WestCare Sleep Disorders Center: Harris Regional Hospital SLEEP AND COLLEGE LIFE Waverly Green, III, MD Teresa Green, MD WestCare Sleep Disorders Center: Harris Regional Hospital Sylva, NC Sleep is a biological requirement, as essential and valuable as good nutrition and exercise. It is an active process that energizes and restores your brain and body. Getting enough uninterrupted and restorative - or quality sleep - gives you the potential to thrive and makes it possible to live a full life. Sleep is essential to your ability to perform both cognitive and physical tasks at your peak and engage fully in life. While sleep needs and patterns change from childhood into adolescence and through adulthood, sleep still plays a vital role and contributes to every aspect of your development--physically, psychologically, emotionally, and socially.

Overview Why Sleep is Important Consequences of Sleep Deprivation Recognizing Sleep Disorders Tips for Good Sleep Here is what we will cover today. Why sleep is important The consequences of fatigue in the workplace Shift work perils and countermeasures Common Sleep Disorders and Problems NSF Healthy Sleep Tips, educational materials, and national campaigns and programs

Sleep is Vitally Important... Growth and physical development Learning & memory consolidation Cognitive & physical performance Mood and emotional stability Health maintenance and prevention of disease Sleep is important for all these reasons. Sleepiness affects vigilance, reaction times, alertness, mood, hand-eye coordination, and the accuracy of short-term memory.1-2 Sleep and sleep-related problems also play a role in a numerous human disorders and affects almost every field of medicine. Recent research has shown that there is a connection between sleep and appetite control. You may be at risk of eating too much if you are continually sleep deprived, as many of us are. The lack of sleep sets off a chain of events that lowers the level of a hormone called leptin that causes people to overeat.3 Think of your body as a computer. Walking around in a sleep-deprived state is like working on a computer with a fragmented hard drive. You are not getting all the performance from that computer that you could. As you sleep, your body repairs itself and gets ready for the next day. References: 1. Bonnet MH. Sleep deprivation. In: Kryger M, Roth T, Dement W. editors, Principals and Practice of Sleep Medicine, 2nd ed. 1994. Philadelphia: W.B. Saunders. 1994. 50-67. 2. Dinges, D.F., Kribbs, N.B. Performing while sleepy: Effects of experimentally-induced sleepiness. In:Monk, T.H., ed. Sleep, Sleepiness and Performance. New York: John Wiley & Sons, 1991. 97-128. 3. Spiegel K et al. Leptin levels are dependent on sleep duration: relationships with sympathovagal balance, carbohydrate regulation, cortisol, and thyrotropin. J Clin Endocrinol Metab. 2004 Nov;89(11):5762-71.

Sleep Needs Vary Over the Life Cycle Newborns/ Infants 0 - 2 months 2 - 12 months 10.5-18 hours 14-15 hours Toddlers/ Children 12 - 18 months 18 months - 3 yrs. 3 - 5 yrs. 5 - 12 yrs. 13-15 hours 12-14 hours 11-13 hours 10-11 hours Adolescents/Young Adults On Average 9 hours Adults/Older Persons 7-9 hours Over the life cycle, our sleep needs and the amount of hours required to sustain a quality lifestyle vary.   Infants or newborn babies (up to 2 months) need 10.5-18 hours over a 24-hour cycle. Sleep is definitely a priority for new babies and they need a lot of sleep to grow and develop. From 2-18 months, the average baby requires 13-15 hours of sleep. Around 18 months and during the toddler or pre-school age, children need around 11-14 hours of sleep. When children reach the age of 5 they need 10 hours at night. Most children give up a nap by the age of 5. Adolescents need about as much sleep as when they were younger—8 ½ - 9 ½ hours. Although teens are often involved in activities that deprive them of sleep, it is just as important to their development. Teens experience a lot of daytime sleepiness due to chronic sleep deprivation. Adults perform best with 7-9 hours although most adults get between 4 and 10 hours of sleep. Contrary to a common myth, older adults need just as much sleep as younger adults; however, they often have more medical or sleep problems, they often do not sleep as efficiently due to pain, discomfort or disruptions and may not experience as much deep sleep as they age. Reference: Mindell J, Owens J. A clinical guide to pediatric sleep. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.

Yet… College Students are Chronically Sleep Deprived Average significantly less sleep (6-7 hours). A 2hr sleep debt each night! Most experience excessive daytime sleepiness on a regular basis (50-70%) Report twice as many sleep problems as the general population

Why? The obvious: The less obvious: Academic workload Social activities, extracurricular activities, and jobs Computer / internet / TV / cell phones Excessive caffeine use, alcohol and/or recreational drugs Delayed sleep phase and irregular sleep wake schedules

Class start times / delayed sleep phase Genetic predisposition Social pressures Academic workloads Class start times / delayed sleep phase Sleep Time Genetic predisposition Risk taking behavior including the use and abuse of recreational legal and illegal drugs and alcohol is extremely common in adolescence.11 These behaviors often contribute to problems with daytime sleepiness and are also an additive risk factor for Motor vehicular accidents. Forty percent have tried an illicit drug. Ninety percent of high school students have tried alcohol. Sleep problems are significantly more common in individuals using illicit drugs, alcohol and nicotine. There are an enormous variety of intrinsic and extrinsic factors that influence daily sleep amounts in the adolescent. These factors can affect not only the development of sleep disturbance, but also the development of a variety of awake behavioral problems and psychiatric illness in this population.12 11. Johnson EO, Breslau N. Sleep problems and substance use in adolescence. Drug Alcohol Depend 2001;64(1):1-7. 12. Halbower AC, Marcus CL. Sleep disorders in children. Curr Opin Pulm Med 2003;9(6):471-6. Substance abuse Computer, Internet, TV, Cell phones

Delayed Sleep Phase Sleep Schedule Contributing to the physical changes that occur as adolescence approaches, teens also experience a biological shift to a later sleep-wake cycle. Studies have found that, in teens, the sleep-inducing hormone melatonin is secreted later in the evening – around 11:00 pm – and also drops later in the morning. This sleep tendency to later times, often called a “delayed sleep phase syndrome,” puts teens into conflict with typical schedules, particularly early school start times. This slide shows what would be a natural sleep schedule for a teen. Many teens are physiologically not able to fall asleep before 11:00 pm. You can lie down earlier, but you might find it hard to actually fall asleep. After getting the 9 1/4 hours of sleep that you need in order to wake without an alarm clock or other intervention, a natural wake time would be around 8:00 am or so – again, putting you in conflict with earlier school start times. In order to get to classes on time, many students must wake early and shorten their sleep time.

QUESTION: What do the following disasters have in common? Three Mile Island Chernobyl Exxon Valdez Space Shuttle Challenger

QUESTION: What do the following disasters have in common? Three Mile Island Chernobyl Exxon Valdez Space Shuttle Challenger All are attributed in some degree to the poor judgment of sleep deprived workers.

Effects of Sleep Deprivation Impaired alertness/excessive daytime sleepiness Alertness is impaired after: 3 hrs of sleep for 1 night 5 hrs for 2 nights However, although the individual’s subjective sleepiness levels out, cognitive and performance impairment does not: * We are not always aware of the severity of our impairment *

Effects of Sleep Deprivation Impaired performance (cognitive and motor) Impaired short-term memory Decreased reaction time and judgment Increased number of errors Impaired information processing All of which can lead to lower academic performance… Sleepiness negatively affects mood, judgment, reaction-times, attention, vigilance, vision, short-term memory, and motivation—similar to alcohol. Sleep loss makes it easier to fall asleep at inappropriate times, affecting a worker’s ability to perform safely.1 It is important to for you to remember that a person does not have to fall asleep at the wheel to be a danger to themselves and others. Just being tired or drowsy can significantly impair your performance. 70% to 90% of industrial and transportation accidents are due to human error.2-3 References: 1. Dinges, DF. The Nature of Sleepiness: Causes, Contexts, and Consequences. In: Albert J. Stunkard & Andrew Baum (Eds.) Perspectives in Behavioral Medicine: Eating, Sleeping, and Sex. Hillsdale, N.J. Erlbaum; 1989: 147-180. 2. Heinrich, H. Industrial accident prevention (4th edition). New York: McGraw-Hill. 1959. 3. Nagel, D. Human error in aviation operations. In: E. Wiener and D. Nagel (Eds.) Human Factors in Aviation. San Diego: Academic Press. 1988; 263-303

Effects of Sleep Deprivation Would you ever take an test drunk?…… 18 hours awake produces performance impairment = 0.05% Blood alcohol level (BAL) 24 hours awake = 0.10% BAL. Chronic sleep restriction of 4-6 hrs for 2 weeks also results in performance deficits = 0.08% BAL On 4 hours sleep, 1 beer can have the impact of a six-pack.

Sleep and College Performance Study at St Lawrence Univ. “All nighters” correlated with lower GPAs Study at Stanford Univ. Academic and athletic performance in basketball players improved with lengthening of sleep time Study in South Korea Staying up late associated with poorer academic performance Study of sleep patterns in 111 students 2/3 had pulled all-nighters during the prior semester Students who pulled all-nighters had lower GPA’s Independent of procrastination, though also associated with decreased GPA

Effects of Sleep Deprivation Health Problems Mood disturbances – depression, irritability, and anxiety Weight gain Insulin resistance leading to diabetes Impaired immunity Increased cardiovascular problems – hypertension, stroke, heart attack

The Consequences of Sleep Deprivation on the Highway One of the most serious consequences of sleep deprivation is driving drowsy – leading to injury, and possibly, death.

Sleepiness and Driving 15-20% of all MVA’s felt to be sleep related. DOT estimates 100,000 MVA’s per year direct result of driver sleepiness/drowsiness. 1500 fatalities / 71,000 injuries per year. Excessive sleepiness 2nd leading cause of car accidents, and a major cause of truck accidents in the US. The peak age for fall-asleep driving accidents is 20. Drivers under 30 account for 2/3 of all drowsy-driving crashes.

Drowsy Driving Recognizing The Warning Signs Trouble focusing, keeping your eyes open or your head up Daydreaming; wandering/disconnected thoughts Yawning or rubbing your eyes repeatedly Drifting from your lane, tailgating, & missing signs or exits Feeling restless & irritable These are some of the signs that you should be self conscious while driving or before leaving for a trip. Sleep is very insidious and people are notoriously bad at estimating their own alertness, so you have to be very vigilant in looking for the slightest change in how you feel. Trouble focusing, keeping your eyes open or your head up Daydreaming; wandering/disconnected thoughts Yawning or rubbing your eyes repeatedly Drifting from your lane, tailgating, & missing signs or exits Feeling restless & irritable

Drowsy Driving Countermeasures While Driving Stop driving Pull off the road at a safe place and take a short nap Let a passenger take over the driving Consume caffeine (best combined with a nap) Don’t rely on “drowsy driving devices” Be aware of shoulder rumble strips “Old tricks” (e.g., turning up the radio, chewing ice) people use to “keep themselves awake” do not work for long. Just because your eyes are open does not mean that you are alert. Below are the only proven countermeasures to help prevent a drowsy driving and/or increase alertness for a sustained period of time: Stop driving - A very simple solution. This is the only sure way to save yourself. Find a place to sleep for the night (e.g., motel, friend’s house) Naps - Take 15 to 45 minute nap. More than 20 minutes can make you groggy for 15 minutes after or more after awakening. Let a passenger drive – It’s good to share driving, especially on long trips. Caffeine - Consume the equivalent of 2 cups of coffee. Caffeine is available in various manners (soft drinks, chewing gum, tablets) and amounts. Remember, caffeine takes about 30 minutes to enter the blood stream and will not greatly affect those who regularly consume it. Try taking caffeine and then a short nap to get the benefits of both. Alerting Devices – At this time, there are no validated devices available to alert drowsy drivers. There are a lot of “snake-oil” products out there. Be very wary about these devices. Continuous shoulder rumble strips – These are deep grooves placed on the side of a high-speed road, have been shown to be very effective in reducing off-the-road crashes. If you hit these, get off the road at a safe spot immediately – you may be tired.

Watch for Sleep Disorders Insomnia Affects up to 40% of college students Involves difficulty falling asleep or staying asleep, associated with daytime impairment Can be a normal reaction to short term stress When chronic can lead to long-term problems

Watch for Sleep Disorders Obstructive Sleep Apnea Airway closure during sleep, that leads to partial or complete pauses in breathing. This leads to drop in oxygen levels, rise in carbon dioxide levels, and eventually arousal from sleep Symptoms: snoring, pauses in breathing, gasping, frequent awakenings restless sleep, and daytime sleepiness Risk factors: obesity, male gender, small upper airway family history, neuromuscular disease

Watch for Sleep Disorders Restless Legs Syndrome Unpleasant, tingling, painful or restless feeling in the legs occurring primarily in in the evening. Worsened by rest/inactivity and relieved by movement. Can be associated with legs movements during sleep. Can be associated with sleep disruption and daytime sleepiness.

Watch for Sleep Disorders Narcolepsy Severe excessive daytime sleepiness and uncontrollable “sleep attacks”, sleep paralysis, and hallucinations at the onset of sleep May be associated with sudden episodes of muscle weakness triggered by emotional situations 1/2000 people and often diagnosed late due to subtlety of symptoms Can be very disabling, but is treatable with medications

When Should You Get Help? Trouble getting to sleep or waking up frequently during the night for several weeks Excessive daytime sleepiness (falling asleep at inappropriate times despite adequate sleep) Sudden attacks of sleep or muscle weakness (especially associated with emotional situations) Loud snoring or witnessed episodes of not breathing during sleep

Healthy Sleep Tips Maintain a regular sleep schedule, even on weekends. Allow for relaxing activities during the hour before sleep Create a sleep friendly environment: Go to bed only when sleepy and get out of bed if unable to fall asleep. Exercise daily, but not too close to bedtime Avoid caffeine, nicotine, and alcohol, especially in the late afternoon and evening Avoid naps, particularly in the late afternoon or evening Make Sleep a Priority! Establish a regular sleep schedule: going to bed and waking at the same time every day Creating a lifestyle that includes establishing a regular sleep schedule is a key step toward getting a good night’s sleep. This will allow you to get in sync with your natural circadian clock and sleep will come easier. A regular schedule keeps our brain and body in balance. This is just as important for the weekend. Keeping to this schedule at all times will improve your ability to fall asleep, maintain sleep and achieve restorative sleep - so essential to your quality of life.   Here are some tips for developing a healthy sleep style during the day: Avoid caffeine, alcohol and nicotine, especially close to bedtime. Caffeine is a stimulant that has alerting properties, so consuming products like coffee, tea, cola and chocolate within 6 hours before bed can cause disruptions to your sleep Nicotine is also a stimulant and may keep you from falling asleep. After it loses its effect and when you are sleeping, you may experience withdraw, which can again disrupt sleep or cause problems waking in the morning. Nicotine has been known to cause nightmares. Alcohol helps to relax people and promotes sleep, but just like nicotine, can cause disrupted sleep during withdrawal. Exercise, but not too close to bedtime. Overall, exercise helps to promote good sleep, but not too close to bedtime. During exercise our body temperature rises and we become more alert. After about 6 hours, the body cools down and helps to signal the body that it is time for sleep. Try exercising in the afternoon for best results. Avoid naps, particularly in the late afternoon or evening.