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SleepDeprivation:
DireConsequences
Suzie Bertisch, MD, MPHClinical DirectorofBehavioral SleepMedicine,
Division ofSleepandCircadianDisorders,
Brigham andWomen’s Hospital
Assistant Professor ofMedicine,
HarvardMedical School
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Learning Objectives
§ Identify and distinguish causes of sleep deprivation
§ Recognize acute and chronic consequences of sleep deprivation and disruption
§ Encourage and implement behavioral changes to counteract the effects of sleep deprivation and disruption
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Sleep is Biological Imperative
Credit: Michael Prerau, PhD
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Sleep-wake regulation: Brain systems
Saper, Nature, 2005; 1257-63
Wake Systems Sleep Systems
BF = Basal Forebrain. VLPO = Ventrolateral preoptic area. LH = Lateral hypothalamus peri-fornical area. LC = locus coeruleus. LDT = Laterodorsal pontine tegmentum. PPT =
Pedunculopontine tegmentum. TMN = Tuberomamillary nucleus of the posterior hypothalamus. vPAG = Peri-aqueductal gray.
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Why sleep?
§ Clearance of neural waste
§ Brain processing and memory consolidation
§ Memory and learning
§ Physical restoration
Credit: The Center for Sleep and Consciousness, University of Wisconsin-Madison School of MedicineCOPYRIGHT
National Sleep FoundationHe et al. (2009) - Science
There is a “short sleep phenotype” in less than 3% of the population where 6 hours of sleep per night is sufficient.
How Much Sleep?
Slide c/o Eric Zhou, PhD
Most adults need about 7-9 hrs/night to function at their best.
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Prevalence U.S. Adults Sleeping <7 hours
0%
20%
40%
60%
White Black Hispanic Other
MMWR 3/4/2011
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What controls sleep?
Homeostatic Process: How long you’ve been awake
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What controls sleep?
1. Homeostatic Process
How long you’ve been
awake
2. Circadian Process:
Body Clock
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Nobel prize winners Jeffrey C. Hall, Michael Rosbash and Michael W. Young:
for their discoveries of molecular mechanisms controlling the circadian
rhythm
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Cognitive performance requiring vigilant attention becomes unstable with sleepiness
Doran SM, Van Dongen HP, Dinges DF. Sustained attention performance during sleep deprivation: evidence of state instability. Arch Ital Biol. 2001.
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“Chronic restriction of sleep to 6 hours or less per night produced cognitive performance deficits equivalent to 2 nights of total sleep deprivation.”
Van Dongen et al. Sleep, 2003
Sleep Deprivation Decreases Attention
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Cumulative adverse effects of chronic partial sleep restriction are greater in objective than subjective reports of sleepiness
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5
10
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BL 2 4 6 8 10 12 14
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BL 2 4 6 8 10 12 14
Deficits
Objective Subjective
Days of sleep restriction Days of sleep restriction
4h TIB 8h TIB6h TIB
Van Dongen et al. Sleep, 2003
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Harvard Work Hours, Health, and Safety Study:Motor Vehicle Crash Risk in Interns on
Commute Home from Hospital
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0.2
0.4
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Crashes per 1000 commutes from the hospital
Extended shifts (>24 hours) Non-extended shfits (<24 hours)
OR: 2.3, p<0.001
Barger, L. K. et al. N Engl J Med 2005
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“A significantly lower number of adenomatous polyps that were detected and removed by gastroenterologists who were sleep-deprived than by those who were not.”
Benson et al. AJG 2004
Sleep Deprivation Impacts Performance
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“The risks of adverse outcomes of elective daytime procedures were similar whether or not the attending surgeon had provided clinical care during the night.”
Sleep Deprivation Impacts Performance?
Govindarajan A et al. N Engl J Med 2015;373:845-853
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Sleep Deprivation Impacts Mood
Haack and Mullington. Pain, Volume 119, Issues 1–3, 2005, 56–64
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Habitual sleep group
Extended sleep group (10 hours/night for 4 days)
sleep/night4 hours8 hours
12
10
8
6
4
2
0
14
16
0 hours
Fin
ger
Wit
hd
raw
al
Late
ncy (
sec)
Sleep restriction Sleep extensionPain threshold ¯ Pain threshold
Roehrs et al., 2012Roehrs et al., 2006
Sleep Deprivation Alters Pain Thresholds
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§ Metabolic disturbance
§ Cardiovascular disease?
§ Pain syndromes
§ Immune system compromise
§ Cancer risk?
§ Mortality
Chronic Sleep Deprivation: Health Consequences
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Patel et al. Am J Epidemiol 2006;164:947-54
Chronic Sleep Deprivation: Weight gain
16 Yr Weight Gain:
5 Hours 9.1 kg
6 Hours 7.3 kg
7 Hours 6.1 kg
8 Hours 5.8 kg
9 Hours 6.6 kg
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Chronic Sleep Deprivation: Mortality
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Regulation of sleep and wakefulness
Additional factors
§ Sleep fragmentation/quality
§ Sleep disorders
§ Sleep inertia
§ Environmental factorsCOPYRIGHT
Sleep Health
RegUlar timings in and out of bed
Satisfactory sleep
Alertness
Time
Ease of falling or staying asleep
Duration
Buysse, D.J., 2014. Sleep health: can we define it? Does it matter?. Sleep, 37(1), pp.9-17; Harvey, Allison G., and Daniel J. Buysse. Treating Sleep Problems: a Transdiagnostic Approach. The Guilford Press, 2018.
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Countermeasures
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Identify the problem
§ Sleep insufficiency (<7 hours)
§ Poor sleep habits
§ Sleep disorder
May be > 1 item
Key: Defining the problemà
Tailor the treatment
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Symptom: Excessive daytime sleepiness
Won’t SleepCan’t sleep
enoughCan’t Sleep
-Insufficient sleep
-OSA
-Periodic leg movements
-Narcolepsy
Not enough Increase central
needFragmented
-Idiopathic Hypersomnia
-Sleep deprivation
-Poor sleep habits
Sleep study indicated
-Circadian rhythm disorders
-Shift work
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Sleep Insufficiency: Effects of sleep loss are cumulative
Belenky et al, J. Sleep Research, 2003
How much recovery sleep is needed is not well understood
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Symptom: Excessive daytime sleepiness
Won’t SleepCan’t sleep
enoughCan’t Sleep
-Insufficient sleep
-OSA
-Periodic leg movements
-Narcolepsy
Not enough Increase central
needFragmented
-Idiopathic Hypersomnia
-Sleep deprivation
-Poor sleep habits
Sleep study indicated
-Circadian rhythm disorders
-Shift work
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Sleep insufficiency: Sleep is the best countermeasure
§ Educate patients on cognitive and physical consequences
§ Devise a tailored plan to extend sleep
§ NAPS: may be strategic when external limitations
§ Effective prior to long bouts of sleep deprivation
§ Tip: Try at times at natural circadian dips (ex-2pm)
Won’t Sleep
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Other countermeasures
Driving strategies
§ turning up radio
§ opening window
§ chewing gum
§ cold air
§ Bright light
§ Exercise
§ Posture
§ Caffeine
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Caffeine
Credit HSPH
• Reduces some sleep-related deficits at doses of 75-150 mg
• Effects within 15 – 30 minutes; half-life 3 to 7 hours
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“Sleep Hygiene”: Practices that help sleep
§ Exercise
§ Daily routines
§ Treating medical problems
§ A comfortable sleep environment
§ Keeping your bed for sleep (and sex)COPYRIGHT
“Sleep Hygiene”: Practices that hurt sleep
§ PERSONAL ELECTRONIC DEVICES
§ PERSONAL ELECTRONIC DEVICES
§ Alcohol
§ Caffeine
§ Nicotine
§ A poor sleep environmentCOPYRIGHT
Minimize Blue Light Exposure
§ Orange tinted glasses
§ Manually reduce brightness
§ Nightshift (adjusted)
§ F.lux
§ Word processing: black background with whitelettersCOPYRIGHT
Symptom: Excessive daytime sleepiness
Won’t SleepCan’t sleep
enoughCan’t Sleep
-Insufficient sleep
-OSA
-Periodic leg movements
-Narcolepsy
Not enough Increase central
needFragmented
-Idiopathic Hypersomnia
-Sleep deprivation
-Poor sleep habits
Sleep study indicated
-Circadian rhythm disorders
-Shift work
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Lack et al., Sleep 2005;28(5):616-23; McCurry et al., J Am Geriatr Soc 2005;53(5):793-802. Buscemi et al., J Gen Intern Med 2005;20(12):1151-8;
Barion and Zee. Sleep Med. 2007 Sep;8(6):566-77..
Delayed sleep phase
§ Seasonal affective disorder
§ Adolescents / teenagers
§ Behavior contributors (screens, lights at bedtime)
§ Shift workers
Treatment
• Limit evening light
• Melatonin (dose 0.5-3 mg, 3-5 hrs before bedtime)
• Light therapy (1–3 hrs of 2,500–10,000 lux in am)*
NB: Timing of light can be tricky. Don’t
give too early.
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Shift Work
§ Take a nap before or during break
§ Try to keep the same schedule on work days anddays off.
§ Use moderate amounts of caffeine early in the shift
§ Avoid sunlight if you need to sleep during the day.Wear sunglasses.
§ Make others aware of your schedule—keepsleeping environment dark and quiet
§ Consider melatonin to shift/ light therapy
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Symptom: Excessive daytime sleepiness
Won’t SleepCan’t sleep
enoughCan’t Sleep
-Insufficient sleep
-OSA
-Periodic leg movements
-Narcolepsy
Not enough Increase central
needFragmented
-Idiopathic Hypersomnia
-Sleep deprivation
-Poor sleep habits
Sleep study indicated
-Circadian rhythm disorders
-Shift work
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Insomnia Disorder: Clinical Diagnostic
Criteria
DSM-V-TR
>3 months of
Difficulty
maintaining
sleep
Difficulty falling
sleepOR OR
Causes significant distress or impairment in functioning
AND
* Sleep problem cannot be accounted for by another sleep
disorder (e.g., sleep apnea), a medical problem, a substance
(e.g., alcohol, or medication), or a psychiatric condition.
Early morning
awakenings
* Vast majority do not have excessive daytime sleepiness—they can’t nap
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What Insomnia is Not
§ Sleep apnea
§ Circadian phase disorders
§ Restless legs syndrome
§ Night terrors
§ Sleepwalking
§ Nocturia
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Sleep on This:
Sleep Deprivation
§ Adversely impacts performance, though ability to recognize this deficit is poor
§ Increases propensity to commit errors and endangers worker safety, though impact on patient outcomes not clearly defined
§ Impacts short-term health and is associated with a multitude of chronic health consequences
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Effective Lifestyle Interventions for Sleep
§ Goals: Sleep at least 7 hours/night; improve sleep disruption/disorders to improve daytime function/outcomes
§ Identify causes of sleep disturbance/insufficiency
§ àTailor diagnostic and management plan accordingly
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Resources
§ Harvard Healthy Sleep Initiative
§ http://healthysleep.med.harvard.edu/
§ AASM Sleep Education: http://sleepeducation.org/
§ American Thoracic Society
§ Sleep Diary
http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf
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Thank you for your attention
Questions?
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