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SLEEP DEPRIVATION

SLEEP DEPRIVATION. Jeffrey Lin, M.D. Fellow, Sleep Medicine Stanford University Medical Center 5/6/2009. http://davidavery.files.wordpress.com/2008/04/sleep-deprived.jpg. OBJECTIVE. History of sleep deprivation studies Animal Studies Defining sleep deprivation

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SLEEP DEPRIVATION

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  1. SLEEP DEPRIVATION Jeffrey Lin, M.D. Fellow, Sleep Medicine Stanford University Medical Center 5/6/2009 http://davidavery.files.wordpress.com/2008/04/sleep-deprived.jpg

  2. OBJECTIVE • History of sleep deprivation studies • Animal Studies • Defining sleep deprivation • Consequences of sleep deprivation • Treatment of sleep deprivation • Liabilities of sleep deprivation • Current studies regarding sleep deprivation

  3. HISTORY OF SLEEP DEPRIVATION • 1894: Marie De Manaceine conducted the first documented animal studies • Kept puppies awake for 5 days • 1896: Patrick and Gilbert conducted the first human studies • 90 hour sleep deprivation • 1960: Dement conducted first partial sleep deprivation • REM sleep deprivation • 1964: Randy Gardner stayed awake for 264 hrs • 1989: Rechtschaffen performed sleep deprivation studies with mice using the disk-over-water method

  4. DISK-OVER-WATER METHOD http://web.bvu.edu/faculty/ferguson/Course_Material/polysomnographs/Sleep%20Deprivation%20Data/Apparatus.jpg

  5. FLOWER POT METHOD https:/.../attachments/34242959/flowerpot.jpg

  6. ANIMAL STUDIES • Scrawny appearance w/ disheveled fur. • Severe lesions on the tail and paws...no apparent cause was found • Increased food intake; consumption doubled during the latter phases of deprivation • Increased energy expenditure; doubled during the latter phases of deprivation • Decrease in body temperature, beginning about half way through the survival period • Weight loss; 18% - 20% drop in body weight. • Death; all experimental animals (but no control animals) died after 11-32 days of deprivation • No significant post-mortem differences in the brains or other major organs Bergmann, Fang, Kushida, Everson, & Rechtschaffen, 1986

  7. RANDY GARDNER www.kk.org/quantifiedself/2007/10/eleven-days...

  8. RANDY GARDNER • Stayed awake for a high school science project • Had 2 of his friends keep him awake • Clinical condition monitored • Dr. William Dement • Lt. Cmdr. John Ross

  9. TIMELINE OF EVENTS • Day 1 – Woke at 6 am and ready to go • Day 2 – Difficulty focusing eyes and signs of astereognosis • Day 3 – Moodiness, some sign of ataxia, inability to repeat tongue twisters • Day 4 – Irritability and uncooperative attitude, memory lapses and difficulty concentrating. First illusion/delusion Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

  10. TIMELINE OF EVENTS • Day 5 – More hallucinations • Day 6 – Speech slowing and difficulty naming common objects • Day 7 – Irritability and speech slurring • Day 8 – Increased memory lapses • Day 9 – Episodes of fragmented thinking • Day 10 – Paranoia focused on a radio show. Able to beat Dr. Dement on pinball Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

  11. TIMELINE OF EVENTS • Day 11 – Expressionless appearance, speech slurred and without intonation. Unable to perform serial 7’s past 65 because he forgot what he was doing. • Final day – Appeared in a press conference. “I wanted to prove that bad things didn’t happen if you went without sleep.” Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

  12. TIMELINE OF EVENTS • Day 12 - Fell asleep for 14 hrs and 40 minutes • Stayed awake for 24 hrs, then slept a normal eight hours Moorcroft, W.H. Sleep, Dreaming & Sleep Disorders (1993)

  13. HOW MUCH SLEEP? • Quantity of sleep • How long a patient would sleep if left to awaken spontaneously • How alert the patient feels after different quantities of sleep • Quality of sleep • Appropriate distribution of sleep stages • Timing of sleep • Synchronization of process C and S Pressman, Mark. Definition and consequences of sleep deprivation. UpToDate

  14. QUALITY OF SLEEP • Arousals can occur • Spontaneously • Secondary to sleep disorders • More frequent the arousal, more sleepiness during the day • Artificially disrupting sleep 60 times/hr X 2 days equals 40 – 60 hrs of total sleep deprivation • Sleep disturbance 5 times/hr can affect performance • Even acoustic tones that only caused EEG arousals increased daytime sleepiness Bonnet, MH. Effect of sleep disruption on sleep performance and mood. Sleep 1985; 8:11 Martin, S, Wraith, PK, Deary, IJ, Douglas, NJ. The effect of nonvisible sleep fragmentation on daytime function. AJRCCM 1997; 155:1596

  15. SLECTIVE SLEEP DEPRIVATION • Selective REM deprivation increases the propensity of a subject to enter REM sleep • Night 1 – 17 awakenings • Night 2 – 42 awakenings • Night 3 – 68 awakenings • Subjects required 5-7 times as many arousals to deprive them of SWS vs. REM Agnew HW Jr et. Al. Percept Mot Skills 1967;24:851-8

  16. HOW MUCH SLEEP? • There is wide variation • American average 6 hrs and 40 min • Most desire 40 more min • Societal pressures are decreasing the average sleep time • Wehr: 8.5 hrs • Sleep < 4 hrs or > 10 hrs have increased mortality Wehr, TA et. Al. Am J Physiol 1993; 265:R846-57

  17. MORTALITY AND SLEEP

  18. MORTALITY AND SLEEP

  19. CONSEQUENCES OF SLEEP DEPRIVATION • Physical effects • Increased appetite • Temperature disregulation • Shakiness • Headaches • Increased pain sensitivity • Decreased in immune function Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

  20. IMPARED IMMUNE FUNCTION • 31 healthy males • Night 1 : uninterrupted sleep • Night 2 : awake until 3 am • Blood drawn every 30 min • Sleep monitored by EEG Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

  21. VARIATIONS IN CONCENTRATION Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

  22. IMPARED IMMUNE FUNCTION • IL-6 level rise was delayed in the PSD group • Elevated levels of IL-6 associated with Stages 1,2, and R • IL-6 levels during SWS similar to awake • Similar findings with GH release • Cortisol and melatonin levels did not show such shift Redwine L, et al. J Clin Endocrinol Metab 2000 Oct; 85(10):3597-603

  23. IMPARED IMMUNE FUNCTION • 25 subjects, restricted to 6 hrs of sleep X 1 wk • IL-6 was increased in both sexes • TNF – alpha was increased in men • Peak cortisol secretion was lower • More pronounced in men Vgontzas AN et. Al. J Clin Endocrinol Metab 2004 May;89(5):2119-26

  24. IMPARED IMMUNE FUNCTION • 42 healthy men • Two 2-hr naps daily Vs. total sleep deprivation X 4 days • Blood draws every 6 hrs • Compared to PSD subjects, TSD subjects had elevated TNF-alpha and IL-6 levels on day 4 Shearer WT, et al. J Allergy Clin Immunol 2001 Jan;107(1):165-70

  25. PSYCHOLOGICAL EFFECTS • Irritability • Poor concentration • Aggression • Apathy • Time and place disorientation • Loss of emotional control • Paranoia • Sleepiness Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

  26. PSYCHOMOTOR CHANGES • Perceived exhaustion on endurance test • Decrements in speed and accuracy • Most obvious on long and monotonous tasks Ansch, Browman, Mitler, and Walsh. Sleep: A Scientific Perspective (1988)

  27. SOCIETAL EFFECTS www.personalfinanceanalyst.com/.../

  28. SOCIETAL EFFECTS • 24 – hour society • Car accidents : 90,000 per year • American Airlines 1420 crash • Chernobyl disaster • Exxon Valdez grounding • Shift work • On-Call duties

  29. MAGGIE’S LAW • July 20, 1997: Maggie McDonnell was killed in a head-on collision in Clementon, NJ • The driver of the van had been awake for 30 hrs and smoked crack cocaine before the crash • He was acquitted because the lawyer argued that falling asleep was not a crime • August 2003: Maggie’s law passed in NJ • If a fatal accident was caused by a driver who stayed awake > 24 hrs, they can be charged with vehicular homicide, up to 10 years in prison, and $100,000 fine • August 2005: Man was sentenced to 5 yrs in state prison for killing another driver after being sleep deprived for > 24 hrs Death by auto o vessell. N.J.S.2C.11-5, pub. L. 2003 c. 143. August 5, 2003

  30. COMMERCIAL DRIVERS • August 2005: US Federal Motor Carrier Safety regulations • Drivers may only drive for 11 hrs in any one day • Must have 10 hrs free from duty the day before work • Workday can not be longer than 14 hrs • Restriction on the total number of hrs worked in a week • Prevalence of drivers sleeping < 5 hrs: 13.5% Federal Motor Carrier Safety Administration. HOS regulations. 2005

  31. GROUNDING TIME

  32. Reddy, R. et al. Chest 2009; 135:81-85

  33. Reddy, R. et al. Chest 2009; 135:81-85

  34. 9 + 4.4 minutes 4.8 + 4.1 minutes Reddy, R. et al. Chest 2009; 135:81-85

  35. HOUSESTAFF VS. FACULTY Marcus CL, Loughlin GM. Sleep 1996; 19:763-766

  36. HOUSESTAFF VS. FACULTY Marcus CL, Loughlin GM. Sleep 1996; 19:763-766

  37. TREATMENT FOR SLEEP DEPRIVATION www.flickr.com/photos/doncolleen/1528345670/

  38. TREATMENT FOR SLEEP DEPRIVATION • Limiting time on task • Physical fitness • Exercise • Rest breaks (5-20 min) • Napping • SLEEP Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

  39. TREATMENT FOR SLEEP DEPRIVATION • Recovery sleep • Sleep onset latency shorter • Arousal threshold increased • Increased in SWS first, followed by REM • Increased sleep time • For 1 night of TSD, sleep time may increase 2-4 hrs • Obligatory sleep vs. Facultative sleep Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

  40. SLECTIVE SLEEP DEPRIVATION • Recovery sleep from selective SWS deprivation same as total sleep deprivation • SWS increased on night 1 • REM increased on nights 2 and 3 • Recovery sleep from selective REM sleep deprivation different • SWS does not increase • REM increased on all 3 nights Agnew HW Jr et. Al. Percept Mot Skills 1967;24:851-8

  41. PHARMACOLOGIC TREATMENT http://www.usdoj.gov/dea/pubs/abuse/5-stim.htm

  42. PHARMACOLOGIC TREATMENT Kushida, CA. Sleep Deprivation: Basic Science, Physiology, and Behavior. 2005. Marcel Dekker

  43. CAFFEINE ANYONE?

  44. LIABILITIES OF SLEEP DEPRIVATION www.westsofeastdean.co.uk/large_gavel.html

  45. LIABILITIES OF SLEEP DEPRIVATION • Error of omission – Individual fails to respond quickly to a situation • Error of commission – Individual creates unnecessary risk of harm • Drivers are liable for consequences of falling asleep if they were aware of the risks associated with their sleep disturbance and did not take measures to reduce those risks People V. Schaffer. 364 N.E. 2d 109 (III App. 1977)

  46. DRIVER LIABILITY • Evidence of a person sleeping while driving = Negligence • Drivers bear the burden of rebutting the presumption of negligence • Recklessness • Sufficient rest preceding the crash • Time driving prior to crash • Prior warning that sleep was impending • Recklessness = Monetary judgment

  47. EMPLOYER LIABILITY • May be liable to an employee or third party if the accident occurred within the scope of employment • Employee fell asleep while driving a company truck home, causing a serious crash and injuring others • Employer was liable because the employee had a load of tires to deliver on the way home • On-call employee was driving back to work in a company vehicle and fell asleep, causing injuries to others • Employer was not liable because the employee was on a personal errand Mayes vs. Goodyear Tire & Rubber Co., 144 S.W. 3d 50 (Tex. App. 2004) J&C Drilling Co. Vs. Salaiz, 866 S.W. 2d 632 (Tex. App. 1993)

  48. CLINICIAN LIABILITY • Diagnostic evaluation is warranted when a sleep disorder is suspected • All patients who have sleep disorders should be warned about risk of operating a motor vehicle or dangerous machinery while sleepy • For the high-risk population, they should be advised not to drive until therapy has been instituted and proven effective • Clinicians are liable if they fail to inform the patient regarding risks of medical condition/treatment • Clinicians are not responsible for the actions of patients who fail to take measures to reduce their risk, although the risk of liability may be higher if they are required by state statute to report a driver to the DMV Joy vs. Eastern Maine Medical Center, 529 A.2d 1364 (Me. 1987)

  49. CURRENT STUDIES IN SLEEP DEPRIVATION • “Distinct effects of acute and chronic sleep loss on DNA damage in rats.” • Sleep deprivation of rats • 24 hrs • 96 hrs • 21 days • Evaluate DNA damage in blood, brain, liver, and heart cells Andersen ML, Ribeiro DA, et. Al. Prog Neurophychopharmacol Biol Psychiatry. 2009 Feb 28.

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