1. Dr Neil Stanley Independent Sleep Expert
Why does sleep matter?
Dr Neil Stanley
Independent Sleep Expert

2. Myths in nocturia management
…and related sleep disturbance, are not important and do not need treatment’
…is a disease of the elderly male, and a natural part of the ageing process’
…is only a symptom of some other underlying disorder, and is attributable to overactive bladder (OAB) in women, and benign prostatic obstruction (BPO) in men’
‘Nocturia …

3. The importance of sleep‘
If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process ever made 1 ’
1. Rechtschaffen. The Control of Sleep. In: Hunt, editor. Human Behaviour and its Control. Cambridge, MA: Schenkman; 1971 3

4. Function of sleep
Sleep remains a biological enigma, but is needed for recuperation and restoration of physical and mental functioning
It is important for optimal functioning of the endocrine, metabolic and immune systems
Affects all organs of the body
Sleep deprivation disrupts biological rhythms
Hunter. EMBO reports 2008;9:1070–1073

5. Different stages of sleep (1)
Non-REM (NREM) sleep (75–80%)
Increasing sleep depth and decreasing muscle tone
Decreasing respiratory and heart rates, and decreasing eye movement
Physical rest and restoration of immune system
Stage 1: transition from awake to sleep (1–5%)
Stage 2: true sleep (45–50%)
Stage 3:
Stage 4:
deep, slow-wave sleep (SWS: 25–27%)
SWS characterised by slow breathing, low heart rate, low cerebral blood flow – deepest sleep
REM, rapid eye movement

6. Different stages of sleep (2)
REM sleep (20–25%)
Irregular breathing and increased heart rate
Very low muscle tone
Vivid dreams
Psychological rest, emotional well-being and memory
'Story-like' dream structure but forgotten unless waking occurs at this time 6

7. Restorative sleep (SWS) occurs in first part of night
Normal sleep hypnogram
Stages
Awake 1
REM
REM
REM
REM
REM 2 3
SWS 4
Hours of sleep 1 2 3 4 5 6 7 8
SWS
SWS, slow-wave sleep
Stanley. Eur Urol Suppl 2005;3:17–23 7

8. The time of awakening is important for daytime functioning
Awakening from REM sleep is most natural moment for arousal
Waking up during the first 3–4 hours of the night (slow-wave sleep) is more likely to leave a person groggy and tired during the following day than waking up later at night
…and remember, every time a person awakes, it is probable that their partner is woken too…
Stanley. Eur Urol Suppl 2005;3(6):17–23 8

9. Lack of SWS has physiological consequences
There is a clear role for SWS in the maintenance of normal glucose homeostasis
This suggests that reduced sleep quality with low levels of SWS may contribute to an increased risk of type 2 diabetes
Tasali et al. Proc Natl Acad Sci USA 2008;105:1044–1049

10. Sleep dysfunction: effects of daytime sleepiness
Poor sleep associated with deficits in daily functioning:1,2
Mood disturbance
Cognitive and memory impairment
Reduced performance at work
Poor sleep associated with reduced health:1–4
↑ Morbidity and mortality
↑ Risk of falling, traffic and occupational accidents
↑ Risk of cardiovascular disease and diabetes3
↑ Risk of depression4
↑ Healthcare costs
↓ Immune response
1. Carskadon. Med Clin North Am 2004;88:767–776; 2. Dinges et al. Sleep 1997;20:267–277
3. Newman et al. J Am Geriatr Soc 2000;48:115–123; 4. Buysse. Geriatrics 2004;59:47–52 10

11. Sleepiness leads to traffic accidents
Fatigue is thought to be involved in 16–60% of road accidents1,2
Even moderate sleep deprivation is at least as dangerous whilst driving as low-level alcohol intoxication1,2
The most vulnerable times for accidents are between
2 am and 7 am, and in the mid-afternoon3
1. Williamson & Feyer. Occup Environ Med 2000;57:649–655; 2. Asplund. Eur Urol Suppl 2005;3:24–32; 3. Horne & Reyner. BMJ 1995;310:565–567

12. But why are we discussing sleep at a urology congress?

13. Nocturia is the leading cause of sleep disturbance in older adults
How often do the following disturb your sleep? 90
n=1424; aged 55–84 80
Nocturia
Headache 70
Physical pain
Money problems
Care-giving
Family problems 60
Health concerns
Uncomfortable bed
Prevalence (%) of self-reported causes of disturbed sleep
Cough 50
Night-time heartburn 40 30 20 10
Every
Few
Few
Rarely
Never
night/almost
nights/ week
nights/ month
every night
National Sleep Foundation. Annual Sleep in America Poll (2003); Bliwise et al. Sleep Med 2009;10:7–8

14. Nocturia makes people feel like they sleep badly
Respondents with nocturia:
Significantly more likely to define themselves as having insomnia (p<0.0001)
Significantly more likely to report low sleep quality (p<0.0001)
Nocturia is independent predictor of poor sleep regardless of gender and comorbid medical conditions
Bliwise et al. Sleep Med 2009;10:7–8

15. Nocturnal waking associated with sleepiness, naps and sick leave in general adult population
Nocturnal awakening frequency/week * * *
*p<0.001 vs
awakening <3 nights/week * * *
Proportion of patients * * *
Telephone survey. Participation rates: 85.6% in California, 81.3% in New York and
83.2% in Texas.
Daytime sleepiness
Naps per week
76% of respondents reported need to go to the toilet as reason for awakening
43% of subjects with nocturnal awakenings reported having great difficulty resuming sleep once awakened
Ohayon. J Psychiatr Res 2008;43:48–54

16. Desmopressin prolongs the first period of sleep beyond the SWS
Adapted from Diekelmann & Born Data on duration of first sleep period taken from Van Kerrebroeck et al suggest that slow-wave sleep (SWS) sleep is disturbed in nocturia patients and that treatment with desmopressin may preserve the SWS period
Reprinted by permission from Macmillan Publishers Ltd: Diekelmann S & Born J. The memory function of sleep. Nat Rev Neurosci 11(2):114–126, copyright 2010.
Slow-wave sleep is disturbed in nocturia patients and desmopressin prolongs the first sleep period beyond the SWS1,2
1. van Kerrebroeck et al. Eur Urol 2007;52:221– Diekelman & Born. Nat Rev Neurosci 2010;11(2):114–126 17 17

17. Poor sleep predicts life dissatisfaction
Poor sleep predicts a consistent pattern of life dissatisfaction
Poor sleep may have direct impact on brain, emotions and mood
Paunio et al. Am J Epidemiol 2009;169:206–213

18. Nocturia is associated with reduced QoL in patients with LUTS43
Nocturia is associated with reduced QoL in patients with LUTS
Percentage of patients with LUTS rating QoL as good or very good
90.6
42.9
Non-nocturics
Nocturics
Amongst LUTS patients, the proportion who rate QoL as good is more than halved if nocturia is present
QoL, quality of life; LUTS, lower urinary tract symptoms
Hernandez et al. Curr Med Res Opin 2008;24:1033–1038 19

19. Conclusions: why does sleep matter?
Sleep is vital for:
Fragmented sleep can impair all of these
Nocturia is the major cause of fragmented sleep and therefore has many non-trivial consequences
Nocturia should be treated to bring meaningful benefits for the patient
Health
Well-being
Alertness
Essential biological/
physiological rhythms