Dr ABEER ALHARBI PULMONARY ANDSLEEP CONSULTAN KFH-MEDINA-KSA

1. Abeer Alharbi MD
KSAConsultantPulmonary and Sleep

3. Introduction
Sleep is considered to be important for energy conservation,
thermoregulation, and tissue recovery
sleep is essential for cognitive performance, especially memory
consolidation

4. During a normal night of sleep, a person will alternate between
periods of NREM and REM sleep. Each cycle is approximately 90
minutes long, containing a 20-30 minute bout of REM sleep

5. SLEEP
REM sleep is considered important for learning, memory
consolidation, neurogenesis, and regulation of the blood-
brain barrier function
Non REM sleep is related to hormonal release (e.g., growth
hormone secretion), the decline in the thermal set point
,and is characterized by a reduction of cardiovascular
parameters(e.g. ,lowering of bloodpressure

6. DEFINITION
Sleep deprivation is the condition of not having enough
sleep; it can be either chronic or acute.
Acute sleep deprivation refers to no sleep or a reduction in
the usual total sleep time, usually lasting one or two days.
Chronic sleep deprivation (also called sleep restriction) exists
when an individual routinely sleeps less than the amount
required for optimal functioning.

7. Sleep deprivation
Sleep has two dimensions: duration (quantity) and depth
(quality).
When individuals fail to obtain adequate duration or quality of
sleep, daytime alertness and function suffer

9. Prevalence
In 1990 the prevalence of insufficient sleep was 20.4% (16.2% in
men and 23.9% in women).
Sleep. 2001 Jun 15;24(4):392-400
In2005-2008 more than one-third of individuals reported
sleeping less than seven hours per night on weekdays or
workday nights
MMWR Morb Mortal Wkly Rep. 2011;60(8):239.

10. Prevalence
A research was carried out by a group of scientists from the
University of London.
They evaluated a sample size of 17,000 college students
(within the age group of 17 to 30 years, living in 24
countries), for sleep patterns and general health.

11. Saudia rabia
Parents of elementary school children were surveyed regarding
their children’s bedtime, rise time, sleep duration at night and
daytime nap duration during weekdays and weekends.
The study comprised 511 (50.5 percent) boys and 501 (49.5
percent) girls .
During weekdays, bedtime for the whole group was 21.3 +/- 1.8
hours, rise time was 5.9 +/- 0.5 hours, total sleep time (TST)
was 8.4 +/- 1.1 hours, and TST and nap was 9.98 +/- 1.3 hours.
Conclusion:
Nighttime sleep duration is shorter in Saudi school children
compared to published data..
Singapore Med J 2006; 47(10) : 875

12. Risk groups
ƒMales and females of all ages
Adolescents, among whom restricted sleep times are common
Caregivers who look after the needs of a family member who has
a chronic illness
People who perform shift work
People who have a sleep disorder that causes insufficient sleep
People who have a medical condition that causes insufficient
sleep

14. Physiological effects

15. Effects
Mood
o Irritability
o Lack of motivation
o Anxiety
o Symptoms of depression

16. Effects
Performance
o Lack of concentration
o Attention deficits
o Fatigue o Restlessness
o Lack of coordination
o Poor decisions
o Increased errors
o Forgetfulness Distractibility
o Lack of energy

17. Effects
Health
o High blood pressure
o Heart attack
o Obesity
o Diabetes

18. Cognitive effects
 1 Attention
 1.1 Neural substrates
 1.2 Auditory attention
 1.3 Divided attention
 1.4 Exogenous and endogenous attention
 1.5 Selective attention
 1.6 Supervisory attention
 1.7 Visuospatial attention
 2 Executive function
 2.1 Decision making
 2.2 Complexity
 2.3 Innovation
 2.4 Risk
 2.5 Planning
 2.6 Error correction
 3 Memory
 3.1 Working memory
 3.2 Long-term memory

19. Attention
 .1 Neural substrates
 .2 Auditory attention
 .3 Divided attention
 .4 Exogenous and endogenous attention
 .5 Selective attention
 .6 Supervisory attention
 .7 Visuospatial attention

20. Mechanisms behind sleep loss effects
The lapses are caused by microsleeps characterized by very
short periods of sleep-like electro-encephalography (EEG)
activity

21. Divided attention
Increased cerebral response during a divided
attention task following sleep deprivation
13 normal control subjects performed the task while
undergoing (FMRI) scans after a normal night of sleep and
following 35 h TSD
Behaviourally, subjects showed only modest impairments
following TSD
J Sleep Res. 2001 Jun;10(2):85-92

22. With respect to cerebral activation, the results showed activation in
prefrontal cortex
left inferior frontal gyrus
bilateral parietal lobes

23. Increased cerebral response during a divided attention
task following sleep deprivation

25. Divided attention
Divided attention task required more attentional resources
following TSD than after normal sleep.
J Sleep Res. 2001 Jun;10(2):85-92

26. The chronic sleep restriction experiment involved
randomization to one of three sleep doses (4 h, 6 h, or 8 h time
in bed per night), which were maintained for 14 consecutive
days.
The total sleep deprivation experiment involved 3 nights without
sleep (0 h time in bed).
Each study also involved 3 baseline days and 3 recovery days

27. Neurobehavioral Performance
The neurobehavioral assessment included
psychomotor vigilance task to measure behavioral alertness.
The PVT measures simple reaction time to a visual stimulus,
presented approximately 10 times/minute
Lapses (reaction times greater than 500 ms) indicative of
reduced behavioral alertness

28. Neurobehavioral Performance
The neurobehavioral assessment also include
a computerized digit symbol substitution task to measure
working memory.
This subject-paced task involves the matching of digits (0–9)
to symbols (circle, triangle, etc.).
The number of correct responses in 1.5 min was counted to
measure working memory performance.
A serial addition/subtraction task was included in the
assessment to measure cognitive throughput.

29. Impairment in psychomotor vigilance test PVT and digit symbol
substitution task DSST for the 4 h group after 14 days was equal to that
of the total SD group after 2 nights

30. DSST

31. Subjective sleepiness ratings showed an acute response to sleep
restriction but only small further increases on subsequent days,
and did not significantly differentiate the 6 h and 4 h conditions
SSS Sleepiness score

32. Conclusion
Chronic restriction of sleep periods to 4 h or 6 h per night over 14
consecutive days resulted in significant cumulative, dose-
dependent deficits in cognitive performance on all tasks.
.
Sleep. 2003;26(2):117.

33. The Effect of One Night's Sleep Deprivation on
Adolescent Neurobehavioral Performance
Twelve healthy adolescents (6 male), aged 14-18 years
SLEEP 2014;37(11):1799-1807

34. The estimated marginal means (± standard error) of Psychomotor Vigilance Task
(PVT) lapses at each time point across baseline and sleep deprivation days.

35. The estimated marginal means (± standard error) of Psychomotor Vigilance Task
(PVT) fastest 10% reaction time at each time point across baseline and sleep
deprivation days

36. The estimated marginal means (± standard error) of number of Digit
Symbol Substitution Task (DSST) correct responses at each time point
across baseline and sleep deprivation days

37. The estimated marginal means (± standard error) of sleepiness scores on
the Karolinska Sleepiness Scale (KSS) at each time point across baseline
and sleep deprivation days

38. Psychomotor Vigilance Task (PVT) lapses per test bout for each participant at
each time point

39. Patterns of performance degradation and restoration during
sleep restriction and subsequent recovery: a sleep dose-
response study
J. Sleep Res. (2003) 12, 1–12

40. With mild to moderate sleep restriction (7- and 5-h TIB), performance initially
declined and, after a few days, appeared to stabilize at a lower-than-baseline
level for the remainder of the sleep restriction period. In contrast, with severe
sleep restriction (3-h TIB) performance declined continuously
J. Sleep Res. (2003) 12, 1–12

41. Following chronic, mild to moderate sleep restriction (5 or 7 h TIB), 3 days of
recovery sleep (8-h TIB) did not restore performance to baseline level
J. (2003) 12, 1–12. Sleep Res

42. Interindividual differences
Although in general the cognitive performance of aging
people is often poorer than that of younger individuals,
during SD performance in older subjects seems to
deteriorate less.
women may endure prolonged wakefulness better than men,
whereas physiologically they recover slower

43. Cognitive recovering from sleep deprivation
Recovery sleep is distinct from normal sleep.
Sleep latency is shorter, sleep efficiency is higher, the amounts
of SWS and REM-sleep are increased and percentages of
stage 1 sleep and awake are decreased
J Sleep Res. 2005;14:7–15
Sleep Research Online. 2001;4(1):33–41.
After chronic partial sleep restriction, the recovery process of
cognitive functioning seems to take longer than after acute
total SD.
Sleep, 20:267–77.

44. Executive function
.1 Decision making
.2 Complexity
.3 Innovation
.4 Risk
.5 Planning
.6 Error correction
Prefrontal cortex
Anterior cingulate cortex

45. A One-Hour Sleep Restriction Impacts Brain Processing in Young
Children Across Tasks: Evidence From Event-Related Potentials
6 typically developing, male children (mean age=7.66years,
range6.6–8.3years)
All six participants had normal PSG .
Actigraphic recordings revealed that the mean daily reduction
in average sleep duration during the restriction week was
43.6±2.8 min
Dev Neuropsychol. 2013;38(5):317-36

46. .
An event-related potential (ERP)
It is any stereotyped electrophysiological response to a
stimulus

47. Scalptopography The Color variations reflect amplitude variations in the
event-related potential (ERP) waveforms. As ERP amplitude increases above
baseline (purple), colors change from red to yellow to white..
frontall
left temporal area
occipital

48. .
(a) increase in positive
amplitudes over central scalp,
negativity greater over left
frontal areas.
(b)less clearly defined positivity
over central regions for children
during the reduced sleep
condition.
(c) less clearly demarcated front
negativity and less localized
positivity occurred over parietal
areas

49. Conclusion
Across all three tasks, the most marked changes were the
reductions in ERP amplitudes found for the Restricted
condition.
This indicates that a marked decrease in brain processing on
tasks with high processing demands.
Dev Neuropsychol. 2013;38(5):317-36

50. Memory
Sleep is involved in the acquisition, maintenance and
retrieval of memories as well as memory consolidation
.1 Working memory
.2 Long-term memory

51. Working memory
temporarily
store verbal and
acoustic
information
(echo memory)
hold visuospatial information (iconic memory),

52. Memory
Long-term memory can be divided between declarative and
non-declarative .
REM is associated with the consolidation of non declarative
(implicit) memories.
An example would be a task that we can do without
consciously thinking about it, such as riding a bike.
Slow-wave, (NREM) sleep, is associated with the
consolidation of declarative (explicit) memories.
These are facts that need to be consciously remembered,
such as dates for a history class
Diekelmann, S., & Born, J. (2008

53. Preliminary fMRI findings in experimentally sleep-
restricted adolescents engaged in a working memory task
20 healthy adolescents underwent a 3-week protocol which
included a baseline week, followed in random order by a
sleep restriction week (SR) and a healthy duration week
(HD)
Behav Brain Funct. 2009;5:9

54. Composite activation/deactivation maps, showing contrast of 2-back task
with 0-back task in each experimental sleep condition. Warm colors (orange to
yellow)

55. Conclusion
Regions that are normally active during an attention-demanding
working memory task in the well-rested brain became even
more active to maintain performance after chronic sleep
restriction.
In contrast, regions in which activity is normally suppressed
during such a task in the well-rested brain showed even greater
suppression to maintain performance after chronic sleep
restriction.
Behav Brain Funct. 2009;5:9

56. Effect of on-call-related sleep
deprivation on physicians’ mood and alertness
88 junior physicians working in one university hospital
completed a questionnaire, before and after completion of a
shift, that collected data, patterns of work and sleep, Profile of
Mood States (POMS), and Stanford Sleepiness Scale.
Based on duration of sleep the physicians had during on-call in
comparison to their usual average sleep, the participants were
categorized into group 1 (those who slept many fewer hours),
group 2 (those who slept fewer hours), or group 3 (those who
slept the same number of hours).
.
Annals of Thoracic Medicine 8, 1.2013

59. More than 87% of the participant slept 5 or fewer hours while working
an on-call shift.

60. Among all participants, the percentage of physicians who were alert
post-on-call was significantly reduced compared to the percentage pre-
on-call (P = 0.001)

61. The post-on-call total POMS scores of groups 1 and 2 were significantly worse
than their pre-on-call scores (P = 0.001 and 0.038, respectively), while there
was no significant difference between the pre- and post-on-call POMS scores of
group 3 (P = 0.165).

62. Risk of traffic collisions
Excessive sleepiness is the second leading cause of car crashes
and a major cause of truck crashes in the United States
Am J Respir Crit Care Med 2006; 174:446
JAMA 1998; 279:1908.
performance begins to degrade after 16 hours awake, and 21
hours awake was equivalent to a blood alcohol content of .08
percent, which is the blood alcohol limit for drunk driving in
Canada, the U.S., and the U.K
Nature 388 (6639): 235.

63. Quality of life
Sleep-deprived patients often cut back on activities they enjoy,
claiming that they do not have enough energy to perform the
activity. Inappropriate drowsiness and unplanned naps
Patients who fall asleep at work or whose productivity suffers
due to sleepiness may be reprimanded, denied advancement,
or fired

64. Association of Sleep Time With Diabetes
Mellitus and Impaired Glucose Tolerance
A community-based, prospective, cohort stud y
Participants were 722 men and 764 women, aged 53 to 93
years.
Usual sleep time was obtained by standardized questionnaire.
Arch Intern Med. 2005;165:863-868

65. subjects sleeping 5 hours or less and 6
hours per night had adjusted ORfor
DM of 2.51 and 1.66
Adjusted OR for IGT were 1.33 and 1.58

67. Slow-wave sleep and the risk of type 2
diabetes in humans
9healthy young volunteers were each tested under two
experimental conditions in randomized order: (i) after 2
consecutive nights of “baseline”ƒsleep and (ii) after 3
consecutive nights of “experimental suppression of SWS”.
Proc Natl Acad Sci USA. 2008;105(3):1044–9

69. S.I. (P 0.009) (a); AIRg (P 0.73) (b); DI (P 0.02) (c); and glucose tolerance (P 0.03) (d).
I
glucose tolerance was reduced by ≈23%disposition index (DI) (DI = S.I. × AIRg) was
≈20%
S.I. was decreased by ≈25%

70. BP
In a prospective cohort study that followed 535 young adults
(age 18 to 30) for 15 years, a shorter duration of sleep was
associated with a greater likelihood of developing
hypertension, even after adjusting for possible confounders
(adjusted OR 1.37, 95% CI 1.05-1.78)
Arch Intern Med. 2009;169(11):1055

71. BP

72. BP

73. .

74. Cardiovascular morbidity
Inflammation is one plausible mechanism for the observed
relationship between short sleep duration and CVD
Clin Endocrinol Metab 2010; 24:775.
Nat Sci Sleep 2013; 5:93.
Even a relatively mild restriction of sleep (eg, from eight to
six hours for eight days) increases the level of pro-inflammatory
cytokines.

75. Experimental Sleep Restriction Causes
Endothelial Dysfunction in Healthy Humans
16 healthy volunteers underwent a randomized study of usual
sleep versus sleep restriction of two‐thirds normal sleep time
for 8 days/8 nights
The main outcome was endothelial function measured by
flow‐mediated brachial artery vasodilatation (FMD).
J Am Heart Assoc. 2014 Nov 25;3(6).

76. sleep restriction groups howed an
impairment in FMD (8.6±4.6% during the
acclimation phase vs 5.2±3.4% during the
experimental phase, P=0.01
whereas no change was seen in the
control group (5.0%±3.0 during the
acclimation phase vs 6.73±2.9%
during the experimental phase, P=0.10

77. Cardiovascular morbidity
In a prospective cohort study of 495 healthy individuals, a
longer sleep duration was associated with a significantly
reduced incidence of coronary artery calcification when the
sleep duration was measured by actigraphy, but not when
the sleep duration was determined by self-report
JAMA. 2008;300(24):2859.

78. Five-year calcification incidence was 12.3% (n = 61). Longer measured sleep
duration was significantly associated with reduced calcification incidence
(adjusted odds ratio, 0.67 per hour [95% confidence interval, 0.49-0.91 per
hour]; P = .01

81. Cardiovascular morbidity
In a cross-sectional study of 30,397 adults, the prevalence of
myocardial infarction, angina, or stroke was higher among
individuals who slept ≤5 hours per night than among those
who slept seven hours per night (OR 2.2, 95% CI 1.78-2.71) .
The overall prevalence of the cardiovascular outcomes in
the population studied was 7 percent.
An important limitation of this study is that sleep duration
was self-reported
Sleep. 2010;33(8):1037

82. Immunosuppression
immune response to vaccination against influenza virus
decreases after six days of restricted sleep
JAMA. 2002 Sep;288(12):1471-2.
There is also evidence for an enhanced susceptibility to the
common cold with poor sleep efficiency

83. Sleep Habits and Susceptibility to the Common Cold
A total of 153 healthy men and women (age range, 21-55 years)
For 14 consecutive days, they reported their sleep duration
and sleep efficiency,for the previous night and whether they
felt rested.
Subsequently, participants were quarantined, administered
nasal drops containing a rhinovirus, and monitored for the
development of a clinical cold (infection in the presence of
objective signs of illness) on the day before and for 5 days after
exposure.
Arch Intern Med. 2009;169(1):62-67
.

84. participants with less than 7 hours of sleep were 2.94 times (95% confidence interval [CI],
1.18-7.30) more likely to develop a cold than those with 8 hours or participants with less than
92% efficiency were 5.50 times (95% CI, 2.08-14.48) more likely to develop a cold than those
with 98% or more efficiency. more of sleep

85. Effects of Sustained Sleep Restriction on Mitogen- Stimulated
Cytokines, Chemokines and T Helper 1/ T Helper 2 Balance in
Humans
9 healthy males participated in an experimental sleep
protocol with two baseline sleep-wake cycles (sleep 23.00 –
07.00 h) followed by 5 days with restricted sleep (03.00 –
07.00 h).
Dec 2013 | Volume 8 | Issue 12PLOS ONE

86. cortisol significantly suppressed l during the first hours of restricted sleep
(03.00-05.00 h), (p<.05)
monocyte numbers were higher during the first part of night during sleep
restriction condition at 03.00 h

87. increased TNF-α and monocyte chemoattractant protein-1MCP-1
in the late evening and early night hours (p’s<.05

88. decrease of IL-2 production (p<.05

90. Obesity
Multiple observational studies have demonstrated an
association between short sleep duration and obesity
Possible mechanisms whereby short sleep duration
contributes to weight gain and diabetes risk through effects
on appetite and hormone secretion

91. Obesity

92. healthy young subjects when submitted to partial sleep restriction for 6 days (4-
hour sleep times; mean total sleep time during previous 2 nights, 3 hours 49
minutes; left panels) and after full sleep recovery (12-hour sleep times for 6
nights; mean total sleep time during previous 2 nights, 9 hours 3 minutes; right
panels).

93. 68,183 women who participated in the Nurses' Health Study. It was found that women
sleeping 5 hours or less gained 1.14 kg more than those who slept an average of 7 hours
over 16 years, and women sleeping an average of 6 hours gained 0.71 kg more
2006; 164(10): 947-54.Am J Epidemiol

94. The relative risks ratio of a 15 kg weight gain were 1.32 and 1.12
for those sleeping 5 and 6 hours, respectively
2006; 164(10): 947-54.Am J Epidemiol

95. Sleep and the Gastrointestinal Tract
The effects of SWS can lead to a decrease in colon contractility,
which is considered the “rest period”ƒfor the colon, so
alterations in this stage of sleep can have direct effects on GI
physiology, including diminished mucosal integrity
Nat Rev Immunol. 2004;4(6):457-467.
Gastroenterology. 1991;101(2):373-381.

96. Sleep in Inflammatory Bowel Disease
Sleep Disturbances and Disease Activity
study showed that a greater percentage of patients with
active IBD (82%) had poor sleep quality compared with
patients with inactive IBD (51%).
Inflamm Bowel Dis. 2011;17(9):1882-1889.

97. Sleep in Inflammatory Bowel Disease
Sleep Disturbances Increase the Risk of Relapse
One prospective study looking at patients with IBD (both CD and
UC), found a 3-fold increased risk of disease relapse at 6 months
in patients with clinical remission and poor sleep.
Patients with an abnormal PSQI had a relapse rate of 47% at 3
months and 67% at 6 months compared with 0% at 3 and 6
months in patients with a normal PSQI
Inflam bowel Dis.2013 Oct;19(11):2440-3

98. Sleep deprivation aggravates median nerve injury-induced
neuropathic pain and enhances microglial activation by
suppressing melatonin secretion
Rats were subjected to sleep deprivation for 3 days either before
or after CCI, CCI rats received melatonin supplements during
sleep deprivation.
.
Sleep. 2014 Sep 1;37(9):1513-23.

99. Sleep. 2014 Sep 1;37(9):1513-23
The experimental animals were divided into four groups. Rats in the
first group (preinjury TSD group) were subjected to TSD for 3 days.
Then, the rats were anesthetized immediately and underwent CCI of
the median nerve (n = 10) or sham operation (n = 10).
Animals in the second group were housed in the same apparatus for 3
days but were allowed to sleep (control for total sleep deprivation,
TSDC). Subsequently, the rats (preinjury TSDC group) had median
nerve CCI (n = 10) or sham operation (n = 10).
In the third group (postinjury TSD group), animals underwent median
nerve CCI (n = 10) or sham operation (n = 10). Immediately thereafter,
the rats were subjected to TSD for 3 days.
In the fourth group (postinjury TSDC group), animals underwent CCI
of the median nerve (n = 10) or sham operation (n = 10). Then, therats
were housed in the same apparatus for 3 days but werem permitted to
sleep.

100. The sham-operated rats in all the
four groups had similar mechanical
withdrawal thresholds (Figure 2A)
and thermal withdrawal latencies
(Figure 2B).
A marked decrease of the
mechanical withdrawal threshold
and thermal withdrawal latency
was observed in CCI rats in each of
the study groups as compared to
the corresponding sham operated
rats.
a significantly decreased
mechanical withdrawal threshold
and thermal withdrawal latency
was discernible in CCI rats of the
postinjury TSD group

101. Immunohistochemistry (Figures 3A, 3B,3E, 3F) and immunoblotting (Figure 4) showed little
expression of OX-42 in the cuneate nucleus CN of sham-operated rats in the four study
groups.
In rats who underwent post-CCI sleep deprivation, microglia were more profoundly
activated and neuropathic pain was worse than those receiving pre-CCI sleep deprivation

102. During the sleep deprived period, serum melatonin levels were low over the
24-h period

103. Effect of melatonin treatment on nerve injury-induced
mechanical allodynia and thermal hyperalgesia in chronic constriction
injury (CCI) and sham-operated control rats

104. Conclusions
In rats who underwent post-CCI sleep deprivation, microglia
were more profoundly activated and neuropathic pain was
worse than those receiving pre-CCI sleep deprivation.
During the sleep deprived period, serum melatonin levels were
low over the 24-h period.
Administration of melatonin to CCI rats with sleep deprivation
significantly attenuated activation of microglia and
development of neuropathic pain, and markedly decreased
concentrations of proinflammatory cytokines
Sleep. 2014 Sep 1;37(9):1513-23.

106. Assess Your Sleep Needs
How Much Is Enough?
Pay Attention to Your Sleepiness
Keep a Sleep Diary
Take a Sleep Vacation
Make Sleep a Priority

107. Adopt Good Sleep Habits
•maintaining a regular sleep-wake schedule
•avoiding caffeine, alcohol, nicotine, and other chemicals
that interfere with sleep
•making your bedroom a comfortable sleep environment
•establishing a calming pre-sleep routine
•going to sleep when you're truly tired
•not watching the clock at night
•using light to your advantage by exposing yourself to light
during the day and limiting light exposure in the evening
•not napping too close to your regular bedtime
•eating and drinking enough—but not too much or too
soon before bedtime
•exercising regularly—but not too soon before bedtime

108. Address Your Sleep Issues
•Sleep specialists help people recognize and change
behaviors that interfere with sleep and can diagnose
sleep disorders

109. Make Changes at Work
•Employer-Supported Initiativess
installing bright lights that help maintain the brain's alerting
signal
Offering healthy foods
providing access to an exercise facility and space for nap
breaks.
limit work hours and prevent sleep deprivation for workers—
such as pilots, truck drivers, and medical residents—whose
jobs impact public safety

110. Coping Strategies
Caffeine
It is used regularly by 80 percent of adults in the U.S in liquid,
tablet or gum form.
It can provide improved alertness and performance at doses of
75 mg to 150 mg after acute sleep restriction.

111. Caffeine
Caffeine reduces sleep and sleepiness by blocking access to
the adenosine receptor
The electrophysiological and behavioural data together
provide evidence that caffeine enhances clock sensitivity to
light
Eur J Neurosci. 2014 Nov;40(10):3504-11

112. Coping Strategies
Sleep prior to deprivation
prophylactic nap
Caffeine and a nap
Other stimulants
Include amphetamines, methylphenidate and modafinil.

113. THANK
YOU
‫اليك‬ ‫نتوب‬ ‫و‬ ‫نستغفرك‬ ‫انت‬ ‫اال‬ ‫اله‬ ‫ال‬ ‫ان‬ ‫نشهد‬ ‫بحمدك‬ ‫و‬ ‫اللهم‬ ‫سبحانك‬