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Sleep & Rest Prof. Y.K. Wing Department of Psychiatry The Chinese University of Hong Kong.

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Presentation on theme: "Sleep & Rest Prof. Y.K. Wing Department of Psychiatry The Chinese University of Hong Kong."— Presentation transcript:

1 Sleep & Rest Prof. Y.K. Wing Department of Psychiatry The Chinese University of Hong Kong

2 Sleep is a natural repeated unconsciousness that we do not even know the reason for. Popper & Eccles 1977

3 Theories on the Functions of Sleep Evolutionary theories of sleep Humoral theories of sleep Body restitution theories of sleep Sleep and the motor system Sleep, memory & learning: cerebral development Heat conservation

4 Sleep & Wakefulness: Circadian rhythm Circadian rhythm, circa = around; dies = day (Franz Halberg) Control of rhythm – internal clocks and external cues (Zeitgeber: cues) Paired suprachiasmatic nuclei (SCN) of the hypothalamus – pacemaker function Clock genes (1990s)

5 Human Circadian Pacemaker Regulation of circadian period in humans was thought to differ from that of other species, with the period of the activity rhythm… median 25.2 hours… in adulthood, and to shorten with age. Now revealed that the intrinsic period of the human circadian pacemaker averages 24.18 hours in both age groups, with a tight distribution consistent with other species. Czeisler CA et al Science 1999

6 Models of Sleep Two-Process (S-C) Model Two Oscillator (x-y) Model Reciprocal Interaction Models of the NREM-REM Sleep Cycle REM-on vs REM-off cells

7 Measurement of Sleep Polysomnography measures electroencephalography (EEG) electromyography (EMG) electrooculorgraphy (EOG) electrocardiography (ECG) respiration

8 What is EEG? In EEG recording, the simultaneous activities of many cortical neurons are measured by extracellular macroelectrodes

9 Origin of EEG When thousands of neurons are excited simultaneously, the tiny signal from each cell sum up to generate one large surface signal. Asynchronous activity, on the other hand, produce irregular signals

10 Measurement of Sleep Polysomnography measures Electroencephalography (EEG) Electromyography (EMG) Electrooculorgraphy (EOG) Electrocardiography (ECG) Respiration

11 Sleep Pattern StageFeatures% sleep Wake EEG activities at 8-12 c/s I Drowsiness Activities 4-8 c/s, Slow rolling eye movements 5 II Light sleep EES sleep spindles at 12-14c/s, Single high voltage multiphasic K-complex 50 III Deep sleep Slow wave at 1-4 c/s about 25-50% of an epoch 5 IV Very deep sleep Slow wave at 0.5-2c/s over 50% of an epoch, No eye movement 15 REMStage I like EEG activities, rapid eye movement, absent or lowest muscle tone 25

12 Sleep pattern Difference between NREM & REM sleep Begins with deepening NREM sleep Interrupted about every 90 min by REM Sleep 4-6 NREM-REM cycles/night More REM towards morning

13 How much sleep do we need? Individual variation 8 hrs rule may not apply Sleep as essential vs luxury (cf food) Are we sleep deprived in modern era? Sleep deprivation: consequences

14 Variations in Sleep age related changes intra- & inter-individual differences long & short sleepers nutrition and body weight mood changes circadian rhythms drugs

15 Sleep Disorders Too little sleep (DIMS, insomnia) eg. stress related, anxiety, depression Too much sleep (DOES, hypersomnia) eg. sleep apnea, narcolepsy Sleep wake schedule eg. jet lag, shift work Undesirable behaviour at sleep (parasomnia) eg. sleep walking & terror, bed wetting, REM sleep behavioral disorder

16 Common Sleep Problems AgeSleep disorders 0 to 4 moNight waking & feeding are developmentally appropriate 4 to 12 moNight waking Demand for nighttime feeding 2 to 4 yrsDisorders of Initiating & maintaining sleep 3 to 8 yrsNight terrors 6 to 12 yrsSleepwalking, sleep talking AdolescenceDelayed sleep phase syndrome, Narcolepsy Any ageOSAS Thiedke CC Amercian Family Physician 2001

17 Excessive Daytime Sleepiness (EDS) Sleepiness that occurs at inappropriate or undesirable times or that interferes with daytime activities is general considered excessive by patients & clinicians Aldrich MS., 1999

18 EDS Sleepiness is pervasive in modern society EDS is a frequent symptom that has many possible causes Prevalence rates of EDS may vary from 0.3% - 13.3% (Schmidt-Nowara et al., 1991)

19 EDS – Common Causes Young adults: their quantity of sleep is insufficient as a result of poor sleep hygiene Elderly people: their quality of sleep is poor Shift workers: repeated violations of the circadian rhythm Others: they fall within the realm of pathology, whether primary, as in the intrinsic disorders of sleep, or secondary to a psychiatric, neurologic, or medical condition

20 EDS – Prevalence AuthorDefinition of EDSPrevalence Karacan et al. 1976Too much sleep0.3% Bixler et al. 1979Sleeping too much7.1% Partinen & Rimpela 1982 Excessive tendency to fall asleep during the day 3% Lugaresi et al. 1983Sleepiness independent of meal times 8.7% Klink & Quan 1987Falling asleep during the day12% Schmidt-Noware et al 1991 Falling asleep always/often as a passenger in moving vehicle 13.3% DAlessandro et al., 1995

21 Consequences of EDS EDS deleteriously affects work/school activities Affected social and/or marital life Exhibits a negative socioeconomic impact Increase the risk of a motor vehicle crash Ohayon, MM et al, 1997

22 Average Sleep Duration at Different Ages 4 years 10 years Mid adolescence Later adolescence 12 hours 9-10 hours 8.5 hours 7-8 hours

23 Sleep Disorders in Children 25 % of children experience some type of sleep disturbance Sleep problems may be associated with difficult temperament in children. Instead of appearing sleepy, the overtired child may appear overactive & inattentive. Wake up America, A National Sleep Alert January, 1993

24 Consequences of poor sleep Cause child to be more vulnerable to physical illness Limit parent-child bonding & later interaction Affect childs self-esteem Wake up America, A National Sleep Alert January, 1993

25 Consequence of sleep disorders Sleep disturbance can produce a range of cognitive impairments such as memory, attention, visuospatial abilities and creativity as well In general population, poor academic performance was associated with sleep deprivation Serious psychosocial problems (including alcohol and drug abuse) have been described as a consequence of sleep disturbance in adolescents Stores G 1999

26 Sleep deprivation & appetite Total sleep deprivation in humans has been associated with hyperphagia Leptin & ghrelin – hormones associated the central regulation of food intake Inadequate sleep seems to influence the hormones that regulate satiety & hunger in a way that could promote excess eating Van Cauter E et al 2004

27 Sleep Apnea Syndrome (SAS)

28 SAS Also called Sleep-related breathing disorder Symptoms Loud snoring EDS Morning dry mouth Associated with Mortality 2-3 folds Risk of traffic accidents 2-3 folds Stroke Coronary heart disease Cognitive impairment

29 Type of Sleep Apnea Central apnea thoracic and abdominal respiratory effect absent Obstructive apnea respiratory efforts persist but rendered ineffective by upper airway blockade Mixed apnea the episode begins with absence of respiratory effort followed by upper airway obstruction

30 Epidemiology of SAS 2-4% of general population Male, obese, middle-aged Sex ratio: 2-3:1 for male : female related to hormone? Obesity?

31 Treatment of SAS Obstructive SAS General Weight reduction Sleep hygiene Avoid alcohol/sedative drug Sleep position training Specific CPAP Surgery Dental appliance Central SAS Respiratory stimulants

32 Childhood OSAS Causes: adenotonsillar hypertrophy craniofacial anomalies neuromuscular disease laryngomalacia obesity

33 Sleep Walking

34 Sleepwalking: Definition SLEEPWALKING consists of a series of complex behaviors that are initiated during slow wave sleep and result in walking during sleep.

35 Sleepwalking: Incidence/Prevalence Between 1 and 15% of the general population. Most western studies reported 10-20% of healthy children have had at least one episode of sleepwalking. Above the age of 15 years, the incidence of sleepwalking is 1%. Equal distribution in both sexes.

36 Sleepwalking: Treatment Precautions: Home safety Medications (e.g. Clonazepam) Psychotherapy/Stress management Hypnosis?

37 Behavioral Avoid sleep deprivation. Avoid alcohol. Stress-management techniques.

38 REM Sleep Behavior Disorder (RSBD)

39 RSBD Symptoms violent behaviors during sleep attempt to enact dream injury to self or bed partner Epidemiology 0.5%-1% of the elderly population male, elderly

40 RSBD in Hong Kong SRI in a community sample of 1034 elderly 0.8% reported history of sleep-related injury. prevalence of RSBD of 0.38% (95% CI=0.01 to 0.76%). One subject had suspected RSBD Wing et al & Chiu et al Sleep 2000

41 Etiologies of RSBD Acute Toxic state Withdrawal state Chronic Idiopathic Parkinsons disease Dementia Vascular / neoplastic Fatal familial insomnia

42 Treatment of RSBD Long-acting benzodiazepine: Clonazepam, effective in about 90% of patients Other Medications: melatonin, tryptophan, antidepressants

43 Narcolepsy

44 Narcolepsy - ICSD Is a disorder of unknown etiology, which is characterized by excessive sleepiness that typically is associated with cataplexy &other REM sleep phenomena such as sleep paralysis & hypnagogic hallucinations ICSD 1990

45 What is cataplexy Sudden symmetrical muscle weakness precipitated by emotion (mostly laughter) DDX: convulsion, syncope

46 Narcolepsy In Hong Kong Wing et al 1994 & 1998 100% DR2 & DQW1+ve in Chinese Wing et al 2002Population prevalence rate: 0.034% (95%CI 0.01-0.117)

47 Genetic Breakthrough Lin et al 1999Novel gene mutation of hypocretin in canine narcoleptics Chemelli et al 1999Narcoleptic-like features in hypocretin knock-out mice Nishino et al 2000Low CSF hypocretin level in human narcoleptics Peyron et al 2000Loss of hypocretin-cell in human narcoleptics Mignot et al 2001Complex interaction of HLA association & hypocretin

48 Sleep wake schedule disorder Sleep-wake schedule problem Delayed sleep phase syndrome (DSPS) affect school / work / social function Jet lag industrial catastrophe Shift work e.g. nuclear plant accident

49 Local Sleep Research

50 Sleep in Child & Adolescent

51 Mean Sleep Duration in Weekday R 2 = -0.549 P<0.001

52 Mean Sleep Duration Weekday = 8.35 ± 1.36 Weekend = 10.05 ± 1.18 Holiday = 10.22 ± 1.06

53 Reported & Expected Sleep Duration SSI = Reported Sleep Duration / Expected Sleep Duration SSI < 0.8 = 23.3% Sleep Duration

54 Childhood Insomnia Difficulty in initiating asleep (DIS) Difficulty in maintaining sleep (DMS) Early Morning Awakenings (EMA)

55 Problem Prevalence (>3 times/wk) Sleep onset >30 min DIS3.6%26.6% Difficulty in Initiating Sleep

56 Problem Prevalence (>3 times/wk) Occurred in Recent 1 year DMS1.4%84% Difficulty in Maintaining Sleep

57 Sleeplessness among Chinese societies HKTaiwan*China** N5889651365 Age (range)12.3 (7-16)(13-15)14.6 (12-18) Frequency>3/wk>1/wk>2/wk>1/wk DIS3.6%10.6%27.2%10.8% DMS1.4%4.5%31.9%6.4% EMA1%1.7%22.3%2.1% Overall5.4%14.5%NA16.9% *Sleep 1995 18(8):667-673 **Sleep 2001 23(1):27-34

58 Chronic insomnia & school performance Insomnia was the most powerful predictor of school failure, more significant than parental education and profession. The rate of school failure among insomniacs was twice that of non- insomniacs Sleep Research 1990;19:1

59 Factors related to sleepless children Infancy Colic Middle ear disease Frequent nighttime feeds Early Childhood Poor bedtime routine Inappropriate napping Stressful or undesirable sleep onset associations Middle Childhood Difficulty getting to sleep Night-time fears Overarousal Advanced sleep phase syndrome Parasomnia Adolescence Sleep-disrupting disturbances (recreational, illicit) Circadian sleep-wake cycle disorders Psychiatric disorder A Clinical Guide to Sleep Disorders in Children & Adolescents by Gregory Stores 2001

60 Sleep in Secondary school students

61 Sleep pattern Sleep duration Weekdays:* Boys: 7.86 ± 0.94 Girls: 7.64 ± 0.86 Weekend:* Boys: 9.53 ± 1.42 Girls: 10.00 ± 1.08 *p<0.05

62 Sleep problems (1) Prevalence of Insomnia: Difficulty in falling asleep: 28.6% 10.2% need >30 min to fall asleep Intermittent awakening: 3.5% Early morning awakening: 3.3% no significant difference between gender

63 Sleep problems (2) Other abnormal behavior Mouth breathing: 11.6% Breathing difficulty: 8.7% Snoring: 12.5% Morning dry mouth: 11.7% Non-restorative sleep: 14.7%

64 Summary of local data Sleep duration decreases across age Students tend to compensate their sleep during weekend which may suggest that they might be sleep deprived during school days Difficulty to fall asleep was the most common problems among HK adolescents

65 Sleep deprivation among medical students

66 Prevalence of Insomnia (2004) FemaleMaleOverall DIS*39.9%29.0%35.5% DMS*17.5%15.0%16.5% EMA*14.0%9.4%12.2% SL > 30 min11.2%8.9%10.2% EDS 14 17.2%18.7%17.7% * sometimes or always

67 Sleep across medical years

68 Factors associated with sleep deprivation Risk Factors: Sleep Satisfaction index (SSI), morning unrefreshness, perceived stress & sleep was a determinant of their aspect Protective factor: adequate knowledge of sleep medicine

69 Conclusion Sleep deprivation was prevalent among Hong Kong medical students Sleep deprived students had significantly shorter weekday sleep hours but similar weekend sleep time than sufficient sleep group

70 Sleep in Adult

71 Epidemiology Study on Sleep in HK (1998) Random Sampling of Telephone Number Random Sampling of Family Member sample of households in HK from 1995 HK residential telephone directories Kish table selection age 18 - 65 Structured Questionnaire including demographic data, sleep habit, life style, UNS & SRQ Exclusion Criteria: Non-Chinese non-residential number fax machine age 65 9851 Success Interview

72 Prevalence of Insomnia in Hong Kong (1998) Telephone survey (n = 9851; age 18–65 yr) Li et al. 2002 Difficulty initiating sleep Difficulty maintaining sleep Early morning awakening Insomnia Prevalence (%) Last month – 3 episodes of symptoms weekly in last month Current – subjective report of frequent symptoms 0 5 10 15 20 25 18.5 11.8 7.3 3.9 8.9 6.8 9.3 4.5

73 Standardized prevalence of frequent insomnia Age and sex standardized frequent insomnia prevalence of HK in 1998 = 18.4% (95% CI: 17.6% - 19.3%) Median duration: 5 years Age and sex standardized frequent insomnia (+fatigue) prevalence of HK in 1998 = 12.6% (95% CI: 11.9% - 13.3%)

74 Risk factors of Insomnia Unemployment Lower economic status Alcohol consumption Regular medication Psychiatric disturbance Li RHY et al 2002

75 Sleep problems in Chinese elderly in HK N = 1,034 elderly subjects 75% occasional or persistent sleep disturbance 38.2% insomnia higher rate of insomnia in female than male factors associated with sleep disturbance poor perceived health past history of smoking current depressive disorders more chronic physical illness more life events more somatic complaints 2.8% had taken sleeping pills within a year Chiu et al Sleep 1999

76 Good Sleep Practices - DO Go to bed at about the same time every night Arise at about the same time each morning Exercise early in the afternoon Develop a nightly sleep ritual (e.g. snack at bedtime) Make your bedroom dark, cool & quiet

77 Poor Sleep Practices – DON T Drink caffeine in the afternoon Exercise within 3 hours of sleep Drink alcohol in the evening Smoke before sleep & during the night Use the bed for activities other than sleep & sex

78 Behavioral Technique for Insomnia Stimulus control therapy To curtail sleep-incompatible behaviors & to regulate sleep-wake schedules Go to bed only when sleepy Bed & bedroom only for sleep and sex Get out of bed if unable to sleep for 15-20 min, & return only when sleepy again Arise in the morning at the same time Do not nap during the day Morin CM et al.1994.

79 Contd Sleep restriction therapy to curtail the amount of time spent in bed Paradoxical intention to persuade a patient to engage in his or her most feared behavior e.g staying awake Sleep hygiene education health practices e.g. diet, exercise, substance use environmental factors e.g. light, noise, temperature Morin CM et al. 1994

80 General Strategies for Solving Problems Rehearsal and planning sessions 20 minutes in early evening; in a quiet room. Reflect on the day past. Encourage yourself with achievements. Consider problem areas and loose ends. Reallocate time to deal with these. Consider any other matters e.g. emotional, financial.. Write down the first or next positive step of action to take and when you will take it. If when in bed new thoughts intrude refer them on to next day.

81 Dealing with Frustration or Racing Thoughts Do not try too hard to fall asleep. State to yourself with sleep will come when it is ready, that relaxing in bed is almost as good. Try to keep your eyes open in the darkened room and as they (naturally) try to close tell yourself to resist that just for another few seconds. This procedure tempts sleep to take over. Try to ignore irrelevant ideas and thoughts. Visualize a pleasing scene or try repeating a semantically neutral word (such as the) subvocally every few seconds.

82 Thank You

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