Category: Sleep Disorders

A brief behavioral treatment consisting of two in-person sessions and two phone calls appears to alleviate insomnia in older adults for at least six months, according to a report posted online that will be published in the May 23 print issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

An estimated 15 percent to 35 percent of older U.S. adults have insomnia, according to background information in the article. Individuals with the condition have difficulty falling asleep or staying asleep, non-restorative sleep and symptoms during waking hours that include fatigue, trouble concentrating and mood disturbances. Insomnia is associated with falls and hip fractures among older adults. Even though pharmacologic and behavioral treatments are approximately equally effective, older adults are prescribed hypnotic agents at disproportionate rates and are also more likely than younger patients to experience adverse drug effects.

Daniel J. Buysse, M.D., of University of Pittsburgh School of Medicine, and colleagues conducted a randomized clinical trial of a brief behavioral treatment involving 79 older adults (average age 71.7) with insomnia. Thirty-nine received the treatment, consisting of individualized behavioral instruction delivered by a nurse clinician over four sessions, two in person and two by phone. The other 40 were assigned to an information control group and received only general printed educational material about insomnia and sleep habits.

All participants provided demographic information, completed self-report and interviewer-administered questionnaires about sleep habits, kept two-week sleep diaries and underwent sleep assessment by actigraphy (using a wrist or ankle monitor) and polysomnography (a more in-depth monitoring procedure) before treatment and four weeks after beginning therapy. Participants who showed a response to the brief treatment were contacted again after six months and asked to complete questionnaires and sleep diaries.

After four weeks, a larger percentage of those receiving the brief behavioral treatment showed a favorable response to the treatment (67 percent vs. 25 percent) or were classified as no longer having insomnia (55 percent vs. 13 percent). Based on the results, the authors estimate that for every 2.4 patients treated, one would respond favorably and one would no longer meet criteria for insomnia.

The brief intervention produced significantly better outcomes at four weeks as measured by patients' reports of sleep and health, sleep diaries and actigraphy, but not polysomnography. Improvements were maintained at the six-month follow-up.

"Although brief behavioral treatment for insomnia shares many features with other behavioral insomnia treatments, some particular features make it an especially attractive option," the authors write. The program's strong behavioral focus may avoid some of the stigma associated with "psychological" treatments, it provides patients with a workbook and specific written instructions and it is simple enough to be taught to nurses in a short period of time.

"Thus, brief behavioral treatment for insomnia possesses efficacy, efficiency and acceptability — three characteristics of a successful 'entry level' treatment in a stepped care approach to behavioral management of insomnia," they conclude. "Future studies should examine the feasibility of educating nurses and other health professionals in brief behavioral treatment for insomnia and the effectiveness of brief behavioral treatment for insomnia delivered in actual practice settings on symptom-based, functional and health care economic outcomes."

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Journal Reference:

1. Daniel J. Buysse; Anne Germain; Douglas E. Moul; Peter L. Franzen; Laurie K. Brar; Mary E. Fletcher; Amy Begley; Patricia R. Houck; Sati Mazumdar; Charles F. Reynolds, III; Timothy H. Monk. Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults. Archives of Internal Medicine, 2011; DOI: 10.1001/archinternmed.2010.535

 Washington State University sleep researchers have determined that the air traffic controller in the crash of a Lexington, Ky., commuter flight was substantially fatigued when he failed to detect that the plane was on the wrong runway and cleared it for takeoff.

Writing in the journal Accident Analysis and Prevention, the researchers come short of saying his fatigue caused the accident. But they say their findings suggest that mathematical models predicting fatigue could lead to schedules that reduce the risk of accidents by taking advantage of workers' sleep schedules and biological, or circadian, clocks.

In the case of Comair Flight 5191, the air traffic controller was finishing an overnight shift with just two or three hours of sleep the previous afternoon.

"He was tired," says Gregory Belenky, a paper co-author and director of the Sleep and Performance Research Center at WSU Spokane, "and he was working a schedule that was not circadian friendly."

The Atlanta-bound Delta Connection flight crashed on takeoff shortly after 6 a.m. on August 27, 2006, killing 49 of the 50 people on board. The National Transportation Safety Board concluded the flight crew failed to detect that the plane was on a general aviation runway half as long as the assigned runway.

Bluegrass Airport's lone air traffic controller had cleared the plane for takeoff. But the WSU researchers stress that they are not fixing blame for the crash on him, nor can they say if his fatigue was the cause of the accident.

"We're identifying times of day that are relatively more dangerous than other times of day," says Lora Wu, a Sleep and Performance Center research assistant and co-author of the paper. "We're not trying to place blame on any of the individuals involved."

The researchers used a mathematical model to analyze the controller's work history, which consisted of two evening shifts, two day shifts and the overnight shift leading up to the accident. They also incorporated his circadian rhythm, which tends to prime the body for sleep based on the cycles of day and night.

While the controller had 10 hours off before his last shift, says Belenky, his circadian cycle let him get only two or three hours of sleep and, as he told the NTSB, it was "not real good." A body needs closer to eight hours of sleep, says Belenky, to get the brain "back to spec."

As a result, the researchers estimate the controller was performing at 71 percent of his effectiveness at the time of the accident. They lacked the data to make similar estimates for the flight captain and first officer, but note their behavior suggests they were fatigued. This includes boarding and powering up the wrong aircraft at first and doing an incomplete pre-flight briefing.

The challenge of safer, sleep-friendly scheduling extends to all manner of 24/7 operations, including hospitals, policing, the military, mining and energy generation. Currently, says Belenky, operators use rule-based schedules for staffing. But research suggests that real-time data collection might lead the way to more flexible schedules "based on how much sleep people have actually attained, not on your best guess on how much they were likely to have gotten."

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Journal Reference:

1. Shawn A. Pruchnicki, Lora J. Wu, Gregory Belenky. An exploration of the utility of mathematical modeling predicting fatigue from sleep/wake history and circadian phase applied in accident analysis and prevention: The crash of Comair Flight 5191. Accident Analysis & Prevention, 2011; DOI: 10.1016/j.aap.2010.12.010

Adults who take one of the world's most commonly prescribed sleep medications are significantly more at risk for nighttime falls and potential injury, according to a new study by the University of Colorado at Boulder.

The study, which involved 25 healthy adults, showed 58 percent of the older adults and 27 percent of the young adults who took a hypnotic, sleep-inducing drug called zolpidem showed a significant loss of balance when awakened two hours after sleep. The findings are important because falls are the leading cause of injury in older adults, and 30 percent of adults 65 and older who fall require hospitalization each year, said CU-Boulder Associate Professor Kenneth Wright, lead study author.

To measure balance, the research team used a technique known as a "tandem walk" in which subjects place one foot in front of the other with a normal step length on a 16-foot-long, six-inch-wide beam on the floor. In 10 previous practice trials with no medication, none of the 25 participants stepped off the beam, indicating no loss of balance. All participants were provided with stabilizing assistance to prevent falls during the trials, he said.

"The balance impairments of older adults taking zolpidem were clinically significant and the cognitive impairments were more than twice as large compared to the same older adults taking placebos," said Wright, a faculty member in the integrative physiology department. "This suggests to us that sleep medication produces significant safety risks."

The new CU-Boulder study is the first to measure both the walking stability and cognition of subjects taking hypnotic sleep medicines or placebos. In addition to the balance problems caused by zolpidem, the study also showed that waking up after two hours of sleep after taking zolpidem enhances sleep inertia, or grogginess, a state that temporarily impairs working memory. The study participants were given computerized performance tests that involved adding randomly generated numbers.

A paper on the subject was published Jan. 13 in the Journal of the American Geriatric Society. Co-authors included CU-Boulder's Daniel Frey, Justus Ortega, Courtney Wiseman and Claire Farley. The study was funded primarily by the National Institutes of Health.

The effects of sleep inertia even without sleep medication has previously been shown to cause cognitive impairment, said Wright. But when the CU-Boulder study subjects took zolpidem rather than a placebo, the cognitive impairments essentially doubled.

One unexpected study finding was that young people taking placebos appear to be more cognitively impacted by sleep inertia than older adults taking placebos, he said.

A 2006 study led by Wright showed that study subjects who took no sleep medicine and were awakened after eight hours of sleep were more cognitively impaired, for a short period of time, than a totally sleep deprived person.

Several billion doses of zolpidem have been prescribed worldwide, said Wright, who also directs CU-Boulder's Sleep and Chronobiology Laboratory. Zolpidem is a generic drug that is marketed under a number of different brand names, including Ambien, Zolpimist, Edluar, Hypogen, Somidem and Ivedal.

The CU-Boulder team also measured balance and cognition in older adults who took no sleep medication and were kept awake for two hours past their normal bedtime. They found that 25 percent of these older adults failed the tandem walking balance test, which is consistent with what is seen in people who have insomnia. "Just having insomnia itself increases your risk of falls, even without sleep medication," he said.

The finding that zolpidem affected older adults more than younger adults in balance tests may be explained in part by the fact that both groups were given five milligram doses on study nights. While the normal dose for older adults is five milligrams, the standard dosage for younger adults being treated for insomnia is 10 milligrams. "This is an area that needs more study," he said.

The study results showing that both hypnotic sleep medications and sleep inertia cause significant impairment have important public health implications, said Wright. In older adults, falls have caused millions of nonfatal injuries annually and more than 300,000 fatalities worldwide. "Falls can be very debilitating, especially when older people break their hips and require hospitalization, causing their quality of life to go down," said Wright.

In addition, the cognitive impairments caused by both zolpidem and sleep inertia may impact decision-making, including responding to situations like fire alarms and medical emergencies as well as caring for sick children or driving to a clinic or hospital, said Wright.

"One of the goals of this study was to understand the risk of this sleep medication and of sleep inertia on human safety and cognition and to educate adults and health care workers about potential problems," said Wright. "We are not suggesting that sleep medications should not be used, because they have their place in terms of the treatment of insomnia."

One possible solution to reducing falls of older people due to zolpidem, other sleep medications or sleep inertia would be to install bedside commodes for those who frequently wake up in the night to void themselves, said Wright. Additional research is needed on this important public health and safety topic, he said.

According to a recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM), exposure to electrical light between dusk and bedtime strongly suppresses melatonin levels and may impact physiologic processes regulated by melatonin signaling, such as sleepiness, thermoregulation, blood pressure and glucose homeostasis.

Melatonin is a hormone produced at night by the pineal gland in the brain. In addition to its role in regulating the sleep-wake cycle, melatonin has been shown to lower blood pressure and body temperature and has also been explored as a treatment option for insomnia, hypertension and cancer. In modern society, people are routinely exposed to electrical lighting during evening hours to partake in work, recreational and social activities. This study sought to understand whether exposure to room light in the late evening may inhibit melatonin production.

"On a daily basis, millions of people choose to keep the lights on prior to bedtime and during the usual hours of sleep," said Joshua Gooley, PhD, of Brigham and Women's Hospital and Harvard Medical School in Boston, Mass. and lead author of the study. "Our study shows that this exposure to indoor light has a strong suppressive effect on the hormone melatonin. This could, in turn, have effects on sleep quality and the body's ability to regulate body temperature, blood pressure and glucose levels."

In this study, researchers evaluated 116 healthy volunteers aged 18-30 years who were exposed to room light or dim light in the eight hours preceding bedtime for five consecutive days. An intravenous catheter was inserted into the forearms of study participants for continuous collection of blood plasma every 30-60 minutes for melatonin measurements. Results showed exposure to room light before bedtime shortened melatonin duration by about 90 minutes when compared to dim light exposure. Furthermore, exposure to room light during the usual hours of sleep suppressed melatonin by greater than 50 percent.

"Given that chronic light suppression of melatonin has been hypothesized to increase relative risk for some types of cancer and that melatonin receptor genes have been linked to type 2 diabetes, our findings could have important health implications for shift workers who are exposed to indoor light at night over the course of many years," said Gooley. "Further research is still needed to both substantiate melatonin suppression as a significant risk factor for breast cancer and determine the mechanisms by which melatonin regulates glucose metabolism."

Other researchers working on the study include: Kyle Chamberlain of the University of Surrey in the United Kingdom; and Kurt Smith, Sat Bir Khalsa, Shantha Rajaratnam, Eliza Van Reen, Jamie Zeitzer, Charles Czeisler and Steven Lockley of Brigham and Women's Hospital and Harvard Medical School in Boston, Mass.

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Journal Reference:

1. Joshua Gooley et al. Exposure to room light prior to bedtime suppresses melatonin onset and shortens melatonin duration in humans. JCEM, March 2011

 In the first-ever quantification of energy expended by humans during sleep, a University of Colorado team has found that the metabolic cost of an adult missing one night of sleep is the equivalent of walking slightly less than two miles.

The new findings will help researchers further understand one of the important functions of sleep in humans, said CU-Boulder Associate Professor Kenneth Wright. Wright, who led the study, said the goal was to measure and quantify energy expenditure during both sleep and wakeful periods.

"We found that people do expend more energy when they are awake in bed than when they are asleep," he said. The findings showed the eight hours of sleep saved roughly 135 calories over eight hours of wakefulness.

"While the amount of energy savings for humans during sleep may seem relatively small, it actually was a little more than we expected," said Wright, a faculty member in CU-Boulder's integrative physiology department and director of CU-Boulder's Sleep and Chronobiology Laboratory.

A paper on the subject was published in the January issue of the Journal of Physiology. Co-authors included CU-Boulder's Christopher Jung and Emily Frydenall, as well as Assistant Professor Edward Melanson, Dr. Leigh Perreault and Dr. Robert Eckel of the University of Colorado School of Medicine. Jung, first author on the paper, got his doctorate from CU-Boulder in 2009 and is now at the University of Alaska.

The study showed that compared to a typical night of sleep, the amount of energy expended by study subjects during 24 hours of sleep deprivation was up about 7 percent. In contrast, energy expenditure decreased by about 5 percent during the recovery episode, which included 16 hours of wakefulness following the sleep deprivation night, then eight hours of recovery sleep, Wright said.

"Understanding the function of sleep, especially in humans, is considered one of the most important scientific enigmas," said Wright, who also is an adjunct faculty member at the University of Colorado School of Medicine.

The study, which included seven young adult subjects, was tightly controlled. All participants were required to stay in bed for the entire three-day study. Their diets met individual daily energy requirements, and the content and timing of each meal was exactly at the same time each day during the lab study. The subjects spent the sleep deprivation night in bed watching movies, reading and talking, said Wright.

The first day of the study consisted of a typical 16 hours of wakefulness followed by eight hours of sleep. Days two and three included 40 hours of total sleep deprivation followed by eight hours of recovery sleep.

As part of the study, the researchers studied the effects of sleep stages ranging from light sleep to rapid-eye movement sleep to deep, "slow wave" sleep and awakenings from sleep on whole body energy expenditure, Wright said. The study indicated the most energy was expended during natural arousals from sleep, which occurred less often during the eight-hour sleep episodes following sleep deprivation.

The amount of energy saved during sleep by the study subjects likely would have been higher if they were allowed to continue sleeping after the eight hours of recovery sleep rather than being awakened, which was the final step in the study, said Wright.

The study may have implications for those with sleep disorders such as insomnia or sleep apnea. Insomnia, marked by difficulty going to and staying asleep, and sleep apnea, marked by frequent arousals from sleep, may mean such people "are burning the furnace at a higher rate at night because their sleep is disturbed," said Wright. He noted that more research is needed to address this issue in patients with sleep disorders.

It's likely that the metabolic costs of sleep deprivation would have been higher if the subjects had not been restricted to bed rest and had opportunities to walk around and perform various tasks, said Wright. Other studies have shown that sleep deprivation reduces the levels of leptin — a hormone responsible for telling the brain that the body is satiated — which could mean late-night snacking by "free-ranging" humans, he said.

"One question we have is why humans don't conserve more energy during sleep," he said. "We think there are multiple functions of sleep, and that some energy conserved during sleep may be redistributed to support other important physiological processes." Some energy conserved by sleep might be used for nighttime physiological activities like immune-system function, the strengthening of connections between neurons in the brain as a result of daily learning and experience, and hormone synthesis and release.

One of the health areas scientists are very interested in is how sleep loss may contribute to weight gain and obesity, said Wright. He stressed that energy expenditure during sleep deprivation is neither a safe or effective strategy for weight loss, and that other studies have shown chronic sleep deprivation is associated with impaired cognition. He said more research is needed to understand how short nighttime sleep schedules, typically six hours or less a night across many days, contribute to weight gain and obesity.

Wright said about a half dozen undergraduate research assistants helped in the study. The Sleep Research Society Foundation, the National Institutes of Health, CU-Boulder's Undergraduate Research Opportunities Program and the Bioscience Undergraduate Research Skills and Training programs of the Biological Sciences Initiative at CU-Boulder funded the study.

A 2006 study by Wright and his colleagues showed that people awakened after eight hours of sound sleep have more impaired thinking and memory skills than they do after being deprived of 24 hours of sleep.

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Journal Reference:

1. C. M. Jung, E. L. Melanson, E. J. Frydendall, L. Perreault, R. H. Eckel, K. P. Wright. Energy expenditure during sleep, sleep deprivation and sleep following sleep deprivation in adult humans. The Journal of Physiology, 2010; 589 (1): 235 DOI: 10.1113/jphysiol.2010.197517

The brain under general anesthesia isn't "asleep" as surgery patients are often told — it is placed into a state that is a reversible coma, according to three neuroscientists who have published an extensive review of general anesthesia, sleep and coma, in the Dec. 30 issue of the New England Journal of Medicine. This insight and others reported in their review article could eventually lead to new approaches to general anesthesia and improved diagnosis and treatment for sleep abnormalities and emergence from coma.

The researchers explain that a fully anesthetized brain is much closer to the deeply unconscious low-brain activity seen in coma patients, than to a person asleep. Essentially, general anesthesia is a coma that is drug-induced, and, as a consequence, reversible. The states operate on different time scales — general anesthesia in minutes to hours, and recovery from coma in hours to months to years, if ever. The study of emergence from general anesthesia and recovery from coma could help to better understand how both processes occur.

Understanding that these states have more in common with each other than differences — that they represent a continuum of activity with common circuit mechanisms being engaged across the different processes of awakening from sleep or emerging from coma or general anesthesia — "is very exciting, because it gives us new ways to understand each of these states," says study co-author, Dr. Nicholas D. Schiff, a professor of neurology and neuroscience at Weill Cornell Medical College and a neurologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Co-authors of the study are Dr. Emery Brown of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard Medical School, and Dr. Ralph Lydic from the University of Michigan.

Knowing more about the brain circuit mechanisms may also help researchers develop therapeutic agents to "tweak the circuits as needed, to help us in the areas where we don't do well, such as abnormalities of sleep and, especially, emergence from a coma," Dr. Schiff says. "And while use of general anesthesia is an incredibly safe technique, it can have effects on the elderly, such as slower recovery time and impaired cognitive function afterwards."

In their review, which took three years to develop, the researchers synthesized the newest studies in these three areas, including work of their own. Among their other specialties, Dr. Brown's expertise is general anesthesia, Dr. Lydic's is sleep, and Dr. Schiff's is recovery from coma.

"We think this is, conceptually, a very fresh look at phenomena we and others have noticed and studied in sleep, coma and use of general anesthesia," Dr. Schiff says. "By reframing these phenomena in the context of common circuit mechanisms, we can make each of these states understandable and predictable."

"These findings show that general anesthesia is a reversible coma, and learning about the different ways we can safely place the brain into this state, with fewer side effects and risks, could be an important advance in general anesthesiology," explains Dr. Brown. "Also, in a scientific sense, monitoring brain function under general anesthesia gives us new insights into how the brain works in order to develop new sleep aids and new ways for patients to recover from coma."

Describing the Switching Circuit

One critically important circuit the authors describe involves specific brain areas. One major player is the cortex, which is made up of layers of neural tissue at the outer edge of the brain, and another is the thalamus, a ball of neural tissue at the center of the brain. These areas are connected to each other through nerve cell axons, which act like information highways, passing signals. The cortex and the thalamus "talk" to each other in different ways over a 24-hour cycle.

Also part of the circuit is the basal ganglia, within the front of the brain, which is used to control certain actions. It does this in part by setting up two feedback loops. One is a negative feedback release on behavior, and that part of the circuit is always active when overall brain activity is reduced, Dr. Schiff says. For example, it works to stop a sleeping person from physically acting out their dreams.

The second feedback loop, however, releases the brake imposed by the first feedback loop, the researchers say. Certain drugs, such as the sleep aid zolpidem (Ambien), and propofol, a powerful general anesthetic with similar pharmacologic properties, can trigger that loop to function, producing what is known as "paradoxical excitation."

This phenomenon described in transitions observed in the early stages of general anesthesia appears to be common across all three states, because the drugs are triggering this same feedback loop, the authors explain. Most people given propofol become agitated and confused shortly after falling unconscious. Some people who use Ambien walk, eat and carry out other complex behaviors in an altered state of consciousness arising from sleep. Surprisingly, Ambien has also been reported to restore communication and behavioral responsiveness in some severely brain injured patients. The linkage of these disparate observations within a common circuit model is one of the key insights in the authors' integrative review.

Eventually the brake is switched back on in these three states — giving way to sedation and deeper sleep, or in the case of the severely brain patient, the return to a state of diminished responsiveness.

There is another phenomenon that results from this circuit, the authors say. "Emergence delirium is the flip side," says Dr. Brown. "For example, when bringing a person out of general anesthesia, the brain is woken up enough to be active, but it is not coherent or organized, which can explain the slower recovery time we see in some patients."

It is these two areas — losing consciousness and returning to consciousness — that the researchers believe they might be able to target to provide better therapies for sleep, emergence from coma, and general anesthesia with fewer side effects. And it is by studying general anesthesia — a process that can be well controlled as well as monitored and studied — that researchers will likely make progress in understanding all three states of mind, Dr. Schiff says. For example, because coma patients each have individualized damage to their brains due to injury or stroke or hemorrhages, studying recovery from general anesthesia may offer potential opportunities for developing general strategies for intervention, Dr. Schiff says.

"The quantitative neurobehavioral metrics used to monitor recovery from coma could be used to track the emergence from general anesthesia from a functional state that can approximate brain-stem death to states similar to a vegetative state and eventually to a minimally conscious state," the authors write.

"Moreover, understanding this circuit will help us understand the relationship of brain function to consciousness in general — what it is, how it is produced, and what the variety of brain states truly are," Dr. Schiff says. "Consciousness is a very dynamic process, and now we have a good way of studying it."

The study was supported by National Institutes of Health grants as well as a National Institutes of Health Director's Pioneer Award, and by grants from the James S. McDonnell Foundation.

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Journal Reference:

1. Robert S. Schwartz, Emery N. Brown, Ralph Lydic, Nicholas D. Schiff. General Anesthesia, Sleep, and Coma. New England Journal of Medicine, 2010; 363 (27): 2638 DOI: 10.1056/NEJMra0808281

While regulations have been put in place to restrict the work hours of doctors in training, no such regulations exist for fully trained physicians. An editorial in this week's New England Journal of Medicine argues that sleep-deprived physicians should not be permitted to proceed with an elective surgery without a patient's informed, written consent.

According to the authors, "This approach would represent a fundamental shift in the responsibility patients are asked to assume in making decisions about their own care and might prove burdensome to patients and physicians and damaging to the patient-physician relationship." They further write that "this shift may be necessary until institutions take the responsibility for ensuring that patients rarely face such dilemmas."

Studies have shown that sleep deprivation impairs psychomotor performance as severely as alcohol intoxication. A 2009 study in the Journal of the American Medical Association showed a significant increase in the risk of complications in patients who underwent elective daytime surgical procedures performed by attending surgeons who had less than a six-hour opportunity for sleep during a previous on-call night. Further complicating the matter, people who are sleep-deprived are often not able to accurately assess their degree of self-impairment. Surveys have also revealed that the majority of patients undergoing elective surgery would request a different provider if they knew that their surgeon was sleep deprived.

"Sleep deprivation affects clinical performance. It increases the risks of complications. And it is clear from survey data that patients would want to be informed if their physician was sleep deprived and that most patients would request a different provider," said Michael Nurok, M.D., Ph.D., an anesthesiologist and intensive care physician at Hospital for Special Surgery who is first author of the editorial. "We think that institutions have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians."

These days, some hospitals take steps to minimize the likelihood that a surgeon will be scheduled to conduct an elective surgery in a sleep-deprived state. For example, some busy practices prohibit scheduling surgeries for physicians on post-call days. But not enough is being done. "A lot of institutions are not going to be able to take that leap immediately, so as an interim step, we believe that patients need to be informed," Dr. Nurok said. "This is going to be a policy issue that develops. Elective surgery is the low hanging fruit because there is no urgency to doing it and it can be rescheduled — ideally as a priority with institutional support. It's a nice place to start to think about policy approaches."

The editorial argues that sleep-deprived physicians should be required to inform patients of their condition and the potential hazards that can come with this impairment. If patients opt to proceed as planned, they should be required to sign a consent form on the day of the procedure in front of a witness. Patients should be given the opportunity to go ahead with the procedure, proceed with a different physician if possible, or reschedule. The Sleep Research Society and American Academy of Sleep Medicine have argued that legislation is needed to address fatigue.

The editorial authors identify a number of barriers that may make this informed consent and surgery rescheduling unpopular with patients and physicians. Patients may have made logistical provisions for their surgery and may be unhappy if they have to reorganize their schedule again. Clinicians may lose cases to colleagues and thus income. Departments and institutions may lose income if patients reschedule and seek treatment elsewhere.

And while the study authors acknowledge that there may be financial and administrative costs associated with any informed consent plan, they argue that the costs may be offset by improved surgical outcomes and reduced complications.

"There has been widespread discomfort with the idea that patients are having procedures performed by physicians who are fatigued," Dr. Nurok said. "New policies are needed."

Dr. Nurok is also a member of the Department of Global Health and Social Medicine at Harvard Medical School.

Co-authors of the study include Charles A. Czeisler, M.D., Ph.D., of the Division of Sleep Medicine at Brigham and Women's Hospital and Division of Sleep Medicine at Harvard Medical School; and Lisa Soleymani Lehmann, M.D., Ph.D., from the Center for Bioethics at Brigham and Women's Hospital and the Division of Medical Ethics at Harvard Medical School.

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Journal Reference:

1. Michael Nurok, Charles A. Czeisler, Lisa Soleymani Lehmann. Sleep Deprivation, Elective Surgical Procedures, and Informed Consent. New England Journal of Medicine, 2010; 363 (27): 2577 DOI: 10.1056/NEJMp1007901

Danish sleep researchers at the University of Copenhagen and the Danish Institute for Health Services Research have examined the socio-economic consequences of the sleep disorder hypersomnia in one of the largest studies of its kind. The sleep disorder has far-reaching consequences for both the individual and society as a whole.

Hypersomnia is characterised by excessive tiredness during the day. Patients who suffer from the disorder are extremely sleepy and need to take a nap several times a day. This can occur both at work, during a meal, in the middle of a conversation or behind the steering wheel.

"Hypersomnia is often a symptom of sleep disorders such as narcolepsy, sleep apnoea, restless leg syndrome, violent snoring and/or obesity-related breathing difficulties," explains Professor of Clinical Neurophysiology Poul Jennum from the Center for Healthy Aging at the University of Copenhagen. The professor also leads the Danish Center for Sleep Medicine at Glostrup Hospital, which each year treats patients from across the country.

"Previous studies have indicated that these sleep disturbances affect people's quality of life to a considerable degree both socially and economically. Our studies show that people who e.g. snore violently but especially those who suffer from sleep apnoea, narcolepsy and obesity-related breathing difficulties use the health services more frequently, take more medicine, and are more frequently unemployed. The more serious the sleep disorder the higher the socio-economic cost."

Showing social-economic consequences

Each person who snores violently, suffers from narcolepsy or hypersomnia is calculated to cost Danish society an annual figure of € 10,223 and € 2190 respectively. The figures refer to the direct cost of frequent doctor's visits, hospital admissions or medicine expenses and indirect costs in the form of lost working hours. In addition to this, costs are also incurred in the form of state benefits. The researchers demonstrated that hypersomnia patients received state benefits more often than healthy subjects and took state subsidised medicine more frequently. The study has highlighted the high costs that have arisen, especially those born by society and which is largely due to frequent absence from the work force and lower incomes among the sick.

"Our study is the first to show the actual socio-economic consequences of untreated hypersomnia," explains Poul Jennum and refers to the fact that last year he and his colleagues carried out a similar study on the socio-economic consequences of the sleep disorder, narcolepsy. Here they also found an increase in the intake of medication, a higher rate of hospital admissions, and 30% more unemployment when the disease went undiagnosed and untreated. There is, however, significant potential for better diagnosis and treatment.

Getting better

"We have gotten better in the last few years at diagnosing and treating hypersomnia and the underlying diseases," explains Poul Jennum. "This can be a help to patients because we know that there are a lot of people who go around incredibly tired during the day who do suffer from hypersomnia, but have never been diagnosed or discovered the reason for their tiredness. The question is whether their tiredness is owing to narcolepsy or is the fact that they sleep badly at night owing to some other reason? It's clear to us that those who suffer from hypersomnia are more often ill and where hypersomnia is chronic, the economic costs to society can be quite considerable. That's why it is essential that people with the disorder have access to a system of treatment — otherwise the illness can affect their education, ability to work and thus their economic circumstances and health."

The study has been published in the December 2010 edition of Acta Neurological Scandinavia.

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Journal Reference:

1. P. Jennum, J. Kjellberg. The socio-economical burden of hypersomnia. Acta Neurologica Scandinavica, 2010; 121 (4): 265 DOI: 10.1111/j.1600-0404.2009.01227.x

Caffeine consumption in children is often blamed for sleep problems and bedwetting. Information on childhood caffeine consumption is limited, and many parents may not know the amount or effects of their child's caffeine consumption. In a study published in The Journal of Pediatrics, researchers found that 75% of children surveyed consumed caffeine on a daily basis, and the more caffeine the children consumed, the less they slept.

Dr. William Warzak and colleagues from the University of Nebraska Medical Center surveyed the parents of over 200 children 5 to 12 years old during routine clinical visits at an urban pediatric clinic. Parents were asked to report the types and amounts of snacks and beverages their child consumed on a daily basis.

According to Dr. Warzak, "Some children as young as 5 years old were consuming the equivalent of a can of soda a day." The authors also noticed that the older children drank more caffeinated beverages. "Children between the ages of 8 and 12 years consumed an average of 109 mg a day," Dr. Warzak explains, "the equivalent of almost 3 12-ounce cans of soda."

Researchers found, however, that caffeine was not linked to bedwetting in these children. "Contrary to popular belief," Dr. Evans, coauthor and statistician, clarifies, "children were not more likely to wet the bed if they consumed caffeine, despite the fact that caffeine is a diuretic."

The study authors stress the importance of parental awareness regarding their child's caffeine consumption. "Parents should be aware of the potentially negative influence of caffeine on a child's sleep quality and daily functioning," Dr. Warzak asserts. The authors suggest that primary care pediatricians may be able to help by screening patients for caffeine consumption and educating parents about the potentially harmful effects of caffeine.

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Journal Reference:

1. William J Warzak, PhD, Shelby Evans, PhD, Margaret T Floress, PhD, Amy C Gross, PhD, and Sharon Stoolman, MD. Caffeine Consumption in Young Children. The Journal of Pediatrics, DOI: 10.1016/j.jpeds.2010.11.022

Every year Santa Claus and his team of elves and reindeers stay awake for days and nights so he can deliver presents to children all over the world for Christmas — but he could be putting his and their health at risk. Sleep experts Professor Franco Cappuccio and Dr Michelle Miller, from University of Warwick's Warwick Medical School, discuss the pros and cons of Santa's 'all-nighter'.

Q: Professor, you recently published some research and a new book on sleep deprivation and how it can damage people's health if they are getting less than six hours sleep a night. Is Santa Claus at risk by staying up all night on Christmas Eve?

A: Considering that he does it only once a year, it may not be too bad for his long-term health. However, in the short term there are risks. Lack of sleep will make him drowsy, his vigilance will fade and his ability to think and remember will diminish. There is risk for himself and others: he could fall asleep at the reins and crash his sleigh, he could even end up delivering the wrong present to the wrong person. So let's hope he will listen to what we have to say.

Q: Should Santa sleep longer in the run up to the festive period to counter balance the lack of sleep he gets over the Christmas period? Would that work?

A: I doubt Santa would have the time to sleep in preparation for Christmas. I know he and his team are busy going through the lists coming from all over the world, sorting presents and loading his sleigh. I expect they have a few sleepless nights ahead of Christmas Eve too but it would be good for him to be as well rested as possible. Whilst a little nap on a rooftop here and there (no more than 20 minutes) might help in the short-term, it is no substitute for a good 8h night sleep. Santa also has a responsibility towards his most valuable staff, elves and reindeers. My advice would be to recruit more of them so that he could organise a rota with each elf on no more than a 10h shift, with rest and sleep in between. I do realise, however, that it would be impossible to replace Rudolph!

Q: What stimulants could he use to keep himself awake for that long, and avoid falling to sleep at the reins? Are there added health risks attached to using such stimulants?

A: A large cup of coffee (not de-caff please) could be a quick solution for a little while. It will usually have an effect after about 20 minutes, so have a nap before setting off again. Do not rely, however, on repeating this several times. The effect will reduce with time and he may also suffer unpleasant side effects, like palpitations and high blood pressure.

Q: What about the reindeers? Is there any evidence from the animal kingdom that suggests they are also damaging their health by flying all night long?

A: Every single living creature sleeps, and for a reason. However, both the duration and the patterns vary considerably from species to species. In general, wakefulness in animals is a survival function needed to feed and to keep predators away. Deer normally nap during the day and are quite active at night. For Rudolph and his mates, as long as they are well rested beforehand, they should be ready for the long trip night-time around the world.

Q: At each stop it is traditional for families to leave Santa mince pies and alcohol. Will having both of these treats make Santa feel sleepier?

A: Santa will definitely feel hungry after a sleepless night, since sleep deprivation increases appetite, so he appreciates a bit of grub to keep him going. Since sleep debt also leads to obesity, his pot belly is not a surprise to us. Don't leave him any booze, though! His sleepiness and tiredness already brings his attention to the level of someone who is over the alcohol limit, and there would be a real risk of him crashing his sleigh.

Q: And what would be the best way for Santa to recover after his busy night flying around the world? Is it just a case of sleeping for the whole of Christmas Day and Boxing Day?

A: Surely Santa will feel jet-lagged at the end of his trip! To deliver presents at exactly mid-night all around the world he will have to spend 24h in trans-meridian travel with rapid changes in time zones and little time for his body clock to adapt. He will travel in darkness all the time, so he will be more likely to fall asleep. Catch-up sleep helps to recover from the short-term tiredness and fatigue, but will not help avoid the long-term consequences of sleep deprivation. If he were to do this all year round, he would definitely run the risk of dying prematurely. However, children be reassured: he only does it once a year for us all, and by following my instructions he will remain fresh and zippy!