Rochelle Goldberg, MD, FAASM, FCCP, DABSM€¦ · 17-19 hours w/o sleep > BAC of 0.05% Response speeds, accuracy measures (different tests) Longer hours w/o sleep = BAC of 0.1% Williamson

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Rochelle Goldberg, MD, FAASM, FCCP, DABSM Associated Professor, Internal Medicine,

Sidney Kimmel Medical College Thomas Jefferson University, Philadelphia, PA

Director, Sleep Medicine Services, MLHS

I like to sleep.

No other conflicts related to this presentation.

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Define normal sleep needs

Explain sleep-wake control concepts

Define insufficient sleep

Discuss world wide implications of sleep loss

List health and functional consequences of sleep loss

Sleep needs change with age ◦ Age 5-1010-11h/n; age 11-17 8.5-9.5h/n;

adult 7-9h/n http://www.sleepfoundation.org/article/how-sleep-works

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◦ Homeostatic requirement (Process S)

Increased pressure for sleep the longer the duration of wake thru the day

◦ Circadian rhythm (Process C)

24 hour cycle controlled in suprachiasmatic nucleus in brain stem (sleep pacemaker), light-dark external influences

◦ Sleep inertia (Process W)

Cirelli, Nature Rev Neurosci 2010

Opponent process model

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Diagnostic criteria: ◦ Complaint of excessive sleepiness; ◦ Habitual sleep period (by hx, logs or actigraphy)

is shorter than age-adjusted normative data; ◦ Longer sleep time on weekends, vacations; ◦ PSG: latency <10 min, S Eff >90%; ◦ MSLT: generally short latency (<8min), w or w/o

SOREMPs; ◦ Sleepiness cannot be attributed to other sleep,

medical, neurologic, psychiatric disorders; or medications or substance abuse.

ICSD, second edition

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What is this compound?

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Question 1:

Joe Smythe is a 75 year old man. Prior to retirement he went to bed at 9pm and got up at 5am for work. Since his retirement 10 years ago, he usually goes to bed at midnight, and continues to get up at 5am.

Which of the following is most correct about Joe’s current sleep situation?

A. He should be fine, as he doesn’t need as much sleep now.

B. He should be fine, as long as he maintains the same schedule throughout the week.

C. He is likely to have increased insulin resistance.

D. He is likely to lose weight over time.

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National Health Interview Survey ◦ 30% adults

report <6 hrs/n

◦ 31% HS students reported >8 hrs/school night

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Insufficient rest or sleep among US adults

Shankar A, Syamala S, Kalidindi S (2010) Insufficient Rest or Sleep and Its Relation to Cardiovascular Disease, Diabetes and

Obesity in a National, Multiethnic Sample. PLoS ONE 5(11): e14189. doi:10.1371/journal.pone.0014189

IS prevalence (Finnish Twin Cohort) ◦ 1990 24.4% (16.2%

men, 23.9% women) ◦ 44% with IS in 1981,

still with IS 1990 ◦ In multivariate

analysis, 2/3 factors non-genetic

Hublin C. The Finnish Two Cohort. Sleep 2001; 24(4):392

CDC survey

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Drowsy driving is an acknowledged risk of IS ◦ 1,550 fatalities, 40,000 non-fatal injuries

annually National Department of Transportation

Correlation of drunk and drowsy driving ◦ 17-19 hours w/o sleep > BAC of 0.05%

Response speeds, accuracy measures (different tests)

◦ Longer hours w/o sleep = BAC of 0.1% Williamson AM. Moderate sleep deprivation produces impairments in cognitive and

motor performance equivalent to legally prescribed levels of alcohol intoxication. OccupEnvironMed 2000;57:649

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Microsleeps Errors (lapses, incorrect responses)

Cognitive slowing in subject based tasks Psychomotor responses Short term and working memory

Divergent thinking Compensatory effort to behavioral

effectiveness Performance w increased task duration

Situational awareness neglect “nonessentials”

Derived from: Goel N, Rao H.Neurocognitive Consequences of Sleep Deprivation. Semin Neurol 2009;

29(4): 320-339

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Which of the following has NOT (yet??) been associated with insufficient sleep?

A. Nicotine addiction

B. Weight gain

C. Increased C-reactive protein

D. Memory loss

E. Heart disease risk

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Weight gain/ Obesity

Diabetes

Hypertension

Cardiovascular Disorders

Stroke

Metabolic Syndrome

Dementia

Combination of medical conditions that increase the risk for: ◦ Heart disease ◦ Stroke ◦ Type 2 diabetes.

Conditions: ◦ increased blood pressure

high blood sugar ◦ excess body fat around the

waist ◦ abnormal cholesterol or

triglyceride levels.

KnutsonKL.The metabolic consequences of sleep deprivation.Sleep Med Rev 2007; 11(3):163

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Appetite/hunger responses with sleep deprivation

Healthy normal BMI subjects

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Insufficient rest/sleep and obesity

Odds ratios (95% confidence interval) of diabetes incidence over the follow-up period by sleep duration at baseline

Hours of Sleep Model 1 Model 2 Model 3 ≤ 5 1.91 1.57 1.47

(1.37-2.67) (1.11-2.22) (1.03-2.09) 6 1.25 1.19 1.08

(0.94-1.70) (0.88-1.60) (0.80-1.47) 7 1.00 1.00 1.00 8 1.16 1.09 1.09

(0.89-1.51) (0.84-1.43) (0.83-1.43) ≥ 9 1.85 1.57 1.52

(1.32-2.60) (1.10-2.24) (1.06-2.17)

Model 1 – Unadjusted. Model 2 – Adjusted for physical activity, depression, alcohol consumption,

ethnicity, education, marital status, and age. Model 3 – Adjusted for the variables in Model 2 plus overweight/obesity and hypertension.

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Insufficient rest/sleep and diabetes mellitus



Potential process for insufficient sleep and increased risk for diabetes

Knutson KL. The metabolic consequences of sleep deprivation. Sleep Med Rev 2007; qq(3):163-178.

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Insufficient rest/sleep and any cardiovascular disease (CVD)

Weekday vs weekend sleep >2 hours

Mean age 72.1

Ideal Cardiovascular Health (ICH) ◦ AHA 2020

Higher obesity and hypertension in IS group

Age, race adjusted still poorer ICH

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Insufficient rest/sleep and coronary heart disease (CHD)



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Insufficient rest/sleep and stroke.



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Pain perception (bidirectional)

Premature aging

Altered immune response with increased systemic inflammation

Workplace productivity

The ICU patient

Adolescents/teens-technology; driving risk

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Self-treat issues

Global business ◦ Coffee consumption increased 5% in 2013 ◦ 83% of Americans drink coffee

From Trade publication: NCDT 2013

See Addendum

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Suzie Doe is a 44 year old woman presenting with fatigue and sleepiness. She goes to bed at midnight and gets up for work at 6am. She is most concerned about recent weight gain. Which of the following factors, regarding her insufficient sleep, is most likely mechanism for the weight change?

A. She has decreased appetite for non-carbs.

B. She has increased ghrelin levels.

C. She has reduced insulin resistance.

D. She has increased leptin levels.

E. She drinks too many energy drinks.

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Epidemic: No one is exempt Basic RX: Sleep more ◦ “If you DON’T snooze, you lose!”

“Sleep deficiency contributes to the risk for several of modern societies’ medical epidemics, including CVD, diabetes, obesity and cancer.”

“[This is an]…opportunity for individuals, institutions and communities to promote good health…”

Coffee and tea (8-ounce) caffeine (mg)

Coffee, Drip 115-175

Coffee, Brewed 80-135

Coffee, Espresso (2oz) 100

B&J Coffee Fudge Fr.Yog 85

Coffee, Instant 65-100

Tea, iced 47

Tea, brewed, imported 60 (avg)

Tea, brewed, US brands 40 (avg)

Tea, instant 30

Tea, green 15

Hot cocoa 14

Coffee, Decaf, brewed 3-4

Coffee, Decaf, instant 2-3

Dark chocolate (1 oz) 20

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The Light Weights-Sodas Caffeine (mg)

Diet Rite Cola 0

Sprite 0

7-Up 0

Mug Root Beer 0

Diet Barq's Root Beer 0

Sundrop Orange 0

Minute Maid Orange 0

A&W Root Beer 0

Slice 0

Sierra Mist 0

Fresca 0

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Soft drinks (12-ounce) caffeine (mg)

Red Bull (8.2 oz) 80.0

Jolt 71.2

Mountain Dew / Diet 55.0

Kick Citrus 54.0

Mellow Yellow 52.8

Surge 51.0

Tab 46.8

Shasta Colas 44.4

RC Cola /Diet 43.0

Dr. Pepper / Diet 41.0

Mr. Pibb / Sugar Free 40.0

Red Flash 40.0

Sunkist Orange/ Diet 40.0-41.0

Slim-Fast Cappuccino

Delight 40.0

Ruby Red 39.0

Storm 38.0

Big Red 38.0

Pepsi-Twist,Jazz,Diet,Cherry/ Diet/ One 36.0-38.0/ 55.5

Aspen 36.0

Coke products / Diet 34.0 / 45.6

Snapple Flavored Teas (Reg /Diet) 31.5

Canada Dry Cola / Diet 30.0 / 1.2

A&W Creme Soda / Diet 29.0 / 22.0

Nestea Sweet Iced Tea 26.5

Nestea Unsweetened Iced Tea 26.0

Barq's Root Beer 23.0

Slim-Fast Chocolate Flavors 20.0

Snapple Sweet Tea 12.0

Lipton Brisk, All Varieties 9

Canada Dry Diet Cola 1.2

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Rochelle Goldberg, MD, FAASM, FCCP, DABSM€¦ · 17-19 hours w/o sleep > BAC of 0.05% Response speeds, accuracy measures (different tests) Longer hours w/o sleep = BAC of 0.1% Williamson