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9/14/20 1 Sleep Matters Initiative Impact of Sleep Deficiency and Sleep Disorders on Health and Performance Stuart F. Quan, M.D.* Senior Physician and Clinical Director, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham Health McGinnis Professor of Sleep Medicine, Editor, Sleep and Health Education Program, Division of Sleep Medicine, Harvard Medical School *Dr. Quan is/was a paid consultant to Jazz Pharmaceuticals and Best Doctors; receives research/education support from Mary Ann & Stanley Snider via Combined Jewish Philanthropies, American Academy of Sleep Medicine and the National Institutes of Health; serves as the incumbent of a professorship endowed by Philips Respironics. Dr. Quan’s interests were reviewed and are managed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies. USS Carl Vinson 1 Sleep Deficiency Epidemic Nearly 1/3 of Americans sleep ≤6 hours/night, double the rate from 50 years ago 69% of Americans report regularly getting insufficient sleep 50-70 million Americans suffer from chronic sleep disorders Every month, 56 million Americans admit struggling to keep their eyes open while driving and 8 million fall asleep at the wheel monthly 500,000 driving injuries and 55,000 debilitating related injuries occur annually due to fatigue 6,400 sleep-related fatalities occur annually 20% of serious & fatal crash injuries SLEEP MATTERS INITIATIVE Brigham Health Boston, MA 2 Physician Work Hours, Health, and Patient Safety 3 Percentage of short sleepers (<7h) in the U.S. population From 1965 to 1999 Physician Work Hours, Health, and Patient Safety Populations at higher risk for diabetes Whites African- Americans Hispanics Other 0% 10% 20% 30% 40% 50% 60% 4 24 hours of wakefulness induces performance impairment comparable with blood alcohol concentration 0.10% 5 Characteristics of Sleep Ubiquitous: All animals (e.g., mammals, insects) Obligatory: Animals die if deprived of sleep long enough Complex: REM sleep and non-REM sleep Homeostatically regulated: Amount and content of sleep depends on prior wake duration (including naps, extended wake) If insufficient, waking, performance, alertness, and errors and accidents affected Sleep Disorders exist: Associated with other disorders, including cardiovascular disease 6
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Page 1: Impact of Sleep Deficiency 2020 - excellence.creighton.edu · Sleep Debt Sleep you Need Sleep you Get SLEEP DEBT Sleep Disorders Sleep Inertia 43 Sleep Wake Disorders (>90 Total)

9/14/20

1

Sleep Matters InitiativeImpact of Sleep Deficiency and Sleep Disorders on Health and Performance

Stuart F. Quan, M.D.* Senior Physician and Clinical Director, Division of Sleep and

Circadian Disorders, Departments of Medicine and Neurology, Brigham Health

McGinnis Professor of Sleep Medicine, Editor, Sleep and Health Education Program, Division of Sleep Medicine,

Harvard Medical School

*Dr. Quan is/was a paid consultant to Jazz Pharmaceuticals and Best Doctors; receives research/education support from Mary Ann & Stanley Snider via Combined Jewish Philanthropies, American Academy of Sleep Medicine and the National Institutes of Health; serves as the incumbent of a professorship endowed by Philips Respironics. Dr. Quan’s interests were reviewed and are managed by Brigham and Women’s Hospital and

Partners HealthCare in accordance with their conflict of interest policies.

USS CarlVinson

1

Sleep Deficiency Epidemic• Nearly 1/3 of Americans sleep ≤6 hours/night,

double the rate from 50 years ago• 69% of Americans report regularly getting

insufficient sleep• 50-70 million Americans suffer from chronic

sleep disorders• Every month, 56 million Americans admit

struggling to keep their eyes open while driving and 8 million fall asleep at the wheel monthly

• 500,000 driving injuries and 55,000 debilitating related injuries occur annually due to fatigue

• 6,400 sleep-related fatalities occur annually

20% of serious & fatal crash injuries

SLEEPMATTERS INITIATIVEBrighamHealthBoston,MA

2

Physician Work Hours, Health, and Patient Safety

3

Percentage of short sleepers (<7h) in the U.S. populationFrom 1965 to 1999

Physician Work Hours, Health, and Patient Safety

Populations at higherrisk for diabetes

Whites African-Americans

Hispanics Other0%

10%

20%

30%

40%

50%

60%

4

24 hours of wakefulness induces performance impairment comparable with blood alcohol concentration 0.10%

5

Characteristics of Sleep

• Ubiquitous: All animals (e.g., mammals, insects)• Obligatory: Animals die if deprived of sleep long

enough• Complex: REM sleep and non-REM sleep• Homeostatically regulated: Amount and content of

sleep depends on prior wake duration (including naps, extended wake)

• If insufficient, waking, performance, alertness, and errors and accidents affected

• Sleep Disorders exist: Associated with other disorders, including cardiovascular disease

6

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Sleep Regulation

• Homeostatic• Level of sleep

drive• Circadian

• ~24 hour biologic clock

• Regulates timing of sleep and wake

7

“If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process has ever made.”

---Allan Rechtschaffen, leading sleep researcher

8

Why Does the Brain Need Sleep?

Brain MaintenanceNeural Connectivity

Waste Clearance

Integration of Daily Learning

Restoration ofEnergy Stores

Memory Consolidation

Cognitive Impairment andAlzheimer’s Disease

Impairment ofCreativity and

Problem Solving

Forgetfulness

Fatigue andSluggishness

SLEEPMATTERS INITIATIVEBrighamHealthBoston,MA

9

ATP Levels in the Rat Brain Increase During Sleep

Dworak et al, J Neurosci. 2010 Jun 30;30(26):9007-16

10

Changes in Rat Brain ATP Levels with Sleep Deprivation and Recovery Sleep• ATP levels in SD vs.

Controls are lower • Normalize with recovery

sleep

Dworak et al, J Neurosci. 2010 Jun 30;30(26):9007-16

11

Reduction in Brain Glucose Uptake in Fatigued Rats

Matsui and Watanabe (2008) in Mechanism of Fatigue Studied in a Newly Developed Animal Model of Combined (Mental and Physical) Fatigue, In: Fatigue Science for Human Health. Springer, Tokyo

12

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Sleep and Memory

Stickgold and W alker, Trends Neurosci 2005; 28:408-415

13

Reductions in Sleep Time May be Associated with Future Learning Problems*

0

2

4

6

8

10

12

>9 >7.5 to <9 <7

Hours of Sleep

Silva et al, SLEEP 34; 2011:1197-1205

Odd

s R

atio

s

*p<0.10

14

ARTISTIC RENDITION OF THE GLYMPHATIC SYSTEM

Benveniste et al, Anesth Analg 2019; 128:747

15

Sleep Improves Clearance of β-amyloid from the Brain

Xie et al, Science 2013;342:373-7

16

Synaptic Homeostasis Theory

Tononi and Cirelli, Neuron 2014; 81:12

17

Role of Sleep in Facilitating Creative Thought

Lewis et al, Trends Cogn Sci 2018;22:491

18

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Stage 1

Stage

2

Stage 3

REM

Why Does the Body Need Sleep?Heart Health

and BloodPressure

Regulation

Regulation ofAppetite

Maintenanceof Insulin

and GlucoseMetabolism

ImmuneSystem

Regulation

HypertensionHeart Disease

and Stroke

OvereatingWeight Gainand Obesity

MetabolicSyndrome

and Diabetes

↓ VaccinationResponse

↑ Colds and Flu

SLEEPMATTERS INITIATIVEBrighamHealthBoston,MA

19

Physician Work Hours, Health, and Patient Safety

0

0.5

1

1.5

2

Unadjusted Fully Adjusted*

<6 h6-7 h7-8 h8-9 h> 9 h

Sleep Duration and Hypertension

n = 5910

*Age, sex, race, AHI, BM I

Sleep Heart Health StudyGottlieb et al. Sleep 2006; 29:1009-14

20

Physician Work Hours, Health, and Patient Safety

Short Sleep Duration is Associated with Higher Blood Pressures in Children

Archbold et al. J Pediatr 2012 Jan 25. [Epub ahead of print]

n = 334

60

80

100

120

140

Sys

tolic

Blo

od P

ress

ure

200 400 600 800Total Sleep Time (Minutes)

Baseline Follow-UpFitted values

Total Sleep Time on Systolic Blood Pressure

20

40

60

80

100

Dia

sto

lic B

loo

d P

ress

ure

200 400 600 800Total Sleep Time (Minutes)

Baseline Follow-UpFitted values

Total Sleep Time on Diastolic Blood Pressure

21

Sleep Duration and CHDNurses Health Study*

Physician Work Hours, Health, and Patient Safety

Ayas et al. Arch Intern Med 2003;163:205-209

Sleep Duration, h/d

≤5 6 7 8* ≥9

N 67 267 348 193 59

Person-Yrs 30,115 175,629 288,731 162,662 31,015

RR 1.82(1.34-2.41)

1.30(1.08-1.57)

1.06(0.89-1.26)

1 1.57(1.18-2.11)

RR w/o DM/Htn 1.45(1.10-1.91)

1.18(0.98-1.42)

1.09(0.91-1.30)

1 1.38(1.03-1.86)

RR w/DM, Htn 1.39(1.05-1.84)

1.18(0.98-1.43)

1.10(0.92-1.31)

1 1.37(1.02-1.85)

*10 year follow-up

22

Physician Work Hours, Health, and Patient Safety

Short and Long Sleep Durationsare Associated with Increased Mortality

Kripke et al. Arch Gen Psychiatr 2002; 59(2):131-6

3 4 5 6 7 8 9 >10

Men

Women

Hours of Sleep

23

Physician Work Hours, Health, and Patient Safety

1960 1980 2000Year

10

9

8

7

6

32.9

31.3

30.9

23.3

15.1

14.6

13.3

Average sleep / day(hours)

Percent of U.S.Population Obese

24

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Risk of Obesity from Childhood to Adolescence Tucson Childrens Assessment of Sleep Apnea Study

Physician Work Hours, Health, and Patient Safety

Silva et al. Sleep 2011; 34(9):1197-1205

Odd

s Rat

io

0

0.5

1

1.5

2

2.5

3

3.5

Short Sleep V. Short Sleep7.5 – 9 hours <7.5 hours

*

* p<.05

N=304

25

Daytime Leptin and Ghrelin Levels

Physician Work Hours, Health, and Patient Safety

Spiegel et al. Ann Int Med 2004; 141:846-850

1.5

2.0

2.5

3.0

3.5

9 11 13 15 17 19 21Clock Time

2.2

2.8

3.4

LEPTIN(ng/ml)

GHRELIN(ng/ml)

After 2 days of10-h bedtim es

After 2 days of4-h bedtim es

p level % change

Leptin 0.041 -19%

Ghrelin 0.038 +24%

26

Ratings of Hunger and Appetite

Physician Work Hours, Health, and Patient Safety

Spiegel et al. Ann Int Med 2004; 141:846-850

Hunger

Global Appetite

After 2 days of10-h bedtim es

After 2 days of4-h bedtim es

p level % change

Hunger (cms) <0.01 +19%

Global Appetite (cms) 0.010 +20%

9 11 13 15 17 19 21Clock Time

3.5

5.5

7.5

22

32

42

52

27

Insufficient Sleep and Obesity: Possible Mechanisms

Insufficient Sleep

Increased GhrelinDecreased Leptin

Greater Appetite

Increased Fatigue

Less Physical Activity

Weight Gain

28

Impact of Sleep Restriction on Glucose Disposition

Physician Work Hours, Health, and Patient Safety

Spiegel et al. Lancet 1999; 354:1435-9

Odd

s Rat

io

0

1

2

3

4

5

6

Kg AIRg Sg DI

Rested5 d Slp Restr

Kg=Glu Tol (%/min)AIRg=Ins Resp (mU/mL/minx100Sg=Glu Eff (%/min)DI=Disp Index (Ins Resp/Ins Sens x1000)

29

Short Duration of Sleep and Incidence of Type 2 Diabetes

Physician Work Hours, Health, and Patient Safety

Cappuccio et al. Diabetes Care 2010; 33:414-420

Com bined effect (random m odel): P=0.024; n=90,623Num ber of incident cases: 3,079

30

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Insufficient Sleep and Diabetes

• Risk of Type 2 Diabetes 30% higher in persons who sleep less than 6 hours per night

• Increased risk of metabolic syndrome• Mechanisms

• Reduction in insulin secretion• Elevation in cortisol• Increased sympathetic nervous system activity• Mediated by increased obesity (from insufficient sleep)

31

Insufficient Sleep and Diabetes

Less evidence for impact of insufficient sleep and Type 1 diabetes• Insulin effectiveness decreased with <4 hours sleep• Short sleep duration=worse diabetic control• Preliminary data in children show sleep extension decreases glucose

variability

32

Effect of Sleep Extension on Glucose Variability in a Child with Type 1 Diabetes

Courtesy of Dr. M ichelle Perfect

33

Risk of a Cold and Sleep Deficiency

Prather et al, Sleep 2015;38:3153

34

Antibody Response to Hepatitis B Vaccination as a Function of Sleep

Prather et al, Sleep 2012 35;1063

35

Physical Performance Impacts of Too Little Sleep

Overall Impact• Decreased Reaction Time• Diminished Motor Skills• Decreased Short-term Maximal

Muscle Strength• Reduction in Sprint

Performance• Decreased Endurance

Example: Impact of 2-2.5 H Sleep Deficiency on Tennis Serving Accuracy

Reyner and Horne, Physiol Behav 2013; 120:93-6

Effect of Sleep Extension on Basketball Players

Mah et al, Sleep 2011;34:943-50

36

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Safety Impacts of Too Little Sleep

Drowsy driving is a RED ALERT!

37

Being awake for 18 hours is sim ilar to being legally drunk

37

Mental Impact of Sleep Deficiency

• Longer reaction time

• Lapses in attention or concentration• Lost information• Errors of omission• Poor short term memory• Poor mood (increased fatigue, confusion, stress, and irritability)• Reduced motivation• Sleepiness

• Distractibility• Poor performance (at circadian low points, when sedentary, on long, difficult, or externally

paced tasks with no feedback, in unchanging sound, particularly with reduced light or sound and low motivation, interest, or novelty)

Bonnet and Arand Sleep Med Rev 2003; 7:297-310

38

Reaction Tim e(sec)

Cohen et al. Science Translational Med 2010

Effects of Insufficient Sleep Worsen…

• Within a day• Across days

Can’t learn to live with less sleep

5.6 h/night

8 h/night

39

Self-assessment Problem With Insufficient Sleep

Objective Subjective

Van Dongen et al., SLEEP 2003.

40

41

TimingDuration Quality

What is Healthy Sleep?

Duration Timing Qualityo Adults need at least

7 hours of sleep per night

o Children and adolescents require even more

o Sleepiness is one sign you aren’t getting enough sleep

o A consistent nightly sleep pattern is critical to keep the body clock that regulates sleep in synch with the 24-hour day

o Genetic factors influence whether you prefer to wake up early or stay up late (morning types versus evening types)

o Consolidation of sleep into 1 or 2 major bouts is important to optimize the restorative value of sleep

o Many sleep disorders fragment sleep, or interfere with sleep maintenance or sleep consolidation

42

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Biological Factors That Cause Fatigue

Hours Awake

Time of Day

Sleep DebtSleepyou

Need

SleepyouGet SLEEP DEBT

Sleep Disorders Sleep Inertia

43

Sleep WakeDisorders(>90 Total)

InsomniaDisorder

ObstructiveSleep Apnea

(OSA)

Shift WorkDisorder

Restless Leg Syndrome

(RLS)

44

Individual Behavior and Sleep

02468

1012

Bedtime Email/ Text No B edtimeEmail/ Text%

<6

Hour

s Sle

ep

Impact of Email/Texting at Bedtime

N=1083

45

Economic Impact of Sleep Deficiency and Sleep Disorders

• Sleep deprivation: $150 Billion• Absenteeism• Workplace accidents• Lost productivity (presenteeism)

• Shift work: $65.2 Billion• Absenteeism, Accidents, Lost productivity• Increased medical illnesses• Personnel Turnover

• Sleep Disorders: $100 Billion

46

March 24, 1989• ~258,000 barrels of oil

spilled in Prince William Sound Alaska

• Economic cost: Billions

• Environmental cost: Incalculable

47

*NTSB Safety Recom m endation, Sept 18, 1990

EXXON VALDEZ

•Greatest ecological disaster in the history of mankind•Urban Legend: The ship’s captain was intoxicated.•Fact*: At the time of the grounding, the ship was under the navigational control of the 3rd mate. “…he could have had as little as 5 or 6 hours of sleep in the previous 24 hours.”

48

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This program increased sleep duration, improved

sleep quality, and reduced daytime sleepiness.

Improved Health and Safety following Sleep Health Education and Sleep Disorder Screening Programs

Reduced injuries and disability day usage– 24% fewer injuries and a 46% reduction in disability day

usage ($2.2 million annual savings).

Sullivan et al. Sleep. 2017;40:1-10.

5-fold higher rate of serious preventable crashes among truck drivers diagnosed with OSA who were not compliant with treatment

Burks et al. Sleep. 2016; 39: 967-75.

Crash rate am ong adherent group only 20% as high as those who were not adherent to treatm ent.

49

Three Pillars of Health

Sleep Exercise Nutrition

50

51