SLEEP HYGIENE AND SLEEP DISORDERS IN GENERAL POPULATION

PUBLIC HEALTH INTERVENTIONS

SINZIANA SEICEAN MD

Motto: “There is no way to cheat Mother Nature”

                                                                                                                Dr. David Dinges

OBJECTIVES:

  1. To define sleep, sleep physiology, and sleep hygiene concepts in an effective manner, easily understandable for health care and especially non health care professionals.
  2. To give general information about the current state of knowledge in sleep disorders.
  3. To explain why sleep is becoming a public health priority: the linkage between years of lost potential life due to causes; which include but are not limited to cardiovascular disease, hypertension, cerebrovascular disease, motor vehicle related injuries, diabetes mellitus, unintentional injury correlated with daytime sleepiness or poor concentration ability; and sleep.

4.      To discuss age specific issues necessary in understanding the magnitude of the burden of sleep problems, which is confronting the present clinical care and population health in the United States.

5.      To review the modifiable risk factors which can be reduced or eliminate through an educated effort to improve sleep in a population perspective.

6.      To identify solutions and review cost effective strategies available to decrease and eventually control some of the aspects previous mentioned.

  1. To highlight the cost of failure to identify these issues as a real public health problem.

8.      To briefly review some of the Internet resources correlated with sleep: Federal organizations, transportation and industry related organizations linked with sleep, Medical organizations, and Support Groups for people with sleep disorders.      

 

DEFINITIONS. SLEEP PHYSIOLOGY

        According to the Webster dictionary, sleep is: “the natural periodic suspension of consciousness during which the powers of the body are restored.”  The sleep process is a very complex amalgam of physiological, biochemical, and behavioral events, which are absolutely necessary for the normal function of the body and maintenance of an internal state of homeostasis.

        The total daily sleep time in hours for man is estimated at approximately 8 hours with a sleep cycles of about 90 min in length.  This may seem to be relatively low in comparison to our mammalian “relatives”: the Marsupialia order needs up to 19.4 hours of sleep, Insectivora up to 15.6 hours, Chiroptera (bat) 19.9 hours, Edentata (armadillo) up to 18.1 hours, Rodentia (squirrel) up to 16.6 hours, Carnivora up to 15.8 hours.  In our Primates Order the length of time in sleep varies between 8 hours for man to 17 hours for the owl monkey.

        An interesting phenomenon is that the sleep cycle length differs for each of these orders.  The human sleep cycle length (of 90 min) is defined by the total time needed to alternate one period of quiet sleep (stage 1 to 4) with one period of REM (dream) sleep.  It is far longer than that of any other species, with the exception of the Asiatic Elephant (124 min).  Next comes the chimpanzee (85min), followed by the horses’ (60 min), but most of the sleep cycles lengths are between 7 and 40 min.  This appears to be correlated with an increase in maturation, brain weight, and encephalization.  Sleep physiologists suggest that sleep organization (represented by the cycle length in min) is at least as important as the sleep time. (1)

        Human sleep, as that of all mammals and birds, is composed of two separate states: NREM (non-rapid eye movements) and REM (rapid eye movement).  NREM is further divided into four stages (stage 1, 2, 3 and 4) through measurements of EEG (electro encephalographic activity).

 Stage 1 is superficial sleep (the easiest to be aroused from) – it persists for 1 to 7 min at the sleep onset. 

Stage 2 represents the gradual progression of sleep  (it is harder to be aroused by stimulus than during stage 1) - it lasts between 10 and 25 min. 

Stage 3 and 4 represent deep sleep (from which it is the hardest to arouse)- with stage 3 lasting only few min. and stage 4 lasting anywhere between 20 and 40 min.

Body movements are usually present in NREM sleep, and are more frequent in the first and second stages.

REM sleep is very different; total muscle atonia (relaxation) is present and episodes of bursts of rapid eyes movement seem to accompany abundant mental activity associated with dreaming - which is recalled if we are suddenly aroused from this stage.  REM lasts only a few minutes at the first cycle and progressively increases in length across the night, with stage 3 and 4 occupying less and less time in REM favor.  The last third of the night seems to be dominated by REM.

The pattern of sleep is affected by age in a consistent way.  Stage 3 and 4 can decrease remarkably with age – abundant in infants and children, they tend to be reduced or even disappear after reaching sixty, especially in men.

 REM (the “dreaming stage”) may remain well preserved into healthy old age but can decline if any organic brain dysfunction appears, or under the influence of certain medications. (2)

The mental concentration founded while being awake which can influence breathing, body position, etc is lost in sleep.  Further research is necessary for the complete elucidation of all compensatory mechanisms involved in sleep physiology. 

Some of the parameters used in the determination of daily sleep quality are: the total time in sleep in 24 hours, the rhythmicity and the continuity of the sleep, knowing that going to bed at approximately the same hour and sleeping without interruption improves the sleep pattern and indirectly, the general health.

                     The demands for sleep differ from each individual and are affected by age.   A minimum of 8 (7 to10) hours of nightly sleep is believed to fulfill the basic biological needs of an adult.  Neonates and babies in their first months of life spend about 80% of their time sleeping with a 30% to 60% of total sleep in REM (dreaming stage).  REM is believed to be associated with the rapid rates of body system maturation, especially of the nervous system.  As children grow into adults, the need for sleep seems to decrease, (9 to 12 hours for children and adolescents, progressively declines to 8 hours).  The sleep demand increases to over 8 hours with disease, strenuous intellectual or physical activities, psychological distress, grief, etc.

          The biological clock” (5), historically ascribed to the association with the solar day, is represented by the 24 hours cycle, and resides in the brain of mammals.  The sunlight appears to be the cue, which resets this clock on a daily basis.

The Sleep-Wake cycle is not the only system that is highly dependent of this circadian rhythm; several other body systems and functions have a 24 hours time frame: rest – activity, mental functions, cardiac output, endocrine system secretions, temperature regulation, and oxygen consumption.

The retinal rods and cones had been considered to be the receptors responsible for light detection until recently.  Extended research is proving that additional subsets of nerve cells are involved, which depend on light sensible pigment called melanopsin thru a non-visual but light – sensing system.  These are similar with the pupillary light reflex system (6). The biological rhytmicity and circadian cycles are extremely important in the maintenance of the sleep-wake system because it regulates a normal healthy balance between our body and the environment.  Due to the increased demands of the industrial era, 7 hours or less of sleep is becoming increasingly common.  The rhytmicity of sleep is frequently dictated by others daily activities.  A great shift in the diurnal pattern of human activity is happening due to shift work, military operation, jet lag, space flights, or simply the exposure to more entertainment possibilities during the night (ranging from “Las Vegas World” vacation time to TV, the Internet, and 24 hours groceries stores.) 

    The short and long term results of not getting enough quality sleep are not entirely elucidated at this time, but could be more serious and extensive than previously believed.  Numerous diseases, which until recently had been attributed exclusively to smoking, obesity, and sedentary life – as well as accidents of all kind, seem to be linked with sleep related issues.

 

SLEEP BEHAVIORS. SLEEP DISORDERS

            One of the first steps in assessing a potential sleep problem is determining sleepiness.

       This is most evident when, regardless of the effort to maintain wakefulness, unintended episodes of sleep may occur during routine daily activities.  Sleepiness may resemble other more subtle forms of manifestation: difficulty concentrating (frequently appearing as the first symptom present especially in school-age children), memory lapses, and fatigue.  Yet symptoms can be as severe as lethargy and loss of energy, which is frequently associated with lack of initiative and emotional lability. (3)    

Sleepiness can be caused by lifestyle factors including but not restricted to: wakefulness at nighttime when the body expects sleep, insufficient amount of time in bed, disrupted (fragmented sleep) by external factors (TV, a snoring bed partner, sick children or nursing baby, etc.), irregular sleep schedule, use of prescribed or illicit drugs, alcohol, tobacco, or by sleep disorders; such as sleep apnea, insomnia, restless legs syndrome, and narcolepsy (4).

         Methods used for reversing sleepiness highly depend of the cause of sleepiness and in a majority of cases; one single night of extended sleep is not enough.  It is recommended to gradually move to earlier bedtimes and to increase the length of nocturnal rather then diurnal time spent in bed.  If daytime naps are chosen, it is recommended to take them at least four hours prior  to the usual nocturnal bedtime in order to avoid a disrupted sleep during the subsequent night. (7) (Sleep hygiene concepts available at the end of the chapter.)

        In order to determine the gravity of the sleep burden and the necessity of public health approach and active intervention, it is first necessary to assess the most common sleep disorders.  Sleep disorders fall into one of the following categories: Hypersomnia, Insomnia, Disorders of wake /sleep cycle and Parasomnias.

 

Hypersomnia (or sleeping too much) was in the past attributed to laziness, a negative personality, or depression.  In fact it is a symptom associated with sleep apnea, narcolepsy and idiopathic CNS Hypersomnia..

             Obstructive sleep apnea (OSA), with prevalence in 2% to 4% of the adult population and 3% prevalence in children from preschool through junior high school, seems to have a great impact in the health of the general population, especially since diabetes effects only 1-2% of the population, asthma 4%, and colon cancer a mere 5%.  This disease can be very debilitating and is associated with numerous other chronic health problems.

OSA is “a breathing disorder characterized by brief interruptions of breathing” (NIH - Sleep apnea definition) during sleep, lasting a minimum of 10 seconds.  The airflow is usually blocked resulting from the collapse of soft tissue at the throat level.

            The typical patient with sleep apnea was believed to be the middle aged, overweight male, which usually snores loudly - especially when sleeping on his back. The disease is far wider spread, appearing in both sexes, overweight and normoponderal, all ages, and furthermore is not necessarily associated with snoring. Recent studies highlighted the enormous number of potentially sleep apneic patients who had not yet been diagnosed, as well as the correlations between sleep apnea and many chronic diseases: cardiac insufficiency, hypertension, myocardial infarction, stroke, depression, adult onset diabetes, chronic renal insufficiency etc.  Successful management and treatment of sleep apnea sometimes improves the co morbid diseases. 

             Another serious aspect was examined through “The Stanford study on long –haul truck drivers” showing prevalence for OSA in 80% of drivers with a 10% severe cases-condition.  This can obviously lead to serious accidents. (The socio-economic impact of this problem will be further discussed in this chapter)

       OSA can be detected with screening questionnaires (see the examples at the end of the chapter) and is diagnosed using a specific medical noninvasive procedure named Polysomnogram.  The treatment for OSA is the nasal continuous positive airway pressure (CPAP) – a permanent but extremely effective treatment, with only minor secondary and adverse effects.  The patient is sleeping with a nasal mask attached thru a hose to a small machine.  This creates positive pressure in the collapsed airways by “blowing” room air thru the nostrils, which allows the airway to remain open during sleep.  The treatment has virtually no contraindication, and the pressure of the air can be adjusted based on the patients’ needs.

Other treatments like surgical-tracheostomy, uvulopalatopharyngoplasty, the use of different oral/dental devises, or simple weight reduction may also be effective based on each case.

 

Narcolepsy used to be considered a rare disease – but the prevalence is 0.2-1.6 per 1000, affecting at least 250,000 people in the USA, so it is relatively as common as multiple sclerosis or Parkinson disease.  It is an extremely disabling and is often undiagnosed.  Narcolepsy consists of excessive daytime sleepiness with abnormal REM sleep: sleep paralyses, hypnagogic hallucinations, and cataplexy (pathological equivalents of REM sleep).  It is the second leading cause of excessive daytime sleepiness, after obstructive sleep apnea.  Many of narcoleptic patients are psychosocially impaired in all areas: school, work, interpersonal relations, leisure, and are more prone to accidents compared to patients with epilepsy, even with treatment.

The cause of narcolepsy with cataplexy appears to be the lack of hypocretin–1 and hypocretin-2 (known also as orexin A or B), which can be measured in cerebrospinal fluid.  Another marker, Human leukocyte Antigens (HLA-DQB*0602) can be found in up to 90% of the patients with narcolepsy and cataplexy.

             Narcolepsy can also be detected with screening questionnaires (eg. the Epworth Sleepiness Scale) or diagnostic testing given by the use of a nocturnal polysomnography (PSG) and a multiple sleep latency test (MSLT) – both noninvasive but relatively expensive procedures.

             Narcolepsy is actually treated with Stimulants, Anticataleptic Compounds, and Hypnotic Compounds.  Strategic time napping can also help reduce the symptoms of sleepiness.

 

Idiopathic Central Nervous System Hypersomnia is a condition similar to narcolepsy, but has Hypersomnia as the only symptom.  The prevalence has not been fully investigated, yet the diagnostic and treatment are similar to that for narcolepsy.

 

Insomnia is a symptom in many underlying medical, psychiatric, and psychological conditions.  It is arbitrarily categorized as transient short term (lasting up to one month) or chronic (longer than one month).  It consists of difficulty in the initiating or maintaining sleep and/or the feeling that sleep is not refreshing and restorative. The prevalence of insomnia in the USA is 30% with high severity in up 10% of the population, women being more commonly affected than men.

The screening questionnaire can prove useful in the detection of insomnia for patients, which many not appear to be affected by this disease.  Most of these cases can be effectively identified, diagnosed, and managed in a primary care practice, if the physician should choose to screen for insomnia and prioritize the detection of the underlying causes.  Once the primary condition is treated, the treatment for persistent insomnia is a combination of pharmacologic and behavioral therapy.  Short-term insomnia can be treated with sedative –hypnotic treatment; or benzodiazepines and zolpiderm.  The risk of dependence, tolerance and abuse in “insomnia population” has been greatly overrated.  Aggressive management is recommended rather than more conservative treatments due to the consequences on mood and performance.

 

Disorders of the wake /sleep cycle are primary (delay sleep phase syndrome, advanced sleep phase syndrome, irregular sleep phase syndrome, non-24 - hours sleep phase syndrome) due to the malfunction of the internal biological clock and secondary, usually due to environmental effects as shift work and jet – lag.  The primary disorders are relatively rare and possibly hard to diagnose and are frequently mistaken for Insomnia / Hypersomnia, psychiatric conditions, or substance abuse.  The prevalence in shift workers in the USA is estimated at 20%.

 

Parasomnias, often misdiagnosed as psychiatric disorders, cover a wide variety of sleep behaviors, which are many times peculiar, distressing, sometimes dangerous and frightening for the patients and their families.  They are disorders characterized by undesirable physical phenomena (motor, verbal or experiential) accompanying sleep (specific stages or sleep –awake transition phase).  Parasomnias are also categorized as primary (referring directly to sleep) and secondary (other diseases manifest during sleep like seizures, arrhythmias, gastroesophageal reflux). The most important primary Parasomnias are as followed:

Nightmare disorder (dream anxiety attacks) or frightening dreams during the REM period are frequently associated with tachycardia and tachypnea.  The patient usually wakes up diaphoretic and is able to recall the nightmare. The prevalence on children 3-5 years is 10-50%, in adults is unknown but up to 50% report occasional nightmares.  Women usually report nightmares more frequently than men (2-4: 1).

Sleep terror disorder is manifested with loud screaming due to extreme panic, usually occurring in stage 3 and 4 of sleep (NREM).  The patient can “respond” to his terror by motor activities without subsequent recollection of those episodes.  It is estimated in the USA a prevalence of 1 to 6 % in children and for adults up to 1%.   It appears that in general male children have more sleep terrors than females.

            Sleeps waking disorder consists of complex automatic behaviors a patient is completing during the deep stages of sleep (3 and 4), such as moving in and out of the bedroom, bumping into objects, etc. without subsequent recollection of the episodes.  The prevalence is estimated at 5% in children with clinical samples as many as 30 % in children and 7% in adults.

 

REM sleep behavior disorder is a “dream – enacting behavior” manifested by talking or yelling, sitting or jumping out of bed, arm flailing, punching or kicking etc. The acute form is relatively common during ethanol (alcohol) or sedative – hypnotic medication withdrawal.  The chronic form is often familiar with a prevalence of 0.5%, generally males are more frequently effected by this disease.

            Restless legs syndrome and periodic limb movement disorder (RLS and PLMD) are common disorders and sometime coexisting in the same patient.  They consist in involuntary limb movements with a striking periodicity, possibly originating from a subcortical region and regulated by some rhythmic fluctuations in the brainstem (Sat Sharma article).  The result is insomnia due to RLS and excessive daytime sleepiness for PLMD; with a prevalence rate of 10% in the general population and a good chance of increasing with age.  It is estimated that PLMD is as high as 40 % in the population over 65 years of age, which speculates one of the reasons for why it is believed that the sleep of the elderly is poor and restless.

                      Nocturnal sleep related eating disorders, with two thirds of patients consisting of females.  This disorder consists in a nightly binging, during full awaking from sleep or a partial arousal, with variable recall the next day.  Interestingly, the affected person can eat anything; from cat food to ammonia cleaning solution, from  “sugar and salt sandwiches” to spaghetti “served ” directly with the hands.  Purging does not occur, and frequently injuries appear during these events.

Parasomnias can be detected with a screening questionnaire (see annex 3) but diagnosis should be done by a corroborating psychiatric, neurological and sleep – wake interviews and examinations with extensive polysomnographic monitoring (PSG), and possible daytime multiple latency testing (MSLT).

 

OTHER SLEEP RELATED ISSUES:

             SIDS (Sudden Infant death syndrome), the worst tragedy parents can face, is defined by the sudden unexpected death of an apparent healthy baby which remains unexplained even after all postmortem investigation; including the infant autopsy, investigation of the scene, and condition under which the baby died, and the family medical history.  Since medicine does not have an answer for this condition, parents frequently live their life after with a feeling of terrible guilt that perhaps something could have been done to prevent the death of their baby.  The prevalence of this syndrome in the USA dropped dramatically from 1.53/ 1000 live births in 1980 to 0.67 /1000 live births in 1998 (CDC and National Center for Health Statistics), proving that the national effort for parents education is working.  These educational efforts focus on knowing that the risk of SIDS can be decreased by simple means such as the child placement in the crib (supine position on a firm mattress with no stuffed animals, blankets, or other objects in the crib), not overheating the infant, avoiding smoking around a baby, and providing special care for prematures and other babies at risk (home monitoring systems, special programs for clinical management offered by different communities etc.)

 

              Sleep and Obesity currently represents an important public health burden due to obesity being an epidemic in the USA population with a 58% ratio in men, 54% in women, and a 15% in children in the population being diagnosed as overweight.  Obesity has a profound impact on a persons’ breathing; obstructive sleep apnea is very frequent and an underdiagnosed phenomenon in this population.

       It is possible that volitional sleep deprivation, and /or sleep disorders with a result in poor, inefficient sleep are causal factors related to this obesity epidemic, knowing the association of sleep disorder breathing with glucose intolerance and insulin resistance.

 

              ADD (Attention –deficit hyperactivity disorder), a disease with increase prevalence in recent years, seems to be highly correlated with poor sleep.  A new research remarks that ADD may be overly diagnosed; due to symptoms related with sleep disorders; which include poor concentration and inattentiveness.  It is also known that sleep deprived children are usually more aggressive, frustrated, oppositional, and have an increase in learning disabilities, just because they are tired.

       

Volitional sleep deprivation is not a disease but is, by far, the most common cause of sleep disturbances, particularly for excessive daytime sleepiness.  Driven mostly by social or economic factors, this chronic sleep deprivation has a great prevalence in the USA, with 20% of working population in shift work and with 49% of the population reporting difficulty getting sufficient sleep (Gallup Survey, 1995 NSF.)  It is known that Americans today sleep 1.5 hours less than a century ago, without any proof that they require less sleep.

A majority of time many people have given up sleep to be more productive or to achieve educational goals, especially in the young population, frequent sleep deprivation is wrongly glorified and assimilated in contemporaneous culture, yet the price for the individual and society is not analyzed.  Perceived as a “waste of time” or a character defect-particularly for going to sleep early, napping or sleeping in weekends, sleep is to often attributed to laziness, work avoidance, depression or boredom, pushing the society to sleep deprivation, with general loss, impaired judgment, reaction time, learning abilities and reasoning. 

 

PUBLIC HEALTH ISSUES

Sleep is becoming a public health priority, not yet thoroughly analyzed, but with profound social and economic implication – highlighted in some of the cost analyses, still incomplete until this date:

   The National Commission on Sleep Disorders considers that sleep loss alone is costing, through higher stress and reduced work productivity, about $150 billion, a lost supported by businesses.

The National Sleep Foundation (NSF) reports over 70 million American Adults (33% to 40% reported in 1999) with a hazardous level of sleepiness.  Dr Martin Thory emphasized that this population contributes to more than 100,000 police reported crashes, causing 1,500 death (40,000 are reported by Gofrey) and 71,000 injuries (250,000 by Gofrey) each year in the USA alone.  More than half of those car crashes involved drivers between the ages of 15 and 24, who were estimated to sleep an average of 6 hours (instead of 9 hours, which is usually recommended for this segment of the population.)

     NHTSA estimated the crashes monetary losses alone to be $12.5 billion ($43.15 billon and $56.02 billon from other sources) every year.

    The implication of sleepiness in traffic accidents has been studied extensively: according to a 1999 survey conducted by NSF, 62% of adults declared that they have driven while drowsy with a 27% admittance to falling asleep behind the wheel – so about 100 million people have driven drowsy and 14 million fell asleep driving.  The work related accidents caused by sleepiness are estimated to produce 945,000 disabling injuries with 5,565 fatalities, and a cost between $43.15 and $ 56.02 billion every year, and a direct cost of $24.7 billion (National Capital Center for cranial pain.)  It appears that staying awake between 17 and19 hours decreases the reaction time up to 50% - even slower than after drinking 50 mg/dl of alcohol (research done in occupational and environmental medicine, which proves that cumulative effects of moderate sleep deprivation can produce cognitive and motor impairments similar to legal levels of alcohol intoxication.)

Working over 60 hours increased the odds of accidents by 40%, and working night shift increased the odds by 6 times (AAAFTS).

              According to NSF, 60% of children are complaining of feeling tired during the day with 15% of them admitting they fall asleep in school.  The cost and consequences of this problem are not yet evaluated but the burden in health and education is obvious.

Television and videos and electronic games are “blamed” for many children sleep and psychological problems, affecting children as young as 1 to 3 years of age.  It is estimated that the average American child spends 4 hours per day in front of a television screen, which causes major changes in the total sleep time, dream content, sleep fragmentation, and biologic rhythms.  Sleeping late and superficial becomes a habit children carry throughout their life.

 Although the cost of sleep disorders has not yet been sufficiently studied, the direct cost of sleep apnea in USA in 1990 was $ 275 million, based on 70 sleep laboratories with a capacity of 5 to 6 patients per night.  But sleep apnea alone, is considered to be associated with a 23 - fold increase in the risk of a heart attack, 2.7 fold increased in vascular death, 27-47.8% in high blood pressure, and up to 9 times increased in motor vehicle accidents.  Mortality rates for mild to severe untreated sleep apneics are 2.1% (for mild) and 10.6% (for severe), but the treatment fully reverses the disease with 0% mortality in treated patients. 

The direct cost of insomnia in 1990 was $15.4 billion, which was spent primary on physician visits and prescription medication.  It does not include over the counter pills, herbal treatments, “miracle mattresses” and all the other “commercial remedies.”              Narcolepsy was reported as being responsible for 18.9% of industrial injuries, due to failure to recognize and properly treat it.

Today the costs have increased significantly, but the treatments for sleep diseases is usually very efficient, so early recognition and treatment of these diseases can be highly efficient in terms of years of lost life and economical costs.  The consequences of not detecting sleep diseases have been well documented.  They include impairment in performance, irritability, memory loss, mood swings, too often treated as psychiatric diseases, errors which result in additional unevaluated cost for society.

Night shift workers schedules are associated with additional problems: ulcers, gastrointestinal disorders, increased respiratory infections risk, attacks in asthmatic patients, headaches, low back pain, susceptibilities to stress which potentially increases smoking and the alcohol use, emotional and marital difficulties, memory lapses, and an overall decline in general health and well-being of the worker. This increases the medical cost, which the employer and society health expenditures must cover.

Industrial accidents due to fatigability can be devastating, taking just these few examples: Three Mile Island, Chernobyl, Challenger, Bhopal, or Exxon Valdez, which were proved to be the result of sleepiness among workers.  Marked increase in job related errors due to tiredness were cited as factors in California Rancho Seco nuclear reactor automatic tripping and the failure to regain control of the plant.  The skipper of the World Prodigy, responsible for the 300,000 barrels of oil dumped into Narragansett Bay, had not slept for 36 hours when the accident occurred.  Similarly, the accidental drainage of

18,000 lbs of oxygen from Columbia space shuttle in 1986 escaped detection because the operator was extremely fatigue.  Sleepy employees, with potentially dangerous degree of impairment, comparable to substance abusers are a worldwide reality.  Many other errors related to sleepiness are documented in gas work employees, truck drivers, train and pilots engineers, etc.  An estimated 80% of policemen admitted they have fallen asleep at least once a week when working night shifts.  Overall, out of all nightshift workers, 50% fall asleep weekly, 75% fight with sleepiness every night shift, and 20% fall asleep at any given night on the job.

Additional information about sleep in adults between 55 to 84 years of age were published on April 1, 2003 by National Sleep Foundation (http://www.sleepfoundation.org ) and represent the results of a national survey, among a random sample of 1,506 American residents. 

        In conclusion, it is helpful to review the Findings National Commission on Sleep Disorder Research from 1992: “millions of Americans are affected by sleep disorders, sleep disorders affect all age groups; minorities and the poor have extremely limited access to sleep medicine, …, America is seriously sleep –deprived with disastrous consequences, …,the cost in dollars ,lives and human suffering is very high ,… ,pervasive failure of knowledge transfer (exist) … they are many serious gaps in research,…, and alarmingly few young investigators (are) in pipeline.”

 

PUBLIC HEALTH INTERVENTIONS

            The Public Health Service, National Institute of Health designed a complex National Sleep Disorders Research Plan since January 1996 and acknowledged the need of a coordinated Public Health Intervention since 1998 with the establishment of a National Commission on Sleep Disorder Research Plan, multidisciplinary in nature.

 The vision was “to improve the health, safety and productivity of Americans.”

The recommendations for Public Health as well as for patient-oriented research were focused on epidemiological techniques, behavioral science and clinical outcome research with experimental therapeutics. These include screening methods for sleepiness and sleep disorders in high-risk population; programs to combat sleepiness, with the goal of improving safety and productivity in healthy workers as well in population with sleep disorders.  Development of technologies for sleepiness detection and monitoring was also proposed, as well as an evaluation of the utility of interventions that ultimately try to counteract sleepiness in certain situations (eg. in military).

            Extended research for the screening of sleepiness and sleep disorders are currently being tested; yet a definite method has not been determined.  Multiple studies were performed to assess the screening value of the following detection and prevention of sleep disorders: home monitoring systems, actigraphy, oximetry, electrocardiogram (EKG), questionnaires, sleep diaries, and artificial neural networks (ANNS).  These tests provided mixed results; therefore a screening method generally agreed upon has not been determined. Encouraging results appear to be linked with oximetry and electrocardiogram analysis.

Research on the shift work has focused on new schedules, daytime light simulation (bright lights), and melatonin administration to the night workers.

The Industrial Sleep Management program was developed because the workplace can be extremely complex and safety requires attention, decision – making capacity, memory, and the ability to perform complex sequences at any given time.

The need for legal rest requirements is obvious for driving or operating “a tractor, a convertible, a truck, a plane, a train, a space shuttle, or a space shuttle with nuclear cargo.”  They are extremely varied: up to 100 hours/month for the commercial airline pilot, up to 260 hours/month for the truck driver and over 360 hours/month for the shipboard personnel.  The absence of legal requirements for accommodations and insufficient education regard sleep, requests an initiative and future interventions.

The Job Accommodation Network (JAN) provides ideas of intervention for workers with sleep disorders (http://www.jan.wvu.edu/media/Sleep.html.)  Reports show that 50% of all these measures cost less than $500, yet employers report to have benefits exceeding $5,000; a worthwhile investment.

Shift workers as well as the general population need to have increased awareness of the short and long term effects of improper sleep, with a priority on the education of children and adolescents.  Current nationwide efforts to increases sleep awareness are concentrated during the National Sleep Awareness Week (March 31 –April 5) when the mass media is stimulated to participate in the public education of sleep problems.  The intervention includes: lectures, conferences, and workshops for the general public.  Brochures on healthy sleep habits, SIDS prevention, snoring, insomnia, and other sleep disorders are provided. 

One of the most successful and renowned programs is represented by the NHLBI Launches Sleep and Children Education Program, with Garfield the cat as “spokescat.”  The goal of the campaign is to encourage children to get at least nine hours of sleep each night, and the theme is “Sleep Well. Do Well.”  One-way used to increase awareness in children is through the website http://www.nhlbi.nih.gov/health/public/sleep/starslp/ where children can play the “Garfield Sheep Shot Game” which promotes sleep education through entertainment.

Although this attempt is well intended and formulated in such a way as to promote children to follow better sleeping patterns, it fails to be widely advertised which defeats the purpose of reaching a widespread audience.

Researchers have demonstrated that performance in elementary school is greatly improved by starting the school day later in the morning, which allows school children to gain additional hours of sleep.  Unfortunately no national steps have been taken by the department of education to generalize the practice of starting the school day at a later hour.

Health information dissemination regarding all of these major sleep related problems; if coordinated by National Institute of Health, Federal agencies and public entities, and nonprofit organizations; could have a huge impact and potential success in increasing the general health of our population.  The result of the smoking campaign in the USA is an example of how behavior changes can be stimulated by education, persistence, and a collective effort.  In addition it should be far easier to persuade the population to respect their internal biological clocks rather than to give up a highly addictive substance such as nicotine contained in cigarettes.  Mass media cooperation towards the spread of informative public messages in regards to sleep deprivation must be encouraged.  Pools should be conducted, prior to the release of widespread public broadcasting, on the impact of advertising slogans such as  “Sleep deprivation can kill.”

Sleep education among all physicians, targeted on Medical Schools programs, postgraduate trainings and continuing medical education levels appears to be a high necessity, knowing that the co morbidity between sleep disorder and other diseases often bring the typical sleep apneic patient first to the cardiologist or the nutritionist.  

Extended efforts of public health interventions performed lately were focused on parents’ education regarding baby sleep hygiene and the promotion of back sleeping for all infants.  Educational efforts and public interventions have greatly reduced the prevalence of SIDS, which out of all sleep diseases has been most drastically addressed.  This demonstrates that widespread public heath interventions can effectively reduce morbidity and mortality in the general population, which encourages future efforts in this field.   

 

 

 

*SLEEP HYGENE RULES:

§         Sleep at nighttime; choose your bedtime at least 1-2 hours before 12 pm.

§         Try to avoid napping too much (if any) during the daytime-this might be a reason for being less sleepy and eventually sleep will be fragmented at night.

§         Follow the same regular schedule, with approximate same hour of bedtime and waking time.

§         The natural light during the daytime hours especially in the afternoon promotes a good sleep.

§         Physical exercise during the day, light exercise in the afternoon, at regular time contributes to better sleep.

§         Avoid copious late dinners-eat dinner around 6pm and if necessary eat something light like a cup of warm milk, some cereals or crackers etc. before bedtime.

§         Avoid Caffeine late in the day-most tea and pop beverages contain caffeine!!!

§         Do not smoke before bedtime –nicotine is a stimulant too!

§         Alcohol may enhance early sleep but the sleep is highly fragmented and sleep maintenance is poor with early awaking in the morning-so alcohol at dinner does not necessarily relax!!!!

§         Keep the bedroom for sleep –avoid TV in the bedroom and falling asleep with the TV on -it is an unhealthy behavior more and more spread in general population, which fragments the sleep and possible doesn’t allow the body to relax and go to deeper stages of sleep.

§         Bedroom should be used just for sleeping –a period of 15-20 min should be enough to fall asleep –if not is highly recommended to leave the bedroom and come back when sleepy; worrying about sleep is not good either-mental games (counting, positive thinking etc) usually help to eliminate or reduce the tension.

§         Persistent problems (the primary care physician and sleep disorder specialist should assess over 2 - 3 weeks).

 

                             

 

EXAMPLES OF SLEEP QUESTIONNAIRE

Different questionnaires are available free on Internet sides. Some examples are

 Screening for Sleep Apnea at

§        A.P.N.E.A. NET found on http://www.apneanet.org/question.htm.

§        Quiz from Phantom of the Night at http://www.healthyresources.com/sleep/apnea/question/quiz.html

Screening for Parasomnias at

§        http://www.postgradmed.com/issues/2000/03_00/schneck.htm  

Sleep self-evaluation form for Parkinson patients:

·        http://www.parkinson.org/qsleep.htm

 

   

FEDERAL ORGANIZATIONS, TRANSPORTATION AND INDUSTRY RELATED ORGANIZATIONS LINKED WITH SLEEP(*)

·        NASA/AMES Fatigue Countermeasures Program-for studies correlated with fatigue. *

http://www.kynd.net/-outspace/5_00nasa.htm 

·        National Center for Sleep Disorders Research *

               Two Rockledge Center, Suite 10038

               6701Rockledge Drive, MSC7920

               Bethesda, Maryland 20892-7920

               301-435-0199

            http://www.nhlbi.nih.gov/health/public/sleep

       http://www.nhlbi.nih.gov/

Information Center at P.O.Box 8057

Gaithersburg, Maryland 20898-8057 

           1-800-222-2225

            1-800-222-4225(TTY)

             http://www.nih.gov/nia

      http://www.niams.nih.gov/ 

     http://www.immunesupport.com/library/powersearch2.cfm/T/CFIDS_FM/cat/research

       http://www.nichd.nih.gov/new/releases/sidsbrainstem.cfm?from=sids

      http://www.nimh.nih.gov/

      http://www.ninds.nih.gov/

      http://www.nhrc.navy.mil/splash/home.html

       http://wrair-www.army.mil/

 

 FEDRERAL TRANSPORTATION ORGANIZATIONS-POSIBLE SOURSE IN SLEEP RESEARCH

 

     http://www.fhwa.dot.gov/

     http://www.fra.dot.gov/site/index.htm

       http://www.fta.dot.gov/  

     http://www.nhtsa.dot.gov/

      http://www.ntsb.gov/

      http://www.dot.gov /  

 

INDUSTRY SLEEP RELATED ORGANIZATIONS

 

      http://www.aaafoundation.org/home/  

       Operation Lifesaver@

      http://www.trucksafety.org/default.asp?contentID=481

         http://www.ots.ca.gov

             http://www.health.gov/NHIC/NHICScripts/Entry.cfm?HRCode=HR0160

       http://www.nsc.org/ 

      http://www.nhtsa.dot.gov/

 

SLEEP SOCIETIES

 

One Westbrook Corporate Center

Suite 920

Westchester, IL 60154

708-273-9335

http://www.dentalsleepmed.org/

11030 Ables Ln

Dallas, TX 752294593

972-243-2272

      http://www.aarc.org/

One Westbrook Corporate Center

Suite 920

Westchester, IL 60154

708-492-0930

http://www.aasmnet.org/

3300 Dundee Rd

Northbrook, IL 60062

847-498-1400

http://www.chestnet.org/

1424 K Street NW,

Suite 302

Washington D.C. 20005

202-293-3650

http://www.sleepapnea.org

1740 Broadway

New York, NY 10019-4374

212-315-4660

http://thoracic.org/

One Westbrook Corporate Center

Suite 920

Westchester, IL 60154

708-492-0930

http://www.apss.org/

8310 Lieman Rd

Lenexa, KS 66214

913-541-1991

      http://www.aptweb.org/

       501 Wythe Street

Alexandria, Virginia 22314

703-683-8371

http://www.bettersleep.org

475 Riverside Dr

6th Floor

New York, NY 10115

212-367-4370

      http://www.brpt.org/

G-3237 Beecher Rd

Suite M

Flint, MI 48532

810-733-8338

      http://www.americasleeps.com/

      10921 Reed Hartman Highway

       Suite 119

       Cincinnati, Ohio 45242

       513-891-3522

       http://www.narcolepsynetwork.org

1522 K Street, NW

Suite 500

Washington, D.C. 20005-1253

202-347-3471

http://www.sleepfoundation.org

819 Second Street SW

Rochester, Minnesota 559002

507-287-6465

htyp://www.rls.org

rlsfoundation@rls.org

11676 Perry Highway

Bldg.1, Suite 1204

Wexford, Pennsylvania 15090

724-935-0836

http://www.thesdds.org

One Westbrook Corporate Center

Suite 920

Westchester, IL 60154

708-492-0930

http://www.aasmnet.org/

PO Box 591687

174 Cook St

San Francisco, CA 94159-1687

http://www.sltbr.org/

http://bisleep.medsch.ucla.edu

 

SUPPORT GROUPS FOR PEOPLE WITH SLEEP DISORDRES AVAILABLE ON LINE

For Sleep Apnea

For narcolepsy

For Restless Legs Syndrome

 

REFERENCES

    1., 5 Kryger Meir, Roth Thomas, Dement William PRINCIPLE AND PRACTICE OF SLEEP MEDICINE, 1989 W.B.SAUNDERS COMPANY, chapters 4: Mammalian sleep, page 39-41. ; 5-section 4, Chronobiology

2. Printz PN, Perskin ER, Vitaliano PP, et al: Changes in the sleep and waking EEGs on nondemented and demented elderly subjects. Jam Geriatric Soc 30(2): 86-93, 1982

 * HTTP://www.stanford.edu/-dement /fed.html Federal Organization, Federal Transportation and Industry related Organizations updated october1, 1998

3. Dinges D.F., Broughton, R.J.  Sleep and alertness. Chronobiological, Behavioral and Medical Aspects of Napping. New York; Raven Press, 1989

4. Guilleminault, C., Carskadon, M. Relationship between sleep disorders and daytime complaints. In: W.P.Koeller, P.W. Orvin (eds.), Sleep, page 95-100 Basal, Switzerland; Karger, 1977.

*6. King –Wai Yau et al (Howard Huges Medical Institute) Tracing the neural circuitry of “Second Sight”, article published in “Science”, February 8, 2002

7. Dingers D. Napping Strategies in Fatigue Symposium Proceedings ,pp47-51 NTSB and NASA Ames Research Center ,Nov 1,2 ,1995

8. National Commission on Sleep Disorders Research. Report of the National Commission on Sleep Disorders Research. DHHS Pub.Washinghton, DC, 1992

9. Andrade MMM, Benedito-SilvaAA, Domenice S, Arnhold IJP, Menna-Barreto L. Sleep characteristics of adolescents: a longitudinal study .J Adol Health 1993;

10. NIH National Sleep Disorders Research Plan, January 1996 at http://www.nhlbi.gov/health/prof/sleep/reschpln.htm

11. Kapur V, et al. The medical cost of undiagnosed sleep apnea. Sleep 1999; 22(6):749-55

12. Sadeh A, Hauri PJ, Kripke D, Lavie P., The role of actigraphy in the evaluation of sleep disorders. Sleep 1995; 18:288-302

13. Brown AC, Smolensky MH, DAlonzo GE, Redman DP. Actigraphy: a means of assessing circadian patterns in human activity.Chronobiol.Int.1990; 125-133

14. Lavie P, Hypertension in sleep apnea syndrome: lessons from nearly 8,000male patients. Sleep 1999:22:s104

15. Ter’an-Santos J, et al. The association between sleep apnea and the risk of traffic accidents. New England Journal of Medicine 1999; 340:847-51

16. Chervin RD, et al. Cost utility of three approaches to the diagnostic of sleep apnea: polysomnography, home testing, and empirical therapy. Annals of Internal Medicine1999; 130(6):496-505

17. Peker Y, et al. Reduced hospitalization with cardiovascular and pulmonary disease in OSA patients on nasal CPAP treatment. Sleep 1997;20(8):645-53. .

18. Nieto FJ,  Young TB, Lind BK, Shahar E, Samet JM,  Redline S, D'Agostino RB, Newman AB, Lebowitz MD, Pickering TG: for the Sleep Heart Health Study, Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study., JAMA 283:14, 1829-36 Apr, 2000

19. Kapur VK, Rapoport DM, Sanders MH, Enright P, Hill J, Iber C, Romaniuk J, Rates of sensor loss in unattended home polysomnography: the influence of age, gender, obesity, and sleep-disordered breathing., Sleep 23: 12, 682-8, Aug, 2000 

20. Gottlieb DJ, Yao Q, Redline S, Ali T, Mahowald MW, Does snoring predict sleepiness independently of apnea and hypopnea frequency? Am J Respir Crit Care Med 162(4 Pt 1):1512-7, Oct 2000 \2001

21. Baldwin C, Griffith, Nieto FJ, O'Connor G, Walsleben J, Redline S, Association of sleep disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study  Sleep 24 (1): 96-105, 2001

22. Kapur VK, Redline S, Nieto FJ, Young T, Newman AB, Henderson JA.  The Relationship between Chronically Disrupted Sleep and Health Care Use.  Sleep, Vol 25 (3): 289-296, 2002.

23. Kapur V, Strohl K, Dodge R, Iber C, Nieto FJ, O’Connor G, Redline S.  Underdiagnosis of sleep apnea syndrome in U.S. communities.  Sleep Breath, Vol. 6 (2): 49-54, 2002

 24. George T. O’Connor, MD, MS; Bonnie K. Lind, MS; Elisa T. Lee, PhD; F. Javier Nieto, MD, PhD; Susan Redline, MD, MPH; Jonathan M. Samet, MD, MS; Lori L. Boland, MPH; Joyce A. Walsleben, PhD; Gregory L. Foster, MA for the Sleep Heart Health Study (SHHS) Investigators.  Variation in Symptoms of Sleep-Disordered Breathing with Race and Ethnicity: The Sleep Heart Health Study.  Sleep.

  25. Shahar E, Redline S, Young T, Boland LL, Baldwin CM, Nieto FJ, O'Connor GT, Rapoport DM, Robbins JA.  Hormone-Replacement Therapy and Sleep-Disordered Breathing.  Am J Respir Crit Care Med. 2003 Jan 16

.  26. Resnick HE, Redline S, Shahar E, Gilpin A, Newman A, Walter R, Ewy GA, Howard BV, Punjabi NM.  Diabetes and Sleep Disturbances: Findings from the Sleep Heart Health Study.  Diabetes Care. 2003 Mar;26(3):702-709.