Amanda Finegold Swain, MDUniversity of Pennsylvania

Student Health Service

Review elements of the normal sleep cycleIdentify common reasons for interrupted

and/or non-restorative sleep in the college-age population

Discuss consequences of disturbed sleep Briefly review treatment optionsDiscuss proper sleep hygiene

An estimated 25-30% of the general adult population, and a comparable percentage of children and adolescents, is affected by decrements in sleep health that are proven contributors to disability, morbidity, and mortality

The contribution of sleep health to living free of preventable disease, disability, injury, and premature death was recently recognized by its inclusion for the first time in Healthy People 2020, a Department of Health and Human Services initiative

National Institutes of Health Sleep Disorders Research Plan, November 2011

National Sleep Foundation. Sleep in America polls. http://www.sleepfoundation.org/article/sleep-america-polls/2005-adult-sleep-habits-and-styles

Nearly 70% of high school adolescents sleep less than the recommended 8-9 hours of sleep on school nights despite a physiological need. Short sleep in this age group is associated with suicide risk, obesity, depression and mood problems, low grades, and delinquent behavior.1,2

Nationwide, 70% of adults report that they obtain insufficient sleep or rest at least once each month, and 11% report insufficient sleep or rest every day of the month.3

1 National Sleep Foundation, 2006 Sleep in America Poll, Washington, D.C. [http://www.sleepfoundation.org/article/sleep-america-polls/2006-teens-and-sleep]

2 Centers for Disease Control. Youth Risk Behavior Surveillance — United States, 2009. Morbidity and Mortality Weekly Report 59:1

3 Centers for Disease Control. Perceived Insufficient Rest or Sleep Among Adults—United States, 2008. Morbidity and Mortality Weekly Report 58:1179.

Sleep is not just time when you are not awake!

Sleep appears to be “an active process during which the brain is involved in a variety of activities that are as complex as those occurring during wakefulness”

Stages and architecture of normal sleep, Mark R. Pressman, PhD, from UpToDate, reviewed last 5/17/2011

Stage N1 sleep is the transition from wakefulness to sleep

Stage N2, “intermediate” sleep, accounts for 40 to 50 percent of the total sleep time

Stage N3 sleep, “deep sleep”, typically accounts for 20 percent of the total sleep time

Stages and architecture of normal sleep, Mark R. Pressman, PhD, from UpToDate, reviewed last 5/17/2011

normally recurs every 90-120 minutesMakes up 20-25% of sleep timeEEG pattern resembles an active, awake EEGInactivity of all voluntary muscles, except the

extraocular muscles, “atonia”

Stages and architecture of normal sleep, Mark R. Pressman, PhD, from UpToDate, reviewed last 5/17/2011

ICSD-2 lists 8 categories of sleep disorders: Insomnia Sleep related breathing disorders Hypersomnias of central origin Circadian rhythm sleep disorders Parasomnias Sleep related movement disorders (Restless Leg Syndrome) Isolated symptoms and normal variants Other sleep disorders ICSD-2 includes over 70 specific diagnoses within the eight

major categories, as well as two appendices for classification of sleep disorders associated with medical or psychiatric disorders.

American Academy of Sleep Medicine, International Classification of Sleep Disorders

InsomniaSleep cycle disturbance“Other”: OSA, RLS, parasomnias,

hypersomniasExternal factors

Difficulty falling and/or staying asleep or non-restorative sleep

Associated with marked distress or significant daytime impairment

SubjectiveAcute/chronic/primary/secondaryNot sleep deprivation!

Morgenthaler T; Kramer M; Alessi C et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. SLEEP 2006;29(11):1415-1419.

Impaired daytime function is reported by most patients. The following are among the most common complaints:

Fatigue Poor attention or concentration*Social or vocational dysfunctionMood disturbanceReduced motivation or energy Increased errors or accidentsTension, headache, or gastrointestinal symptomsOngoing worry about sleep

*can be misdiagnosed as ADDOverview of Insomnia, Bonnet, M et al, UpToDate, reviewed 9/28/12

Circadian rhythm disorders are characterized by chronic or recurrent sleep disturbance due to misalignment between the environment and an individual's sleep-wake cycle

Examples include shift work, jet lag, advanced and delayed sleep phase disorder

DSPD is particularly common in young people, may not be academically sustainable even if socially acceptable

Associated with concurrent depression approximately 50% of the time

International classification of sleep disorders, 2nd ed: Diagnostic and coding manual, American Academy of Sleep Medicine

American Sleep Association, www.sleepassociation.org

American Academy of Sleep Medicine, and Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6):541.

Change in environmentbed, roommate, external noise, lighting, Frequent changes in routine (weekday vs

weekend)Alcohol useDrug use (prescription and illicit)CaffeineDepression and/or anxiety

Should be part of eval for everystudent with sleep complaints

A number of bodily systems are negatively affected by inadequate sleep: the heart, lungs and kidneys; appetite, metabolism and weight control; immune function and disease resistance; sensitivity to pain; reaction time; mood; and brain function

Poor sleep is a risk factor for depression and substance abuse

Driving sleep deprived=driving while intoxicated

Metabolism slows when one’s circadian rhythm and sleep are disrupted

Both adults and children are more likely to be overweight and obese the less they sleep at night

“A sleepy brain appears to not only respond more strongly to junk food, but also has less ability to rein that impulse in”.

“How Sleep Loss Adds to Weight Gain”, Anahad O’Connor, New York Times, 8/6/13

Dreaming may reactivate and reorganize recently learned material, which would help improve memory and boost performance

Memories seem to become more stable in the brain during the deep stages of sleep (REM)

The brain is less effective at absorbing new information without sleep

Mood disorders are found in one-third to one-half of patients with chronic sleep problems

Insomnia is part of the diagnostic criteria for anxiety, depression, PTSD

Poor sleep associated with increased risk of depression and suicidality, and poor impulse control

Two-way street/chicken and egg issue

Sleep hygiene counselingMedicationSleep center treatment may include:

Sleep logs Cognitive therapy Relaxation therapy Biofeedback Sleep restriction Paradoxical intention Phototherapy Chronotherapy

Short-term use of short-acting hypnotics has been shown to be effective in reducing problem sleepiness associated with acute insomniaBenzodiazepines (Restoril, Ativan)Non-benzodiazepine sedatives (Sonata, Ambien,

Intermezzo, Lunesta)Melatonin agonists (Rozerem)

Decrease sleep latency, number of awakenings, increase sleep duration

Treatment of insomnia. Bonnet, M and Arand, D, UpToDate, reviewed 9/10/12.

Antidepressants (Trazodone, doxepin)Antihistamines (Benadryl)Herbal remedies (Valerian)OTC remedies

residual daytime sedation drowsinessdizziness, lightheadednesscognitive impairmentmotor incoordinationdependence complex sleep-related behaviors

Treatment of insomnia. Bonnet, M and Arand, D, UpToDate, reviewed 9/10/12.

Variety of sleep practices that contribute to having good quality sleep and daytime alertness

Mostly common sense

Keep a regular sleep schedule, aim for about the same bedtime and get up at the same time every day. Try not to vary this by more than 2 hours on the weekends. Avoid naps! They can upset your sleep/wake cycle. If you must, you can try napping for about 10-15 minutes but no longer. No caffeine later than mid-day. Exercise! Aim for earlier in the day as exercise in the 4 hours before bedtime can actually wake your body up instead of making you tired. Have a bedtime routine. This helps prepare your body for sleep. For example, stop work/tv/computer at least 30 minutes before bed and do something relaxing and quiet. Try listening to music, reading, or writing in a journal. Do not drink alcohol or use tobacco in the 4 hours leading up to bed. These can act as stimulants that interfere with your quality of sleep. Make sure your bed and bedroom are comfortable, dark and quiet. Use ear plugs, a white noise machine, and/or a night mask if you need to. Turn your clock away from your bed. If you can’t fall asleep then get up and do a quiet activity until you start to feel sleepy. Decrease stress in whatever ways possible! If you tend to lie awake thinking at night then keep a “worry journal” near bed and before you turn out the light make a “to-do” list for the next day or write down any other concerns you might have. Think of the journal as place to keep these things so that they can’t distract you overnight.

Keep in mind, resetting one’s sleep cycle can take weeks!

Ask about sleepNeed to educate students on what is “normal”Ask about depression and anxietyExternal factors play a huge role in college

student sleep issuesMedication can be helpful but usually is notConsider creating a sleep hygiene handoutKnow when to refer

US Dept of HHS: “At A Glance: Healthy Sleep”, NIH Publication No. 09-7426 August 2009. National Institutes of Health Sleep Disorders Research Plan, November 2011 http://www.nhlbi.nih.gov/health/prof/sleep/pslp_pat.pdf Stages and architecture of normal sleep, Mark R. Pressman, PhD, from UpToDate, reviewed last 5/17/2011 International classification of sleep disorders, 2nd ed: Diagnostic and coding manual, American Academy of

Sleep Medicine American Sleep Association, www.sleepassociation.org Classification of sleep disorders, Judd B. and Sateia, M. UpToDate, reviewed 4/1/2011 Morgenthaler T; Kramer M; Alessi C et al. Practice parameters for the psychological and behavioral

treatment of insomnia: an update. An American Academy of Sleep Medicine report. SLEEP 2006;29(11):1415-1419.

Sleep in Mood Disorders. Peterson, M et al. Sleep Medicine Clinics. Volume 3, Issue 2, June 2008, Pages 231–249

Overview of Insomnia, Bonnet, M et al, UpToDate, reviewed 9/28/12 Treatment of insomnia. Bonnet, M and Arand, D, UpToDate, reviewed 9/10/12. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a

week of sleep restricted to 4-5 hours per night. Dinges, DF et al. Sleep. 1997 Apr;20(4):267-77. Perogamvros L. Front Psych. 2013 Jul 25;4:474. doi: 10.3389/fpsyg.2013.00474. eCollection 2013 Prescriber’s Letter, www.prescribersletter.com Understanding sleep disorders in a college age population, Jensen, D. Journal of College Counseling, Spring

2003, Volume 6. http://dietary-supplements.info.nih.gov “Cheating Ourselves of Sleep”, Jane Brody. New York Times, 6/17/13 “How Sleep Loss Adds to Weight Gain”, Anahad O’Connor, NYT, 8/6/13 http://www.health.harvard.edu/blog/categories/health/sleep