Importance of Sleep

1. Importance of Sleep Lisa Medalie, PsyD, RPSGT, CBSM Behavioral Sleep Medicine Specialist The University of Chicago Sleep Medicine

2. Sleep Introduction How sleep is defined and measured

3. What is Sleep? Definition: -A complex reversible state characterized by diminished responsiveness to external stimuli and a stereotypical species-specific posture. -Sleep is generated and maintained by central nervous system (CNS) networks that use specific neurotransmitters located in specific areas of the brain. Characteristics: -Active and highly regulated process -Composed of two fundamentally different states: REM sleep & NREM sleep Purpose Not understood Hypotheses: Restoration and recovery of body systems; immune system support; learning and memory consolidation; protection from predators; brain development; discharge of emotions Kryger, Roth, Dement (2005); National Institute of Health, National Center on Sleep Disorders Research (2003)

4. How do we study sleep? Kryger, Roth, Dement (2005); National Institute of Health, National Center on Sleep Disorders Research (2003)

5. EEG Characterization Wake: alpha, frequency 9-12 hz Stage 1: smaller amplitude and irregular frequency, theta waves with vertex spikes Stage 2: Stage N2 sleep is defined by the presence of either K complexes or sleep spindles Stage 3: large amplitude, very slow waves, delta waves REM: low-amplitude mixed-frequency EEG activity, Kryger, Roth, Dement (2005); National Institute of Health, National Center on Sleep Disorders Research (2003)

6. Sleep Stage Distribution Proportion of sleep stages in normal sleep: • REM:25% • NREM: 75% Stage 1: 5% Stage 2: 45%- 50% Stage 3: 20%- 25% 90-120 min Kryger, Roth, Dement (2005); National Institute of Health, National Center on Sleep Disorders Research (2003)

7. Non-REM vs. REM Sleep Kryger, Roth, Dement (2005); National Institute of Health, National Center on Sleep Disorders Research (2003)

8. Physiology of Sleep:The Two-Process Model Sleep homeostasis(Process S) : -A process that keeps track of how much time has passed awake (or asleep) -SWS increases when sleep pressure is high and decreases when sleep pressure is low. -Adenosine (neurotransmitter) regulates homeostatic sleep drive. Circadian rhythm (Process C): -A clock that keeps time irrespective of what happens in the environment Peaks in alertness = late morning and early evening Troughs in alertness= early morning and early midafternoon Borbély (1982); Daan et al. (1984); Borbély &Achermann (2005)

9. Sleep Patterns and Age Average total sleep time REM percentage

10. Common Sleep Disorders • One third symptoms, 6-10% diagnosis • Difficulty falling and or staying asleep • Impaired daytime functioning and /or distress

11. Sleep and Cognition in Adults Effects of Sleep Deprivation and Sleep Disorders

12. Sleep Deprivation and Cognition A: Correct scores on CPT B: Error scores on CPT Level: Increases with difficulty SD: 24 h sleep deprivation Joo et al. (2012). J ClinNeurol; 8(2): 146-150

13. Insomnia and Cognition Studied 20 patients with Primary Insomnia (mean age, 50 yrs; 18 females) and 20 Age-, gender-, and education matched Good Sleepers Noh et al. (2012). J ClinNeurol

14. Sleep Apnea and Cognition Canessa et al. (2011). Amer J of Resp and Crit Care Med

15. Sleep and Cognition in Children Sleep and Attention Deficit Hyperactivity Disorder (ADHD):A Causal Conundrum

16. Hyperarousal Theory • Hyperactivity in children with ADHD is caused by overstimulation of the central nervous system • The state of physiological arousal in children with ADHD is drastically elevated • Hyperactive behavior in children with ADHD is related to a deficiency in effectively censoring information signaled from the environment • Too much information comes in, and individuals are unable to modulate the impact of overflowing stimulation which presents as hyperactivity (Busby, Firestone & Pivik, 1982; Hastings & Barkley, 1978)

17. HypoarousalTheory • A low level, not high level, of central nervous system arousal causes difficulty inhibiting sensory input and behaviors • Excessive, unproductive behavior is caused by inhibited control of sensory input • Hyperactivity in children with ADHD is a compensatory mechanism for a system which processes external stimulation too slowly • When individuals are processing too slowly to function in their environment, the system overcompensates to speed up the system with fast production of behavior (Satterfield, 1975)

18. Relevance to Sleep • Hyperarousal Theorists: Individuals with ADHD have difficulty settling because of their hyperaroused central nervous system activity. Difficulty settling makes for difficulty sleeping • Hypoarousal Theorists: Sleep disturbance leads to excessive sleepiness which slows processing. Hyperactivity is a compensatory behavior to keep children awake in the face of sleep deprivation

19. Sleep and Cognitive Functioning • PSG on 82 healthy children randomized to sleep deprivation or optimal sleep • Found patients in sleep deprived group exhibited increased symptoms of ADHD the following day • (Fallone et al. 2001)

20. Sleep Disorders and ADHD (Spruyt & Gozal, 2011)

21. Study of Sleep Habits and Stimulant Usage in College Students • Participants: 19 college students (18-22 years old) diagnosed with ADHD and receiving accommodations through Academic Support • Instrumentation: Participants completed a 3 week, medication form and daily medication/academic functioning/sleep habits log • Self report – 0-5 likert scale items (0 = poor, 5 = excellent)

22. Sleep Onset Latency in Medicated vs. Non-Medicated College Students with ADHD -Sleep onset latency difference between medicated and non-medicated groups reached significance. There was a non-reported trend towards significance for medicated students to sleep approximately 60 minutes less than their non-medicated counterparts. - Average total sleep time in medicated group was 6 hours and non-medicated group was 7 hours

23. 50% of medicated students in this study increased their prescribed stimulant dose

24. Review of ADHD-Sleep Relationship • 1. Sleep problems may mimic ADHD symptomatology • 2. Sleep problems may exacerbate underlying ADHD symptoms • 3. Sleep problems may be associated with or exacerbated by ADHD • 4. Psychotropic medications used to treat ADHD may result in sleep problems. • In any individual, the relationship between ADHD treatment and sleep may be: • 1. Direct effect (i.e., improve, worsen sleep) • 2. Indirect effect (i.e., ADHD medications or treatment improve comorbid condition or functioning, and sleep subsequently improves) • 3. May be a moderator of response (e.g., sleep problems may limit dosing necessary to achieve an optimal response (Owens, 2005; Stein, Weiss & Hlavaty, 2012)

25. Parent/school report of ADHD symptoms Screen: BEARS, Clinical Interview RLS OSA Insomnia Sleep Study Sleep Logs, Actigraphy If (+) Sleep Disorder If (-) Sleep Disorder Treat Sleep Disorder then re-evaluate ADHD symptoms Consider ADHD Treatment Options: If use of medication (particular stimulant) educate on sleep hygiene and consider dose timing issues

26. Summary • We are still unsure exactly why we sleep • How we sleep is best explained by shift in EEG activity and by taking into account sleep homeostasis and circadian rhythmicity. • The importance of sleep is at least somewhat confirmed by negative cognitive consequences of insufficient sleep. • Screening of sleep disorders in patients with ADHD seems warranted • Treatment for sleep disorders are available. Patients with complaints of sleeplessness or sleepiness have options.

27. Sleep Complaints Behavioral Sleep Medicine Sleep Medicine Insomnia Circadian Rhythm Disorders Inadequate Sleep Hygiene Nightmare Disorder Night Eating Syndrome Sleep Apnea Periodic Limb Movement Disorder Narcolepsy Idiopathic Hypersomnia Actigraphy Sleep Logs Cognitive Behavioral Treatment for Insomnia Overnight Sleep Study Daytime Nap Study CPAP Medication Management