1. Good Night,
Sleep Tight:
Understanding the
Importance of Sleep
Conversations at the Royal
Elliott Lee MD, FRCP(C)
D. ABPN Sleep Medicine, Addiction Psychiatry
D. Amer Board of Sleep Medicine
Assistant Professor, Royal Ottawa MHC
December 19, 2013
2. Outline
• Functions of sleep
• Factors affecting sleep
- Quantity
- Quality
- Timing
• Is sleep an issue for you?
• Obstructive sleep apnea, Narcolepsy
• How to improve sleep
4. Approximately what percentage of our (adult) lives will
be spent sleeping?
A) 20%
B) 25%
C) 33%
D) 40%
E) 50%
5. Approximately what percentage of our (adult) lives will
be spent sleeping?
A) 20%
B) 25%
C) 33%
D) 40%
E) 50%
6. Why Study Sleep?
We spend 1/3 of our lives sleeping
Severe health consequences - DEATH!
Sleep deprivation costs
$150 BILLION/yr in lost
productivity
(Nat’l Commission on Sleep Disorders, 2003)
7. Functions of Sleep
Body /brain repair
- Increased resilience to
stress/injury
Pain Reduction
Mood regulation
Diminished anxiety
Memory and learning
Immune competence
14. Sleep Deprivation
According to the most recent General Social Survey
done by Statistics Canada (2010), 46% percent of
Canadians will cut back on sleep in order to add time
to their days.
15. Sleep Deprivation
There is a conflict between the biological imperative
for sleep and the social demand for performance. This
poses a fundamental question:
What happens to performance when the pressure for
sleep is increased?
16. Sleep Quantity
Too little – equivalent to functioning with 0.05 blood
alcohol level (<6 hours)1
<7 hours – decrements can be seen in performance
Cognitive function > speed > accuracy2,3
1Williamson
AM and Feyer AM. Occup Environ Med 2000; 57; 649-55
2Koslowsky M and Babkoff H. Chronobiol Intl. 1992; 9(2); 132-6
3Reilly T and Edwards B. Physiology and Behaviour. 2007; 90; 274-84
17. Sleep Disorders Socioeconomic Consequences
More than 100,000 motor vehicle accidents annually
are sleep-related (US).
“Toronto syndrome”
18. Psychomotor Vigilance Task (PVT) errors with
cumulative sleep deprivation
Dinges et al Sleep, 1997; 20(4), 267-77
19. Challenger Disaster
3 Mile Island
Chernobyl
Exxon Valdez
Medical Errors
Transportation
Industry
20. Daylight Savings and Traffic Accidents
Coren S. N Engl J Med. 1996 Apr 4; 334(14): 924
21. Sleep Deprivation and Wt gain?
Women who sleep <5 hours per night, gained 2.5 lbs,
cf. to women sleeping 7 hours/night
Relative risk for obesity (BMI > 30 kg/m2)
5 hour sleepers = 1.15 cf. to 7+ hours
Studied >68 000 women (Nurses Health Study) for 16
years
Hormones? Basal metabolic rate?
22. Sleep Deprivation and Children
Not the same as adults
May be “hyperactive”
- fidget
- poor attention
- cranky
27. Process S(leep)
Homeostatic control
“The longer we’re awake, the more sleep debt we
accumulate i.e. the sleepier we become”
The sleepier we are, the more deficits are seen
To date, there is no surrogate available for good quality
sleep.
28. Process S(leep)
Homeostatic control
“The longer we’re awake, the more sleep debt we
accumulate i.e. the sleepier we become”
The sleepier we are, the more deficits are seen
To date, there is no surrogate available for good quality
sleep.
29. Process C(ircadian)
Sleep tendencies follow a circadian (daily) rhythm
This is controlled by a central “biological clock”
Several inputs also influence this clock, especially
- Light
- Melatonin
33. Consequences of Asynchronous Sleep
Impaired continuity of
sleep
↓ alertness
↑cognitive errors
Like “hitting a tennis ball
off the centre of the
racquet” – sleep is not as
efficient, and sleep
architecture is disrupted
Jet lag, shift work
34. Who is more likely to do rotating or evening shifts in
Canada, men or women?
35. Who is more likely to do rotating or evening shifts in
Canada, men or women?
WOMEN
36. Women are more likely to work
rotating shifts or evening shifts
Men
Women
Irregular
25%
Other
13%
Other
12%
Evening
14%
Irregular
35%
Evening
10%
Night
8%
Night
8%
Rotating
41%
Rotating
34%
Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005
37. Shift Work
International Agency on Research and Cancer (IRAC)
classified shift work as a probable carcinogen in 2007.
40-50% increase in breast cancer risk with >20-30
years of shift work exposure.
Melatonin thought to play a key role; reduces estrogen
levels and shown to have anticancer properties.
Megdal et al. Eur J Cancer. 2005; 41: 2023-32
Grundy A et al. Occup Environ Med. 2013; 70: 831-8
Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9
38. Is sleep an issue for you?
Do you feel satisfied with the quality of your
sleep?
Do you frequently fall asleep if given a sleep
opportunity (a sleep opportunity is defined as a
quiet, dark environment for at least 10 minutes)?
Do you usually need an alarm clock to wake you?
Do you tend to catch up on sleep during the
weekends?
Once awake, do you feel tired most mornings?
Do you frequently take naps during the day?
39. Is sleep an issue for you?
When you can get it, do you consistently sleep
more than 9.5 hours per night?
Do you feel lethargic or slow throughout the day?
Do you sleep longer during times of depression,
anxiety and stress?
Do you snore?
Do your legs bother you at bedtime, interfering
with your sleep?
40. What Happens at the Sleep Lab…
ROMHC: 5 bed clinical lab, 4 bed research lab
STEPS:
1) → Referral
2) → Consultation with a Sleep Specialist
3) → Overnight Sleep Study
4) → Data is Analyzed by RPSGTs
5) → Results Appt with a Sleep Specialist
41. How Do We Measure Sleep in the
Laboratory?
Electrophysiology
EEG – brainwaves (Central & Occipital Leads)
EOG – eye movements
EMG – muscle tone
EKG – heart
Breathing:
1)Airflow
& 2) Effort: Thoracic & Abdominal
Blood oxygen saturation (SaO2)
Audio-visual recording
42.
43.
44.
45.
46. Obstructive Sleep Apnea (OSA)
Definition:
The presence of abnormal breathing
disruptions/cessations (apneas) during sleep
Sleep is disrupted temporarily, usually without recall.
As a result, sleep deprivation and/or excessive daytime
sleepiness occur, usually with snoring at night
Up to 25% of men and 9% of women are thought to be
affected, with 90% of patients likely undiagnosed1
50% of snorers are thought to have OSA2
Strongly associated with cardiac disease
1Young et al. N Eng J Med, 1993; 328(17):
2Lugaresi et al. Sleep, 1980; 3(3-4): 221-4
1230-5
49. Motor vehicle accidents
Hypertension
OSA Consequences
Impaired
glucose
control
Irritability, mental illness e.g. depression
Heart attack and stroke
Memory problems
51. OSA and Attractiveness?
Treatment of OSA with
CPAP has been shown to
improve attractiveness
Perceived to be
- More alert
- More youthful
- Less forehead creases
Chervin R et al. J Clin Sleep Med, 2013; 9(9): 845-52
52. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from obstructive sleep apnea? (Choose
all that apply):
A
B
C
D
E
53. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from obstructive sleep apnea? (Choose
all that apply):
A
B
C
D
E
54.
55. Narcolepsy
A pathologic disorder of sleepiness during the day –
key symptom – sleepiness
May have insomnia at nighttime
Affects about 1/2000 people
Very underdiagnosed; difficult to recognize
80% may have cataplexy, a REM sleep intrusion
phenomenon on wakefulness
Related to cerebrospinal fluid deficiency of hypocretin
(orexin)
59. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from narcolepsy?
A
B
C
D
E
60. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from narcolepsy?
A
B
C
D
E
61. How to Improve Sleep
Get adequate quantity of sleep (7.5-8.5 hrs)
Regular sleep/wake times – timing/routine important
Develop a relaxing pre sleep ritual
- relaxation exercises can be helpful
- avoid stressful/stimulating activities prior to sleep
Avoiding prolonged naps* in the day
Bed – only for sleep (and romance!)
Avoid clock watching
Rule out sleep disorder, psychiatric disorder
62. How to Improve Sleep
Sleep Environment
- Avoid environmental disturbances
- Partner/Children
- Roommate
- External noises – phones, texting, external
(white noise generator may drown out)
- Avoid bright light in evenings
- Temperature – slightly cooler (<21-22oC) is better.
drop in temperature facilitates sleep onset
- Bed should be comfortable – consider memory foam
mattresses/pillows; queen or king size beds
Quiet. Dark. Cool. Comfortable.
64. Which of the following substances has the highest
amount of caffeine?
A) Red Bull, 250 mL
B) Coca Cola, 1 L
C) Starbucks Coffee, Grande (360 mL)
D) Green Tea, 300 mL
E) Caffeine pill, (200 mg tab)
65. Which of the following substances has the highest
amount of caffeine?
A) Red Bull, 250 mL
B) Coca Cola, 1 L
C) Starbucks Coffee, Grande (360 mL)
D) Green Tea, 300 mL
E) Caffeine pill, (200 mg tab)
66. Caffeine – a Canadian Love Affair
Starbucks coffee(20 oz)
400 mg
Second Cup coffee (20 oz)
400 mg
Tim Horton’s coffee (20 oz)
270 mg
Instant coffee (8 oz)*
95 mg
Tea (leaf or bag, 8 oz)
50 mg
Mountain Dew (12 oz)
55 mg
Coca Cola (12 oz)
45 mg
Red Bull (250 ml)
80 mg
Sources: National Coffee Association, National Soft Drink Association, Tea Council of the USA, and information
provided by food, beverage, and pharmaceutical companies and J.J. Barone, H.R. Roberts (1996) "Caffeine
Consumption." Food Chemistry and Toxicology, vol. 34, pp. 119-129.
67. Summary
Sleep is important to consider for performance
Good sleep can improve performance
- Cognition/memory
- Accuracy
- Speed
- Health/Decrease sick days (immune competence)
- Improve mood, anxiety, resilience
Sleep variables to consider: Quantity, Quality, Timing
Rule out sleep disorder
Details are important; BALANCE – key to success
68. When the time to perform has come, the time to prepare
has past.
Bob Bowman, coach of Michael Phelps