awake past midnight and
  lt 6 hrs sleep increased likelihood of
  obesity
  
  (2002) A study of 1.1 million people
  found that increasing BMI occurred when
  habitual sleep amounts fell below 7 to 8 hours
  (2004) A study in
  Wisconsin showed that when sleeping less than
  8 hours, the increase in BMI was
  proportional to amount of decreased
  sleep
  (2005) A
  study done in Virginia showed that overweight and
  obese individuals slept less than
  subjects of normal weight (2005) Short
  sleep duration at 30 mos predicts obesity at 7
  yrs
• Since 1992 13 studies of gt 45,000 children
  support inverse relationship messing with the
  hypothalamus?

Taheri, S. Sleep and metabolism Bringing pieces
of the jigsaw together. Sleep Medicine Reviews.
2007. 11159-162
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Obesity and Sleep Deprivation

• 1999 - Spiegel examined sleep restriction and
  effect on metabolism by sleep restricting
  subjects to 4 hrs/night for one week this led
  to impaired glucose tolerance and changes in
  hormones related to weight gain and hypertension
  changes were reversible with normal sleep times
• 2004 - Spiegel examined effect of sleep
  restriction on hormones related to hunger and
  appetite found that sleep restriction reduced
  hormone leptin (suppresses appetite) by 18
• It also increased the hormone ghrelin (increases
  appetite) by 28 subjects showed subjectively
  increased appetite for calorie-dense foods with
  high carbohydrate content

Spiegel, K. Impact of sleep debt on metabolic and
endocrine function. The Lancet. October 23, 1999.
3541435-1439. Spiegel, K. et al. Brief
Communication Sleep Curtailment in Healthy Young
Men Is Associated with Decreased Leptin Levels,
Elevated Ghrelin Levels, and Increased Hunger and
Appetite. Annals of Internal Medicine. December
7, 2004. 141846-851
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Obesity and Sleep Deprivation

• University of Warwick Medical School (2006)
• Capuccio studied 28,000 children, 15,000 adults
• Sleep deprivation associated with 2-fold
  increased risk of becoming obese
• Greater in BMI waist circumference over
  time
• Theory - increase in appetite due to hormonal
  changes from sleep deprivation
• Lack of sleep produces ghrelin produce less
  leptin
• More research necessary

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Obesity
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Obesity and mortality

• Atherosclerosis
• Heart failure
• Kidney failure
• Type 2 diabetes
• Sleep Apnea
• Cancer
• Osteoarthritis

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Cardiac Risk

• Physiological studies at Harvard, Mayo Clinic and
  University of Pennsylvania sleep deficit may put
  body into a state of high alert increasing
  production of stress hormones driving up blood
  pressure
• Overall mortality increased but . . . major
  risk factor for heart attacks and strokes sleep
  influences functioning of lining of blood vessels
• People who are sleep-deprived have elevated
  levels of substances in blood that indicate a
  heightened state of inflammation in the body,
  which has also recently emerged as a major risk
  factor for heart disease, stroke, cancer and
  diabetes hsCRP
• "Based on our findings, we believe that if you
  lose sleep that your body needs, then you produce
  these inflammatory markers that on a chronic
  basis can create low-grade inflammation and
  predispose you to cardiovascular events and a
  shorter life span" Alexandros N. Vgontzas, Univ
  of PA

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Over 1000 studies CV risk, psychosis

• 2008 University College London/University of
  Warwick UK study of 4,600 men and women aged 35
  to 55, researchers found that women who slept lt 8
  hrs/night had higher risk of dying from CV
  disease than men differences in hormone levels
  may play a role
• 2007 Mayo Clinic new research shows that getting
  less than 5 hours of sleep a night increases your
  risk of death from cardiovascular disease
• 2001 Chicago Medical Institute sleep
  deprivation may be linked to more serious
  diseases, such as heart disease and mental
  illnesses including psychosis and bipolar
  disorder
• 2007 Harvard Medical School and University of
  California at Berkeley link between sleep
  deprivation and psychosis further documented
  study revealed, using MRI scans, that lack of
  sleep causes the brain to become incapable of
  putting an emotional event into the proper
  perspective and incapable of making a controlled,
  suitable response to the event

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Shift work and Cancer

• Harvard researchers 78,000 females worked
  rotating night shifts over 10 yr period shift
  work significantly increased risk of breast
  cancer
• Harvard researchers - same group but those
  working rotating night shift and least 3
  nights/month for 15 years of more had increased
  risk of colon cancer
• 3rd Harvard team of researchers studied more than
  53,000 women who worked rotating shifts and found
  that night work increased risk of endometrial
  cancer by 47 --- and actually doubled the risk
  of endometrial cancer in obese shift workers
• World Health Organization (2007) classified shift
  work as a probable cause of cancer ACS will
  continue to research

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Mortality associated with sleep duration and
insomnia

• Background Patients concern about insufficient
  sleep/chronic insomnia treatment strategies
  guided by how much sleep optimal survival
• Method In 1982, Cancer Prevention Study II
  (ACS) asked participants about sleep duration and
  frequency of insomnia. Cox proportional hazards
  survival models computed to determine whether
  sleep duration/frequency of insomnia was
  associated with excess mortality up to 1988
  (controlling for demographics, habits, health
  factors, and use of various medications)
• Results 1.1 M men and women 30 -102 yrs of age.
  Best
  survival 7 hrs per night
  
  8 hrs or gt and 6 hrs or lt experienced
  significantly increased mortality hazard Hazard
  risk gt 15 for some groups (sleeping gt 8.5 hrs or
  lt than 3.5-4.5 hrs) Rx
  sleeping pill use associated with significantly
  increased mortality after control for reported
  sleep durations and insomnia
• Conclusion Short sleep and insomnia seem
  associated with risk although compares to co
  morbidity risk

Arch Gen Psychiatry. 200259131-136
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Mortality associated with sleep duration and
insomnia
Figure 1. For 636095 women, the average reported
frequency of insomnia, the average number of
sleeping pills used per month, and the mean body
mass index (BMI) according to reported hours of
sleep. The 95 confidence intervals of the BMI
are shown. Also shown are the hazard ratios from
the 32-covariate Cox models and the percentage of
women reporting each sleep duration. The
reference duration of 7 hours is represented by
the lighter bars.
Figure 2. For 480841 men, data comparable to
those shown in Figure 1. BMI indicates body mass
index.
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Insomnia, short sleep duration and mortality

• Random, central PA 1,741 men (followed 14 yrs)
  and women (followed 10 yrs) sleep lab
• Insomnia complaint for 1 year/Normal absence
  of insomnia
• Polysomnographic sleep defined normal sleep - gt
  6 hrs short sleep - lt 6 hrs
• Adjusted for age, race, education, body mass
  index, smoking, alcohol, depression, sleep
  disordered breathing, and sampling weight
• Mortality rate (2007 U.S. SS Death Index) Men
  21
  Women 5
• Results mortality rate significantly in
  insomniac men with short sleep
  compared to normal sleep/non-insomniacs when
  adjusted for diabetes, high BP, other
  factors. Women - no
• Conclusion Insomnia/short sleep in males is
  associated with increased mortality,
  risk that has been underestimated

• Vgontzas AN Liao D Pejovic S Calhoun S
  Karataraki M Basta M Fernández-Mendoza J
  Bixler EO. Insomnia with short sleep duration and
  mortality the Penn State Cohort. SLEEP
  201033(9)1159-1164

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Sleep Debt can we pay back?

• Sleep debt or deficit - cumulative effect of not
  getting enough sleep large sleep debt may lead
  to mental and/or physical fatigue
• Two kinds of sleep debt 1) partial sleep
  deprivation or 2) total sleep deprivation
• Partial sleep deprivation occurs when a person
  sleeps too little for many days or weeks
• Total sleep deprivation means being kept awake
  for days or weeks
• Debate in scientific community over specifics of
  sleep debt as a measurable phenomenon
• 1997 Univ of PA cumulative sleep defect affects
  daytime sleepiness days 1,2, 6 and 7
• 2003 study different groups tested with variable
  sleep times for 2 weeks
  8 hours
  
  
  6 hours
  
  
  4 hours
  
  
  
  total depravation
• Each group in red worsened (by psychomotor
  vigilance task) as time progressed
• 6 hour group at 10 days - functioning as those
  completely sleep deprived for 24 hrs
• Negative effects accumulate over time

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Sleep Debt
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Sleep Aides - hypnotics

• 25 of Americans use sleeping aide
• Age 20 44 use doubled from 2000 2004
• 2 billion on zolpidem (Ambien) in 2004 Global
  5 billion
• Used to be addictive benzodiazepine (Valium,
  Dalmane)
  barbiturates (Seconal,
  Halcion and Quaalude)
• New Lunesta (for longer term use), Ambien CR
  (prevents waking after 4 hours)
• Most recommended for short term use but abused
• Risk for nightly use

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Good news about sleep deprivation

• Sleep deprivation short term fix for depression
• Loss of 1 night sleep improves symptoms in 40-6-
  depressed patients
• One night loss increase in dopamine
  euphoria
• Not viable for treatment on outpatient basis

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Sleep hours trending down National Health
Summary
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Are you sleep deprived?

• You dont need a sleep clinic!
• Do you need an alarm clock to wake up?
• Falling asleep within 5 minutes of head hitting
  pillow
• Napping

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Successful Sleep

• Create sleep chamber
• Maintain regular bedtime/wakeup time
• Dont drink fluids before bed
• Dont work on computer, watch TV or read in
  bed (the 2 Ss only!)
• Comfortable bed, pillows
• Exercise regularly

• Avoid alcohol
• Avoid caffeine
• Establish bedtime ritual
• Dont use tobacco products
• Dont go to bed until youre sleepy
• Wake up? Leave bed
• Spend time outdoors

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Sleep Aide
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References

• Timmer, John. US tossing and turning into a
  sleepless nation 2008
• Vgontzas AN Liao D Pejovic S Calhoun S
  Karataraki M Basta M Fernández-Mendoza J
  Bixler EO. Insomnia with short sleep duration and
  mortality the Penn State Cohort. SLEEP
  201033(9)1159-1164
• Marks Psychiatry May 6, 2009
• Sleep Deprivation Doubles Risks Of Obesity In
  Both Children And Adults Science Daily July 13,
  2006
• Journal of Endocrinology and Metabolism October
  2000 Redwine et al. 85 (10) 3597
• Wilson JF. In the clinic. Insomnia. Ann Intern
  Med. 2008148(1)ITC13-1-ITC13-16. PubMed
• Morgenthaler T, Kramer M, Alessi C, Friedman L,
  Boehlecke B, Brown T, et al. Practice parameters
  for the psychological and behavioral treatment of
  insomnia an update. An American Academy of Sleep
  Medicine report. Sleep. 2006291415-1419
• National Sleep Foundation 2003 Lancet 2002 359
  204-210
• http//www.ehow.com/facts_4841013_percentage-ameri
  cans-sleeping-disorders.htmlixzz1YK8xFwje
• Schulz H (April 2008). "Rethinking sleep
  analysis". Journal of Clinical Sleep Medicine 4
  (2) 99103. PMC 2335403. PMID 18468306
• Recognizing the Dangers of Sleep DeprivationBY
  MAX HIRSHKOWITZ, PH.D., A.B.S.M. AND PATRICIA B.
  SMITH
• Spiegel, K. Impact of sleep debt on metabolic and
  endocrine function. The Lancet. October 23, 1999.
  3541435-1439.
• Spiegel, K. et al. Brief Communication Sleep
  Curtailment in Healthy Young Men Is Associated
  with Decreased Leptin Levels, Elevated Ghrelin
  Levels, and Increased Hunger and Appetite. Annals
  of Internal Medicine. December 7, 2004.
  141846-851

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Sleep Deprivation

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• Betsy.r.sears_at_examone.com
• 913-577-1306