Week 3 - 2 questions and a Power Point

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Neurodiagn J. 52:233–249, 2012 © ASET, Missouri

Poor Sleep Challenging the Health of a Nation

Mary Ellen Wells, RPSGT, R. EEG T., R.NCS.T., MS1; Bradley V. Vaughn, M.D.2

1Neurodiagnostics and Sleep Science School of Medicine

University of North Carolina at Chapel Hill Chapel Hill, North Carolina 2Department of Neurology

University of North Carolina at Chapel Hill Chapel Hill, North Carolina

ABSTRACT. Sleep is integral to the health and well-being of all people. Sleep disorders are on the rise and affect millions of people in America. Misconceptions about sleep are prevalent, and the negative effects of poor sleep on society are underrepresented. The goal of this study is to investigate and report the effects of poor sleep on society. Information is obtained through a systematic review of current literature, including journal articles, books, and reports. Multiple themes emerged from the literature review relative to poor sleep and societal impacts. These themes include major disasters related to insuffi cient sleep, performance and productivity, stress, drowsy driving, substance use and abuse, mortality and morbidity, overall health and wellbeing, effects on healthcare systems, and economic costs. Poor sleep decreases human productivity and performance, and increases mortality and morbidity. The National Sleep Foundation estimates that poor sleep costs America billions of dollars each year and greatly compromises public safety and health. Possible solutions to the Nation’s sleep problem may begin with promoting education and awareness of sleep disorders and their negative societal impact, research in sleep medicine, as well as public education about healthy sleep. The beginnings of these solutions lie in the hands of healthcare workers and educational institutions. Interven- tions in the form of questionnaires have been validated as effective

Received: March 28, 2012. Accepted for publication: May 29, 2012.

Author’s Email: [email protected]

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in determining a person’s risk of sleep apnea. The STOP-BANG ques- tionnaire is one such intervention that may be useful by allied health professionals to assist in patient screening of sleep apnea.

KEY WORDS. Sleep debt, sleep deprivation, sleep disorders, sleep health, sleep hygiene.

INTRODUCTION

More than 70 million people in our nation experience sleep disorders, most of who are unaware of the impact on their daily life. Over 80 medically recognized sleep disorders exist with insomnia, sleep apnea, snoring, jet lag, shift work, sleepwalking, and restless legs syndrome being some of the most common (AASM 2010). Sleep disorders can be deadly and their prevalence is increasing, creating widespread public health challenges. It is no surprise that sleep is problematic considering Amer- icans sleep less than ever before, have less healthy lifestyles, and are subject to the demands for a round-the-clock society.

The purpose of this research is to investigate and report the effects of poor sleep on the health of individuals and on society as a whole. A review of current scholarly literature was conducted and revealed multiple themes related to poor sleep and health consequences. Public health disparities associated with sleep disorders will be discussed, followed by a proposal for promoting awareness and prevention of these deadly and environmentally threatening disorders.

METHODS

The central research question of this study is: What are the negative effects, according to recent scholarly literature, of poor sleep on society? To answer this question, an extensive literature search for publications discussing sleep and society was performed using the PubMed database, Internet search engines, and the exten- sive library collection of The University of North Carolina at Chapel Hill. PubMed is a service of the United States (U.S.) National Library of Medicine, National Insti- tutes of Health, and is a searchable database listing more than 21 million citations for biomedical literature from MEDLINE®, life science journals, and online books.

RESULTS

Over 80 scientific articles, books, and/or publications from professional organiza- tions, government agencies, or other reputable sources were reviewed. Multiple themes emerged citing poor sleep as a contributor to individual and societal health disparities. Themes include major disasters related to insufficient sleep, performance

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and productivity, stress, drowsy driving, substance use and abuse, mortality and morbidity, overall health and wellbeing, effects on healthcare systems, and economic costs.

Major Disasters Involving Sleep Disorders

Sleep dysfunctions are traced as causing factors in the following:

• Exxon Valdez disaster (CBS 2008, CNN 2005) • Challenger space shuttle explosion (Merry and Smith 2001) • Three Mile Island nuclear accident (US NRC 2009) • Chernobyl explosion (Folkard and Lombardi 2006, BBC 2005)

The Exxon Valdez ran aground on Bligh Reef 12:04 AM while under the control of a crewmember who only slept for four hours the night before (CBS 2008). The National Transportation Safety Board determined the responsible crew were not rested and cited fatigue among the probable causes (CNN 2005). The Challenger space shuttle explosion in 1986 was caused by failure of ring seals causing fuel to escape leading to explosion. The people responsible for the O-ring were sleep deprived and required to make the decision to launch in the early morning (Merry and Smith 2001). The partial meltdown of a nuclear reactor at the Three Mile Island nuclear power plant in Pennsylvania occurred at 4 AM (US NRC 2009). The nuclear reactor at the Chernobyl nuclear power plant failed and exploded in the early morning hours (Folkard and Lombardi 2006, BBC 2005). Both the Three Mile Island accident and the Chernobyl disaster involved “human error” and fatigue.

Performance and Productivity

Fatigue, irritability, concentration difficulties, disorientation, changes in mood, visual hallucinations, and paranoid thoughts are some of the problems associated with sleep deprivation and directly affect a person’s performance (Bonnet 2005). Chronic sleep deprivation decreases alertness and impairs judgment, increasing safety risks in the workplace. 20 to 25% of American workers (about 20 million Americans) are shift workers and 60 to 70% of them report sleep problems (NIH 1997).

Insomnia is taking a toll on the American workforce and is defined as the inability to initiate or maintain sleep (Edinger and Means 2005). Insomnia affects 10 to 15% of the general population and is the most prevalent sleep problem (Drake et al. 2004). Studies also have shown that persons with insomnia have the highest accident and absenteeism rates (Leger and Pandi-Perumal 2007). Insomnia cannot be visibly seen like other handicaps, and workers suffering from insomnia may encounter difficulty explaining their condition. Studies show that insomnia symptoms are associated with many health conditions affecting physical and mental health (Siversten et al. 2009).

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American children and teens are not exempt from sleep dysfunctions. In 2004, the National Sleep Foundation’s (NSF) Sleep in America™ poll revealed that children are sleeping less, and more than two-thirds experience frequent sleeping problems (NSF 2004). The NSF’s 2006 Sleep in America™ poll revealed that only one in five adolescents is getting optimal sleep on school nights and those with insufficient sleep are more likely to receive lower grades than their optimally sleeping peers. However, this poll revealed that nine out of ten parents believe their children are getting optimal sleep at least a few school nights a week (NSF 2006).

Many studies on children with sleep-disordered breathing exist showing decreased functioning during the day, negatively affecting their school performance. A study of over 500 preschoolers found that those not getting optimal sleep were 25% more likely to misbehave and are at greatest risk for demonstrating behavioral problems (i.e., aggression, hyperactivity, and noncompliance) (Lavigne et al. 1999). In a study of over 3000 five-year-old children, 25% have symptoms of sleep-disordered breath- ing, and these symptoms are associated with an increased risk of problem behaviors and daytime sleepiness (Gottlieb et al. 2003). There is also evidence suggesting an association between sleepiness and attention deficit hyperactivity disorder (ADHD) (Chervin et al. 2002). One study evaluated almost 300 first grade students, who were in the lowest 10th percentile in their class, and found that 18.1% of them had undiag- nosed sleep-disordered breathing (Gozal 1998). The children who received treatment showed an overall increase in their mean grades.

Stress and Sleep

A strong link exists between stress and sleep, as demonstrated in many studies (Drake et al. 2004). High job demands and low job control is associated with increased sleep problems (de Lange et al. 2009). Across occupations, evidence exists that the following are major risk factors increasing stress and inevitably, sleep distur- bances: manual work; shift work; long hours; feelings of being “rushed”; high- demand jobs; and external factors like noise and vibration (NIH 1997). The Better Sleep Council’s (2009) recent survey reveals that 65% of Americans lose sleep due to stress; 32% are losing sleep at least one night per week, and 16% experience stress-induced insomnia.

One-third of average Americans, according to the NSF, are losing sleep over the state of the U.S. economy and their personal finances (NSF 2009a). The average American according to the NSF works about 4.5 additional hours from home per week in addition to their 9.5 hour workday. In recent polls, many of those working long hours have fallen asleep at work, have been late to work, have driven drowsy, and have even missed family events and leisure activities due to sleepiness (NSF 2008).

Burnout is reportedly on the increase in many countries, and sleep disturbances are directly related (Söderström et al. 2004). Burnout is defined as “a state of vital

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exhaustion” (WHO 2007). Overwork and stress are primary causes of burnout, and consequences include physiological effects (e.g., coronary heart disease and insom- nia) and behavioral effects (e.g., decreases in performance and increases in substance abuse) (Miller et al. 1989). Recognizing the warning signs of burnout and initiating coping strategies early is important in preventing devastating long term effects.

Drowsy Driving

The National Highway Traffic Safety Administration estimates that at least 100,000 police-reported crashes, 1,550 deaths, and 71,000 injuries each year are a direct result of driver fatigue (NSF 2009b). These estimates are likely only the tip of the iceberg since sleepiness is difficult for crash investigators to detect since there are no objective tests (e.g., blood, breath analysis) administered to drivers at a crash scene (NHTSA 1996). The National Transportation Safety Board considers that driver fatigue is the most frequently cited cause of fatal-to-the-driver truck crashes (31%), and that fatigue is the probable cause in 30 to 40% of all truck crashes (NTSB 1990). Insufficient sleep is prominent among teenagers, placing them at a particularly high risk for fatigue related accidents and fatalities (NSF 2006). 15% of high school aged drivers drive drowsy at least once a week according to the NSF (2006).

Driving is associated with many higher-level skills that are particularly impaired when a person is drowsy, including reaction time, vigilance, attention, and informa- tion processing (NHTSA 1998). The NSF found that 60% of American drivers (potentially 110 million people) have driven while drowsy, and 37% admit they have fallen asleep while at the wheel within the past year (NSF 2009). Drowsy driving may be as dangerous as drunk driving (Powell et al. 2001). Telltale signs a person is too sleepy to drive include focusing on one point in the road, heavy eyelids, daydreaming and trouble concentrating, head nodding, and yawning (NSF 2009c). Population groups at the highest risk for drowsy driving include youth (ages 16 to 29, predominately male), shift workers, narcoleptics, and people with untreated sleep apnea syndrome (NHTSA 1998). Accidents and deaths related to drowsy driving are an increasing public health threat because many people are unaware they are at risk and do not know the warning signs of being too tired to drive.

Substance Use and Abuse

Sedatives, hypnotics, and psychostimulant drugs are used to treat many major medical conditions, such as attention deficit hyperactivity disorder (ADHD), insom- nia, heart disease, narcolepsy, and restless legs syndrome (RLS). These drugs can greatly affect the quality of sleep and disrupt sleep/wake patterns (NIH 2003a). Most, if not all, drugs can adversely affect sleep patterns, including the duration and frequency of sleep stages (Barkoukis et al. 2007).

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Sleep disruption is common in individuals with history of substance use disorders (NIH 2003). Symptoms include insomnia, hypersomnia, and parasomnias (Gillin et al. 2005). There is also increasing evidence that people with primary insomnia and no concurrent psychiatric disorder have a higher risk of developing psychiatric disorders such as substance abuse disorders, depression, and anxiety (NIH 2003a). Comorbid sleep disorders are suspected to have a high rate of reverting a person back to dependence after treatment (Mahfoud 2009). Sleep disturbances may persist for months to years after abstinence from drugs such as alcohol (Gillin et al. 2005). Studies have even found that drug abuse can damage areas in the brain that regulate sleep (NIH 2003a).

Patients with a history of alcoholism have a higher rate of sleep problems than non-alcoholics (Brower 2001). When used as a sleep aid, alcohol initially acts as a superforic agent and muscle relaxant which can exacerbate sleep apnea. As the alco- hol is metabolized, the individual incurs more sleep fragmentation, rapid eye move- ment (REM) sleep rebound, and decreased slow wave sleep (Barkoukis and Avidan 2007). Alcohol likely acts on the neurotransmitters that are involved in sleep and can exacerbate pre-existing sleep problems (NIAAA 2009). A study revealed that people with a sleep related breathing disorder who consume at least two alcoholic drinks before bed had a five-fold increased risk of sleep-related accidents than those with a sleep related breathing disorder and little to no alcohol use (Aldrich and Chervin 1997).

Insomnia is often associated with substance abuse. A recent study reveals 46% of patients with sleep problems including insomnia had self-medicated (Mahfoud et al. 2009). Surveys reveal that many people who had self-medicated were unaware or had little understanding of insomnia treatments available (Leger and Pandi-Perumal 2007). Insomnia is the most common sleep complaint of older adults (Friedman 2006) and sedative type drugs likely do more harm than good in older people with insomnia (Clarfield 2006).

Mortality and Morbidity

According to the National Institute of Neurological Disorders and Stroke (2007), “At least 40 million Americans each year suffer from chronic, long-term sleep disor- ders, and an additional 20 million experience occasional sleeping problems.” Sleep problems may be associated with decreased cognitive function, fatigue, loss of energy, lethargy, and emotional instability; and can result in death from associated diseases and accidents (NIH 2003c). In fact, rats died when deprived of sleep for three weeks, similar to the time of death by starvation (Rechtschaffen 1998). Insuf- ficient sleep is linked to the development of many chronic diseases, such as obesity, heart disease, stroke, depression, and diabetes (Balkin et al. 2008, CDC 2012a).

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Epidemiologic surveys by the Centers for Disease Control and Prevention (CDC 2009b) suggest that the average sleep duration in U.S. adults has decreased during the past 20 years. The CDC sites insufficient sleep as responsible for causing sub- stantial injury and disability in accidents involving machinery and motor vehicles. Our population is aging, and one of the most frequent complaints of older people is sleep problems. In the next 30 years, people over 65 will outnumber people under five about three to one (U.S. Census Bureau 2004). Serious complications are more likely to occur in older persons with sleep disorders, such as depressed mood, attention and memory problems, excessive daytime sleepiness, increased use of over- the-counter and prescription sleep aids, increased nighttime falls, and an overall poorer quality of life (National Institute on Aging 2010). The sleep disturbances of the elderly also have a direct effect on the quality of sleep of their caretakers, making sleep disturbances one of the most common reasons older people are put in nursing homes (Shapiro and Dement 1993). A common misperception is that sleep quality declines with age. Sleep needs do change with age, however, poor sleep is not a normal part of aging (National Institute on Aging 2010).

Many sleep disorders are coexistent with other diseases as well as with other sleep disorders, making very vague boundaries in the overall picture of a person’s health. Patients with psychiatric disorders are subject to a high risk of developing sleep disorders (Nofzinger 2005). Sleep apnea alone affects millions of Americans. Sleep apnea has been called the “phantom” killer as it is correlated with a higher risk of stroke, heart attack, and sudden death. A recent study reports that the chance of any-cause death is about one and a half times greater for people with severe sleep- disordered breathing verses people without sleep disordered breathing (Punjabi et al. 2009). Sleep disorders may develop due to other medical conditions and may give rise to confusion, frustration, or depression as well as increased requests for pain medication due to an increased awareness of pain (NINDS 2010). The challenge for management of sleep disorders is determining whether the underlying cause is a medical disease or a relative situational cause, such as stress and environment, or a combination (Wallander et al. 2007).

Overall Health and Wellbeing

Multiple studies have reached the conclusion “too little sleep is bad for you, and too much sleep could be worse” (Grandner and Patel 2009). Many past studies have been conducted on human sleep patterns, revealing the average person sleeps for about eight hours per night. More recently, the NSF found that the average adult is sleeping only 6.9 hours per night (NSF 2005). Sleep loss is considered a part of “normal” life for many people. An important message is that sleep loss is voluntary, and the decline in sleep is not normal. Just because we now live in a global economy, our bodies and our need for sleep will not adapt to that lifestyle.

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There is no real evidence on exactly how much sleep we should have, but what we do know is that too little sleep and too much sleep both increase mortality rates (NIH 1997). Table 1 is identified by the NSF as the “rule-of-thumb” for assessing where a person’s sleep needs should be. Keep in mind that many other factors are involved in determining individual sleep needs including age, health, and lifestyle (NSF 2009). How can the right amount be determined for an individual? If someone isn’t refreshed when they wake up, they are not getting the right amount.

Effects on Our Healthcare System

The cost is surprisingly high for accidents related to sleepiness. Add to that bil- lions and billions more to the healthcare system for related costs of prescriptions, therapies, diagnostic testing, and doctor visits. When such a significant problem aris- es in the healthcare system, the effects ripple out and affect every aspect of everyday life, regardless if someone is or isn’t experiencing a sleep disorder.

Fatigue has become a point of interest in the training of resident doctors. Residents are now required to work under 80 hours per week, and have mandatory rest periods. The Accreditation Council for Graduate Medical Education (ACGME) regulations draw attention to the issues of fatigue in healthcare education. Although the evidence is currently mixed as to the benefit of these measures, further research is needed to measure the intended and unintended consequences of these new regulations.

Patients with obstructive sleep apnea utilize almost twice the healthcare resources as control matched subjects according to several studies, with most being attributed to increased days spent in the hospital, increased physician fees, more specialist consultations, and increased medication prescriptions (Kryger et al. 1996, Lee et al. 2008). Effective treatment of obstructive sleep apnea with continuous positive airway pressure (CPAP) decreases healthcare costs, while those with obstructive sleep apnea

Table 1. How much sleep do you really need?

Age Sleep Needs

Newborns (1 to 2 months) 10.5 to 18.0 hours Infants (3 to 11 months) 9.0 to 12.0 hours during night and 30 minute to 2.0 hour

naps, one to four times a day Toddlers (1 to 3 years) 12.0 to 14.0 hours Preschoolers (3 to 5 years) 11.0 to 13.0 hours School-aged Children (5 to 12 years) 10.0 to 11.0 hours Teens (13 to 17 years) 8.5 to 9.25 hours Adults 7.0 to 9.0 hours Older Adults 7.0 to 9.0 hours

Adapted with permission of the National Sleep Foundation. For further information, visit www.sleepfoundation.org.

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left untreated have increasing healthcare costs as demonstrated in a ten year study (Albarrak et al. 2005). Another study found that physician costs decreased 33% after treatment for obstructive sleep apnea, and days spent in the hospital decreased by 50% in patients with diagnosed obstructive sleep apnea who are adhering to treatment (AASM 2000).

The Cost to Our Economy

The Institute of Medicine (2006) estimates “hundreds of billions of dollars a year are spent on direct medical costs related to sleep disorders such as doctor visits, hos- pital services, prescriptions, and over-the-counter medications.” The cost has been quietly rising since sleep disorders often mask themselves behind other situations and disorders. Medical errors alone cost the economy up to $29 billion each year (U.S. Department of Health and Human Services 2000), and many are likely related to sleep deprivation. Many large studies have indicated that insomnia is a predictor for premature death at the same degree as obesity, and adds health related costs to society (Shapiro and Dement 1993).

About 20% of serious injuries from automobile accidents are a result of a sleepy driver (IOM 2006). Motor vehicle accidents are the number one killer of young adults, and sleepiness is highly associated due to poor sleep habits of many youth. The National Highway Safety Administration estimates that accidents involving fatigued drivers cost Americans 12.5 billion in reduced productivity and property loss (Everding 1999).

DISCUSSION

Our understanding of the far reaching effects of sleep and sleep disorders is expanding across many health-related fields. Educating healthcare workers, caregiv- ers, patient support groups, and organizations is vital to increase awareness of sleep disorders and promote healthy sleep. Improving healthcare access and processes, safeguarding employment, and helping preserve financial stability for persons expe- riencing sleep disorders should be common goals of everyone involved in health care. Several areas for improvement in the public’s awareness of sleep disorders will be discussed next.

Sleep Hygiene

Sleep hygiene is promotion of regular, healthy sleep. The CDC and the NSF are excellent resources for sleep hygiene tips to share in educational programs (NSF 2009). The tips are quite simple and usually only require minor changes to environ- ment and lifestyle, and the long-term benefits to overall health are documented.

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The NSF lists the following as good sleep hygiene practices (Thorpy 2011):

• Establish consistent sleep and wake schedules, even on weekends. • Create a regular, relaxing bedtime routine such as soaking in a hot bath or listen-

ing to soothing music – begin an hour or more before the time you expect to fall asleep.

• Create a sleep-conducive environment that is dark, quiet, comfortable, and cool.

• Sleep on a comfortable mattress and pillows. • Use your bedroom only for sleep and sex (keep “sleep stealers” out of the

bedroom – avoid watching television, using a computer, or reading in bed). • Finish eating at least two to three hours before your regular bedtime. • Exercise regularly during the day or at least a few hours before bedtime. • Avoid caffeine and alcohol close to bedtime and give up smoking.

Adolescents have many characteristics different from adults that can influence their biological clock, such as their desire to stay up late and remain engaged in late night, social activities, media, and other extracurricular activities. The CDC list the following sleep hygiene tips specifically for young adults (CDC 2012c):

• Avoid caffeinated drinks after lunch. • Avoid bright light in the evening. • Avoid arousing activities around bedtime (e.g., heavy study, text messaging,

getting into prolonged conversations). • Expose yourself to bright light upon awakening in the morning. • While sleeping in on weekends is permissible, you should not sleep more than

two to three hours past your usual wake time, to avoid disrupting your circadian rhythm governing sleepiness and wakefulness.

• Avoid pulling an “all-nighter” to study.

Research in Sleep Medicine

Translational research has enhanced our understanding of the impact of sleep dis- orders on our health. Three areas have made major leaps forward, due to application of sophisticated techniques in genetics and epidemiology. In 1998 two independent teams of investigators led by Mignot and Yanagisawa linked narcolepsy in animals to disrupted signaling of the neurotransmitter orexin, also called hypocretin (Chemelli et al. 1999, Lin et al. 1999). Loss of orexin/hypocretin containing neurons was soon linked to human narcolepsy with cataplexy, but not narcolepsy without cataplexy (Peyron et al. 2000, Crocker et al. 2005). This link has spurred an expansion of knowledge in the relationship of orexin/hypocretin to state regulation and the link to other wake promoting substances such as histamine, dopamine, and norepinephrine.

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Although the current standard for diagnosing narcolepsy remains polysomnography with multiple sleep latency testing, we may see in the future classification of the hypersomnias based on the levels of wake promoting neurotransmitters. Similarly the hunt for the etiology destroying the orexin/hypocretin producing neurons has lead to the hypothesis of autoimmune processes. Unfortunately, the results of small trials of immunomodulation have been mixed at best.

Our understanding of restless legs syndrome (RLS) has also grown. Current diag- nostic criteria for RLS is based on four clinical questions (Allen et al. 2003, AASM 2005), but these criteria only provide approximately an 85% sensitivity and specific- ity compared to expert interview (Hening et al. 2008, Benes et al. 2009, Allen et al. 2010). Further etiological work has demonstrated a link between iron in the central nervous system and RLS (Connor et al. 2003, Earley et al. 2006). This linkage has been expanded by genetic work both in families and in populations showing at least eight different genes associated with RLS or the motor manifestation periodic limb movements (Caylak 2009, Sas et al. 2010, Trenkwalder et al. 2010). Some of these genes are related to iron regulation, whereas others are not. Additional work has demonstrated a complex relationship of cortical hyperexcitability, spinal cord processing, dopamine production in the A11 neuronal group, and dopamine receptors. Approved treatments now include two dopamine agonists, ropinirole and pramipexole and a newer form of an antiepileptic, gabapentin encarbil.

One of the most common diagnoses made in the sleep laboratory is obstructive sleep apnea (OSA). As many of us envision these as sleepy obese individuals, ground breaking epidemiological studies have shown that the extent of OSA in our popula- tion to be over 20% of the adult population (Young et al. 2008). These studies have shown the link of sleep apnea increasing the risk of hypertension, diabetes, obesity, stroke, cardiovascular disease, and accidents (Young et al. 2008). We also understand that many individuals with obstructive sleep apnea are of normal weight and are not sleepy during the day, but they still incur the health risks. These revelations help us understand the importance of accurately detecting and treating this group of dis- orders. Economic pressures have led to studies looking at ambulatory technologies in attempts to develop similarly sensitive and specific markers and also identify patient groups that may be accurately tested and treated through these more limited measures.

Keeping the Public Informed

The fact is that many people either do not recognize they have a sleep problem or do not take their problem seriously enough to seek treatment. Healthcare workers are key in informing the public about sleep disorders. Information should be taught across health curricula and be readily available to the public, such as information about normal sleep and circadian rhythms, plus information about symptoms, risk

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factors, and the most common sleep dysfunctions. Information on the dangers of stress and burnout as well as warning signs and coping strategies should be readily available. New initiatives should be created to inform people of the signs of drowsy driving and what actions should be taken to prevent accidents, injury, and death. Keeping this information out in the open will help facilitate positive behavior change (NIH 2003a).

Education initiatives should be created directly targeting at risk populations, such as young adults, the elderly, shift workers, truck and long distance drivers, minorities and the underserved, pregnant and menopausal women, and those with certain risk factors such as obesity (NIH 2003a). Since sleep research has only recently been gaining recognition, relatively few high school textbooks provide any scientific information on the relationship between sleep and bodily changes, as well as how those changes affect human performance (NIH 2003b). Parents play a key role in helping their children get adequate sleep and new initiatives should be created to help inform parents and children.

Implications for Current Practice

Much emphasis has been placed on only a few sleep disorders, such as sleep apnea and insomnia; however, the reality is that there are currently 97 different sleep disorders. These sleep disorders have varied symptoms, which are often missed by undertrained health professionals. Symptoms may also be viewed as unimportant or as symptoms of other diseases, but there may in fact be an underlying sleep disorder. Many of these sleep disorders can be treated, but they must first be identified, which may prove challenging to undertrained health professionals. Not identifying these disorders can lead to missed opportunities for therapy and/or the beginnings or wors- ening of associated conditions (e.g., cardiovascular disease, diabetes, depression, obesity).

Health professionals (i.e., physicians, nurses, allied health workers) are typically in the front line of the healthcare team. With direct patient contact, the allied health professional provides an additional connection between patients and physicians. Patients may feel more comfortable revealing previously undisclosed symptoms to allied health professionals than to other healthcare providers. This opportunity should be capitalized by the allied health professional to convey the information to the provider for the patient to receive appropriate intervention.

The NIH PROMIS project showed that relatively sensitive screening questions can be asked of patients, such as “Do you feel tired or sleepy during the day?” and “Are you satisfied with your sleep?”. These questions can open the door to identifying patients with potential sleep issues. Example screening questionnaires include the STOP-Bang Questionnaire (Chung et al. 2008), the Epworth Sleepiness Scale (Stoohs 1997), and the Stanford Sleepiness Scale (Herscovitch and Broughton 1981).

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CONCLUSIONS AND FUTURE DIRECTIONS

The effects associated with poor sleep are widespread, and associated with public safety, environmental hazards, and increased mortality and morbidity. Building public education campaigns is key to helping people make informed decisions about their health, lower their risk factors, and help create a social environment to facilitate behavioral change (NIH 2003a). Incorporating sleep disorder education into com- munity college and university health education programs is also vital for awareness of sleep disorders (NIH 2003a). Continuing education programs offered through medical facilities and community education centers are a low cost way to help spread information to the community.

The National Center on Sleep Disorders Research suggests directing educational initiatives to high-risk populations and receptive audiences (such as young children) as ways to help prevent and detect early symptoms of sleep disorders. Also suggested is targeting those who can help facilitate a change in others, such as teachers, coaches, school officials and nurses, parents, health educators, and pediatricians (National Center on Sleep Disorders Research 2011). Cultural differences should influence the types of materials made available to ensure a wide audience can be reached and technology should be used, such as webcasts and Internet materials.

According to the National Institute of Neurological Disorders and Stroke (2007), “Sleep research is expanding and attracting more and more attention from scientists. Researchers now know that sleep is an active and dynamic state that greatly influences our waking hours, and they realize that we must understand sleep to fully understand the brain. Innovative techniques, such as brain imaging, can now help researchers understand how different brain regions function during sleep and how different activities and disorders affect sleep. Understanding the factors that affect sleep in health and disease also may lead to revolutionary new therapies for sleep disorders and to ways of overcoming jet lag and the problems associated with shift work. We can expect these and many other benefits from research that will allow us to truly understand sleep’s impact on our lives.”

Sleep medicine has come a very long way over the past few decades and has made a tremendous impact in public education of sleep disorders. The words “sleep apnea” and “CPAP” are not uncommon in everyday vocabulary. However, even though people are becoming more educated about sleep disorders, the prevalence of them is still increasing. Prevention by means of education is key, and there is still a long way to go.

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