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SLEEP AND SOCIETYWilliam C. Dement, M.D., Ph.D., Sc.D

Stanford University Center of ExcellenceFor the Diagnosis and Treatment of Sleep

Disorders

October 1, 2013Sleep Symposium

Las Vegas, NV

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After the first half century of sleep research, and sleep medicine, America and the world have arrived at a moment of great challenge and opportunity. We know enough to respond.

The challenge: we must change the way society deals with sleep.

The opportunity: the entire human race will be lifted to a new level of energy, health, and safety.

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-Why we need sleep

-Negative consequences of sleep deprivation and sleep disorders

- Failure of effective knowledge transfer-Progress and potential for progress

This presentation will outline…

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But first… A Few

Historical Highlights

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A new clinical discipline, sleep disorders medicine, was born at Stanford University in the summer of 1970. We didn’t know for sure what to do or how to do it. However, most of the basic framework which would guide the development of new sleep disorders centers was in place at Stanford by the end of 1972.

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At first it was difficult to convince other medical colleagues that there really were sleep disorders, and to become involved. By 1975, however, there were four other sleep centers in America following the Stanford model. They joined together to formthe American Academy of Sleep Medicine (originally named the Association of Sleep Disorders Centers).

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We had also begun to address the problem of developing a quantitative, objective measure of daytime sleepiness.The Multiple Sleep Latency Test (MSLT) was developed in the Stanford University Summer Sleep Camp (1975-1980) by Dr. Mary Carskadon, and validated in the Sleep Disorders Clinic. (mention Jerry House plaque)

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Throughout the 1970’s, more than 80 percent of the referralsto sleep disorders centers were patients with obstructive sleep apnea, and most were severely ill.

Until 1981 when continuous positive airway pressure (CPAP) and uvulopalatopharyngoplasty (UPPP) treatments were introduced, the only treatment was chronic tracheostomy.Though the results were often miraculous, this treatment wasone of the biggest barriers to expansion of the field.

In 1981, there were only 23 fully accredited sleep disorders centers throughout the USA. Today, there are >1000 accredited centers, ~1345 physician specialists who are diplomates of the American Board of Sleep Medicine, and “>15,000 RPSGTs.

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In spite of this progress, today many Americans and others with sleep disorders continue to be undiagnosed and untreatedor misdiagnosed and mistreated.

Thus, in 2013. . .Inadequate and unhealthy sleep remains one of America’s (and the world’s) largest, deadliest, and most costly problems. (USA & Europe not so bad)

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SOME NEGATIVECONSEQUENCES

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It is now known that sleep is regulated homeostatically in all individuals. In the real world,the most important aspect of this process is that the effect of partial nightly sleep loss is cumulative.

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THE ACCUMULATIONIS CONCEPTUALIZED

AS SLEEP DEBTThe cumulative daily hours of sleep less than the

mean daily amount neededALL lost sleep accumulates as a debtSleep debt can only be reduced by getting extra

sleepSleep debt can accumulate rapidly or very

graduallyMost people have a sizable sleep debt.

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Besides reduced daily amounts of sleep, human beings can accumulate a large and dangerous sleep debt (become fatigued) from excessively frequent interruptions of sleep. This is likely to occur in obstructive sleep apnea and periodic limb movement disorder.Fatigue or tiredness (not sleepiness) is the number one symptom and consequence of sleep debt and sleep disorders.

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FUNDAMENTAL PRINCIPLESAll lost (or frequently interrupted sleep) accumulates as a debt that is only reduced by obtaining extra sleep and/or diagnosing and treating your sleep disorder.

The larger your sleep debt…

• the more tired you will feel.• the more impaired you will become.• the more likely you are to become drowsy.• the faster you will fall asleep. • the more likely we are to fall asleep and die.

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ESTIMATED COSTS OF SLEEP LOSSAND SLEEP DISORDERS IN LIVES AND DOLLARS

• ≥50,000 unnecessary deaths/yr• Countless injuries, disabilities, failures, misery• Accidents ~$100 billion/yr• Health care ~$300 billion/yr

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Exxon Valdez 1989• One of the worst

environmental disasters in history.

• Cost: over $2 billion clean-up and $5 billion fine for Exxon.

• Cause: “Sleep deprivation of the 3rd mate in charge of the bridge” as noted in the NTSB final report.

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Star Princess 1995• Grounded near Juneau, Alaska with 1,568

passengers, 639 crew.• Damage to vessel bottom included

rupture of oil tanks.• Total cost of repairs - $27 million.• NTSB report concluded:

– “The pilot was chronically fatigued as a result of obstructive sleep apnea.”

• NTSB recommendations included: – “Advise pilots about the effect of fatigue on performance

and about sleeping disorders such as sleep apnea.”

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21Head-on train collisions in Pennsylvania and Colorado due to fatigue

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This is the accident that captured the attention of the Honorable Mark O. Hatfield, Senior Senator from the stateof Oregon and led directly to S.104 which established the National Center on Sleep Disorders Research.

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The first aircraftaccident where fatigue was specifically identified as the direct cause.

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VIDEOCHINA AIRLINES

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BUS

ACCIDENT WILL BE DESCRIBED

RECENT (2000) BUS CRASHWITH IMPORTANT IMPLICATIONS(NOBODY DID ANYTHING!)

27IT’S A GOOD THING THIS SLEEPY DRIVER WASN’T DRIVING

YOURCHILDREN’S SCHOOL BUS

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29WHITE PLAINS, NEW YORK JULY, 1994

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Two photos of worst accident• photo of car

• photo of dead little girl

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Two photos of worst accident• photo of car

• photo of dead little girl

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Other Areas

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If jurors, judge, and/or lawyersare sleeping, is it a fair trial?

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PLANT SHUTDOWNCOST ~$2 BILLION

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IOM Report.To Err is Human.98,000 deaths per year causedby physician error.What percent dueto fatigue?

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•••N = 614 Heavy Rig Truckers•••Do you feel fatigued… All the time - 14% Most of the time - 39% Frequently - 35% Occasionally - 9% Never - 3%

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What is the signal that gets you

off the road? Head drop with startle

and/or hallucination - 82%THERE MUST BE A BETTER WAY

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~100 MILLION AMERICANSCHRONICALLY ILL

WITH SLEEP PROBLEMS

35 MILLION AMERICANS HAVE OSA100 MILLION+ HAVE TROUBLESOME SLEEP

DEBT

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Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. NEJM. 1993; 328: 1230-1235

Nieto F, Young T, Lind B, Shahar E, Samet J, Redline S, D’Agostino R, Neman A, Lebowitz M, Pickering T. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. JAMA. 2000; 283: 1829-1836

Peppard P, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. NEJM. 2000; 342: 1378-1407.

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Prevalence of Sleep apnea

in Truckers(N = 200; Age = 35 + 9 years; Males = 91%)

ODI>5 = 79% AHI>5 = 87%ODI>10 = 46% AHI>10 = 47%ODI>20 = 19% AHI>20 = 21%ODI>30 = 9% AHI>30 = 13%SOURCE: R.A. Stoohs, et.al., Sleep and Sleep-Disordered Breating in Commercial

Long-Haul Truck Dirvers, Chest, May, 1995.

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IGNORANCE IN THE WORKPLACE

In the Trucking Companies WhoseDrivers had Obstructive Sleep Apnea:

Had Ever Heard of Obstructive Sleep ApneaOr Knew What It Was!

• Driver• Manager• Safety Manager• Company Physician

Not One

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In Moscow, Idaho, USA, entire family practice population carefully screened

OSA: 34% males; 19% femalesRLS: 27% males; 31% femalesInsomnia: 30% males; 35% females

More than 60% of all patients had oneor more sleep disorders. None identified!

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“Increasing prevalence” of

obstructive sleep apnea

1970: Did not exist1980: Estimated at 5,000,000 by ASDC1990: Estimated at 10,000,000 by NCSDR1993: 30,000,000 RDI ≥5 (Young, et al., NEJM)1995: 80,000,000 if loud snoring included2000: 46% of everyone - RDI ≥1 (JAMA)2010: ~38,000,000 RDI ≥5

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VIDEOTAPE

FIBEROPTIC VIEWSOF UPPER AIRWAY

IN “BENIGN SNORERS”

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Sleep vs. Alcohol• 18 hours of sustained wakefulness produces

performance impairment equal to a blood alcohol

concentration (BAC) of .05; 24 hours = .10 BAC

(Dawson & Reid, 1997)

• Moderate sleep apnea produces performance impairment greater than a BAC of .08

(Powell et. al., 1999)

• Four hours sleep a night for six nights. Driving

performance worse than drunks (Powell et. al., 2001)

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$3M example: the Walter Reed StudyN = 66 truck drivers (sleep apnea ruled out)3 consecutive nights of 8 hours sleep followed by modified MSLT

0-5 “Pathologically Sleepy” - 25 (38%)5-10 Borderline (very unsafe) - 29 (44%) 10-15 Fairly Alert - 8 (12%) 15-20 Good Alertness - 4 (6%)

58ALL OF THESE ARE ADDITIVE

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The root cause of all these problems…

Erroneous beliefs and lack of factual knowledge about sleep

deprivation, biological rhythms, and sleep disorders

throughout our society.In short, pervasive ignorance.

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Nearly half a century, a huge reservoir of knowledge about sleep, sleep deprivation and sleep disorders has been building up behind a dam of pervasive ignorance and unresponsive bureaucracies. We don’t know how many preventable tragedies are occurring right now, today, this instant. It is time to either lower the floodgates or blow up the dam.

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Percent of Stanford students with no previous exposure to

sleep knowledge

Year

Percentage

1.8 percent!!!

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This pervasive lack of public and professional

awareness is at the bottom of every other problem.• No benefits from sleep

science • Inappropriate skepticism

• Retention of sleep mythology

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“We know enough,

it is time to act.”The Honorable James Hall

Chairman, National Transportation Safety BoardPress conference, National Sleep Awareness Week,

March 2000

TRUE PROGRESS BEGINS

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Anecdotal though they may be, there are some very impressive anecdotes. Summarize Dr. Jerauld Labarbaur and maybe Wilbur Matthews (PendletonOre).

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Question: Do we know enough? Can we aggressively pursue identifying and treating OSA and other patients?

Answer: YES!!!

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Rule of Thumb:If your snoring bothers your

bedpartner, it is serious

• Spousal arousal is also very serious• Treat two for the price of one• Progresses if untreated; don’t know rate

• Long term FU sparse; several studies relating CVD and stroke to snoring

• Kids and young adults should breathe quietly

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Moreover,the gap between what little

is being done to prevent unnecessary deaths and to

improve lives today, and what could be done…

is very large

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“Fatigue is a direct cause or contributing factor in every accident due to human error unless specifically ruled out.”

-National Transportation Safety Board

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Accident Investigation• Human Error• Time of Day• Prior Continuous Wake• Estimating Sleep Debt• Sleep Disorders

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REMINDER…All lost sleep accumulates as a debt that is only reduced by obtaining extra sleep.

The larger your sleep debt… • the more tired you will feel.• the more impaired you will become.• the more likely you are to become drowsy.• the faster you will fall asleep. • the more likely we are to fall asleep and die.

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With truly effective education about sleep, a sample of over the road commercial truck drivers were ableto eliminate fatigued driving, improvetheir health, and improve quality of life for themselves and their families.

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The educational experience and validation must achieve the outcomes of thorough understanding, positive behavioral changes, and making healthy sleep a top priority. The sleep education and training must be clear, simple, and very compelling. We have found thatwe must present the scientific basis for the facts and what they say must be done. We have also found that these essentials can be readily and then eagerly comprehended by professional drivers.

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Sleep And Fatigue Experienced Truckers Educating America’s MotorcarriersTHE SAFE TEAM

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WE HAVE PRECISELY DEFINED

THREE LEVELS OF

SUBJECTIVE/BEHAVIORAL WAKING ALERTNESS

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Level One - Wide awake and energetic, peak alertness, high motivation; absolutely no feeling of tiredness.Level Two - Definitely not at peak; low motivation, may feel tired, fatigued; remaining attentive and focused does not require conscious effort. Level Three - Conscious effort required to remain attentive and focused; drowsy, sleepy, unmotivated;must resist ever more strongly or sleep will occur.

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There are two very important

sleep-related problemsin the trucking industry…

Pervasive sleep deprivationand a pandemic of

undiagnosed, untreated obstructive sleep apnea.

-NCSDR: Report to U.S. Congress 1992

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. . . All caused by sleep disorders

A case of murder America’s largest oil spill A baby wasting away A disabling stroke Leaping off a 10th floor

balcony Unable to move a muscle Emergency evacuation of

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Passengers Cardiac arrest during sleep

Sleeping pill overdose Chronic fatigue Writhing, twisting, turning,

jerking all night long Asleep at the wheel Passing out Cant fall asleep when I want

to

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Highest priorities- Mainstream educational system-Save people who are at death’s door

HOW TO GET FROM HERE TO THERE

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Two Slides of...• Drowsiness is red alert• Drowsiness is red alert 2

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Areas of knowledge Everyone must master…

• Sleep homeostasis, sleep debt, sleep need

• Levels of alertness and why we are tired

all the time• Clock-dependent alerting• Understanding the health and performance impact of common sleep disorders

• Nature of sleep

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Knowledge about themselvesthat everyone must master…• Personal sleep requirement

• Hours of personal “forbidden zone”

• Tiredness and the moment of drowsiness

• How to estimate personal sleep debt

• Tolerable sleep indebtedness

• Sleep quality, snore score

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Two truckers; small sleep debt versus large sleep debt with same amount of sleep every night. Trucker with big debt having difficulty

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FELT GREAT!

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CONDITION 1

1. RT 283 ms

2. RT 264 ms

3. RT 247 ms

6 S’s RT 265

CONDITION 2

1. RT 202 ms

2. RT 185 ms

3. RT 170 ms

6 S’s RT 183

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A Bill to establish a National Office (Center)for Healthy Sleep, Safety and Productivity

in the Department of… The National Office (Center) will establish

mechanisms for effective transfer of knowledge about sleep to the American

public. This truly vital knowledge has been accumulated from years

of research on sleep, sleep deprivation,sleep disorders, and biological rhythmsbut is largely unavailable to the general

public

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As the field of sleep medicine and sleep research was slowly expanding, there wasa parallel growth of health maintenance organizations as well as increasingly strong efforts to hold down medical costs. It is becoming more and more difficult for primary physicians to encompass entirely new areas which will involve learning how to diagnose and treat illnesses they have never heard of. Even at Stanford Medical Center, this resistance has been very difficult to overcome.

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The Brush FiresCommunity Solutions:

It Will Work!

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Walla Walla, Washington

“The city they liked so much they named it twice.” Population - 28,800 #1 historical event:

“The Whitman Massacre” (1846) Definitely a “sleepy little town.”

96Main Street, Walla Walla, Saturday afternoon ‘93. Truly a sleepy little town!.

97Richard Simon, M.D., DirectorABSM 1996; Accredited 1998Saint Mary’s Hospital

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Sleep Tests in Walla Walla, Washington

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• Walla Walla would be an ideal site for long term outcomes documentation and research.

• The rate of diagnosing and treating obstructive sleep apnea in Walla Wallais 100x the rate in American society

• The rate of diagnosing and treating insomnia in Walla Walla may be 1000x the rate in primary care medical practice.

CONCLUSIONS

100No longer a sleepy little townMain Street, Saturday 2001

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If Walla Walla is nowa“wide awake little town,”

how and why?

Can this community solution be successful exported?

Once again, state societies!An idea whose time has come!

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Obstructive Sleep Apnea“The flagship”

Identification is easy.Testing/confirming and assessing

severity is easy.Treating and documenting efficacy

and compliance over time is difficult.

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CONCLUDING SUMMARYSTOP IF OUT OF TIME

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Reprise: What everyone should know about sleep

• true nature of sleep - not less active, but different - instantly blind and deaf - two entirely different organismic states• sleep need, sleep deprivation, sleep debt• biological rhythms and clock dependent alerting• opponent processes in sleep/wake regulation• fatigue, sleepiness, drowsiness• fatal fatigue, alcohol, drowsiness is read alert!• teen sleep, baby sleep, older sleep• getting the sleep we need and how good it feels• symptoms of common sleep disorders

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Level Two: What all health professionals should know

about sleep• tips for sleep fitness• how to reset the biological clock• nuances of sleep debt• diagnosis and treatment of common sleep disorders - particularly snoring and obstructive sleep apnea• sleeping pills: pros and cons• common age-related sleep problems• when and how to consult a sleep specialist