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To Sleep or Not to Sleep…

To Sleep or Not to Sleep…. To Sleep or Not to Sleep…. Consequences of Sleep Loss. Scenarios. Scenarios. 0123. 2400. 0004. 0200. 0400. 0645. 0149. Objectives. Sleep Science history Sleep Mechanics 101 Sleep Deprivation Consequences Shift-work risks ‘evidence’ Strategies

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To Sleep or Not to Sleep…

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  1. To Sleep or Not to Sleep…

  2. To Sleep or Not to Sleep… Consequences of Sleep Loss D. Nesdoly MD FRCPC

  3. Scenarios

  4. Scenarios 0123 2400 0004 0200 0400 0645 0149

  5. Objectives Sleep Science history Sleep Mechanics 101 Sleep Deprivation Consequences Shift-work risks ‘evidence’ Strategies Future research

  6. Sleep Science History 1930 Berger- “Father of EEG” 1937 Loomis- first overnight EEG human sleep recordings 1968 Standardized manual 1974-Williams normative sleep data 2010-Accreditated Sleep Centers

  7. Sleep Basics • 3 Mechanisms • ANS • PNS  • SNS  • Homeostatic Sleep Drive • Circadian Sleep Rhythm

  8. Sleep Stages

  9. Sleep Stages

  10. Sleep Stages

  11. Sleep Waves

  12. Sleep Architecture

  13. Sleep Architecture

  14. Sleep Architecture

  15. Circadian Sleep Disorders irca

  16. Sleep Quantification • Objective • MSLT • MWT • PVT • Subjective • Sleepiness scales • Stanford (1973 7 point) • Karolinska (1990 9 point) • Epworth (1991 situation-specific dozing likelihoods)

  17. Effects of Sleep Deprivation

  18. Effects of Sleep Deprivation

  19. Effects of Sleep Deprivation

  20. Recovery Studies

  21. Recovery Studies

  22. Recovery Studies

  23. Recovery Studies

  24. Shift-work Syndrome • Prevalence • (U.S.-22 M SW +3% ) • Canada 11% rotating, 6% evening, 2% nights • Prototype • Insomnia / Sleepiness • Fatigue / Headache / Anxiety • Indigestion / Pyrosis • Hypertension • Weight gain • Menstrual irregularity / Sub-fertility / SA • Depression • Drowsy driving

  25. Sleep Deprivation Impact Individual Family Community Society

  26. Shift-work Impact

  27. Shift-work Impact

  28. Shift work + Cardiovascular Disease Modest (+) associations w shift work (40%) Causal link research inconsistent Daylight Saving Time * Janszky (2008) Acute MI  risk Mondays “Spring” Incidence ratio 1.051 “Autumn” Incidence ratio 0.985

  29. Shift work (LAN) + Cancer Schernhammer (2001) Nurses Health Study Cohort 240,000 women over 30 years Control for major risk factors, stress, SE status Cancer relative risk  Breast 36-79 % Colon 35% Endometrial 43% 2007 IARC classifies ‘night shift work’ as probable carcinogen (2A)

  30. Shift work (LAN) + Cancer Observational studies: modest (+) relationship b/w LAN + breast Ca Pukkala (1995) Flight attendants > 15 Y Tynes (1996) Radio + telegraph operators Prostate Ca  Airline pilots Firefighters Health practitioners + physicians

  31. Circadian Disruption Shift work + Risk of Ca Seattle Research group LAN + Breast Ca Case control study 60-Hz magnetic fields +  nocturnal melatonin Night shift work + biomarkers Melatonin + hormones Genotypes (hCLOCK, Per2, Per3)

  32. Shift work + Pregnancy Moderate (-) effect on fetal growth SGA / LBW No association for pre-term delivery or pre-eclampsia

  33. Study Limitations Epidemiologic vs RCT Selection bias “Survivor population” (entrance + drop-out) Lower socioeconomic status Shift work definition Exposure measurement

  34. Shift Work Proposed Mechanisms

  35. Shift-work + Risk Needle-stick events Ayas (2006) Trinkoff (2007) Clinical performance Howard (2003)-Anesthesia Lockley (2004)-ICU Smith-Coggins (2006)-Emergency

  36. Transportation Safety Prototype ‘drowsy driver’ Young male < 25 Shift-worker Untreated sleep disorder (OSA / Narcolepsy) Event 2400-0700 Social Media: “Contagious”

  37. Transport + Sleep Deprivation Commercial Truck Rail Air / ATC Performance impairment = Ethanol intoxication Dawson 1997 Powell 2001 Vakulin 2007

  38. Drowsy Driving Strategies Awareness Legislation Highway rumble strips Operator behavior Naps Caffeine Environmental stimuli

  39. Sleep Loss Countermeasures Pharmacologic Non-pharmacologic

  40. Sleep Loss Countermeasures Pharmacologic Antihistamines Benzodiazepines Non-benzodiazepines Antidepressants Serotonin modulator SSRIS SNRI Tetracyclic Tricyclic Melatonin receptor agonist Alternative Valerian Kava Chamomile Synthetic melatonin Non-pharmacologic

  41. Sleep Loss Countermeasures Pharmacologic Non-pharmacologic Behavioural Sleep deprivation Reconditioning Relaxation techniques CBT Schedule strategies Restrict maximum 3 consecutive shifts Forward shift rotation Participatory approach

  42. Sleep Hygiene Wolkove, N. et al. CMAJ 2007;176:1449-1454

  43. Sleep Hygiene Wolkove, N. et al. CMAJ 2007;176:1449-1454

  44. Sleep Hygiene Wolkove, N. et al. CMAJ 2007;176:1449-1454

  45. Sleep Hygiene Wolkove, N. et al. CMAJ 2007;176:1449-1454

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