"How Long Can You Go? Acute And Chronic Sleep Deprivation" Arman Murabia (05/04/2022)

May 12, 2022

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00:00So I think we have some people already here.
00:03So good afternoon everybody
00:04and welcome to Yelp seminar.
00:07Today again, we're delighted to have
00:09one of our Norwalk sleep fellows
00:11this time Doctor Armand Marabia.
00:13And he discussing acute and
00:15chronic sleep deprivation,
00:16which is a really interesting topic.
00:20So anyway, before I turn this over,
00:21Doctor was going to be introducing him.
00:23I just want to give the usual reminders.
00:24So first, the sleep seminar lectures
00:26are available for CME credit
00:28and to receive credit to text,
00:29the ID for the lecturer to Yale
00:31Cloud CME by 3:15 PM today.
00:33The ID shows up on the slide and also
00:35will show up in the chat recordings of
00:37the lecture are available within two
00:39weeks at the site noted in the chat.
00:41And if you have questions during the talk.
00:44Please use the chat feature.
00:46We will moderate the questions at
00:48the end and as usual will give you
00:51permission to unmute yourself at the end.
00:53So now I will turn the session over to Dr.
00:55Ian Weir,
00:56who who is the program director
00:57for the Newark Hospital Pulmonary
00:59Fellowship and the Norwalk Hospital
01:01Sleep Fellowship and he is going to
01:03introduce our speaker doctor Marabia.
01:05OK, great, thank you so much.
01:07I have the honor today to
01:09introduce Doctor Marabia.
01:10So Doctor Murray has been with
01:12us for now almost four years
01:14prior to coming to Norwalk.
01:16He went to undergraduate at NYU,
01:18then to Ross Medical School and
01:20then his residency was at Brooklyn
01:23Methodist Hospital and we were lucky
01:25to have him match into our pulmonary
01:27critical care and Sleep program.
01:29And so we've done two years
01:31of pulmonary at Norwalk.
01:32A year of critical care at Yale,
01:34and now he's finally finishing.
01:36From all that in,
01:39in sleep fellowship,
01:40he'll be then traveling to the
01:43beautiful state of Virginia
01:44where he'll be working in both
01:47critical care and Sleep Medicine.
01:49For ANOVA,
01:49I believe is the one of is
01:52the main institution there,
01:54and so in terms of what I can
01:56tell you about Doctor Mirabi,
01:57always like to find some
01:59interesting facts and fun things.
02:00But you know,
02:01one of my sort of most memorable
02:04moments was during this COVID pandemic,
02:07and I and I got to really work
02:09very closely with the fellows,
02:11and we had our COVID unit of about 20.
02:13I'm sorry,
02:1430 to 40 intubated patients
02:16on ventilators with COVID,
02:18and I was just amazed about
02:20how Armand took it.
02:21He worked on a shift,
02:23took care of all those patients,
02:25and with the faculty attendings,
02:27and was just an unbelievable
02:29resource and really saved so many
02:32lives and did such an amazing job.
02:34He's been involved in quality work.
02:37To help develop our entitled
02:40CO2 policy at Norwalk,
02:42he's been very involved in in the
02:44Sleep fellowship and teaching.
02:45Our fellow are the Fellows residents.
02:47So it's been an absolute
02:49pleasure to have him.
02:50As for these four years,
02:52I'm so proud of him and I know
02:54he's going to go to Virginia
02:55and be a superstar there,
02:57so it's with great honor.
02:59I want to introduce Doctor Moravia
03:00and we'll be talking about acute
03:02and chronic sleep deprivation,
03:04and he's going to have a lot of
03:06interesting fun facts for us so.
03:07Should be a great time.
03:08Thanks everybody for joining.
03:10Thank you Doctor Weir for
03:11that lovely introduction.
03:12So good afternoon everyone.
03:14I'm Roman. One of the fellows,
03:16like Doctor Weir had mentioned so
03:18I'm going to get started on the
03:20talk so we're going to talk about
03:22acute and chronic sleep deprivation.
03:23Make sure I can.
03:25This is our CME disclosure.
03:27In addition, slide the information
03:29is also available.
03:30Towards the end.
03:35So I kind of got interested in this
03:37topic of sleep deprivation because I
03:39think if you look at the statistics they
03:41are quite staggering in terms of how
03:43prevalent it is and how many Americans
03:46suffer from having sleep problems.
03:48But what's more kind of appreciative
03:50of this is what are the manifestations
03:52of sleep deprivation and how it
03:55involves almost every organ group,
03:56every type of cognitive to mood disorders,
04:00and really has an overall impact.
04:02Quality of life functioning and and you know,
04:06just just functioning on a daily basis,
04:08so I think it was important topic
04:11to kind of at least review.
04:12And there's a lot of pretty interesting
04:14things that I've I've come across while
04:16I was doing my research for this.
04:17I hope everyone else can benefit
04:19from that as well.
04:25So the objectives today will go and
04:27define insufficient sleep will go
04:29somewhere with some over some of the
04:31epidemiology data that's available.
04:33We'll talk about the different
04:35effects of both the acute and
04:37sleep deprivation of changes,
04:38and then what we've seen in the sleep
04:40architecture talk about recovery,
04:42sleep and and and some of the
04:44phenomenons we see as we record
04:45some PSG data and then go over
04:47some fun facts and then I'll kind
04:48of end off with a familiar fatal
04:50insomnia because I think it ties
04:52in nicely and especially in the
04:54early portions of the disease.
04:55Process and how it can
04:57mimic insufficient sleep.
05:01So.
05:04So when you really define
05:06insufficient sleep, it's it's.
05:08It's really hard to.
05:10Say, is there a quantity reduction
05:12or is there a particular number?
05:16Because there is such a wide range
05:18of what is needed and what is normal
05:20for a person in the population,
05:22but it's defined as having insufficient sleep
05:25and that could be both the total sleep time,
05:28which will be the duration or the
05:30quality of sleep that's going to
05:32result in decrease alertness,
05:33performance and lead to any
05:35type of health issues,
05:37and acute deprivation is going
05:39to be defined as having these.
05:41Reductions within a time
05:42frame of one to two days,
05:44whereas chronic becomes more of
05:46a habitual process where you
05:47getting less than the amount needed
05:50for this optimal functioning on
05:51a on an almost nightly basis.
05:56So if we look at the ICSD
05:59definition and the criteria,
06:00one thing I did want to point out is you
06:02can see all these alternative names here.
06:05So behaviorally induced
06:06insufficient sleep syndrome,
06:08insufficient nocturnal sleep,
06:10chronic sleep deprivation,
06:11sleep restriction, they kind of go hand
06:14in hand in terms of the presentation,
06:17but they're essentially, you know,
06:18different ways of of saying the same thing,
06:21and one of the kind of hallmarks of of this
06:23is when you're when you're defining is.
06:25Is having symptoms of daytime
06:28sleepiness and that's important because
06:30you can have someone who sleeps 5
06:32hours and does not have any symptoms
06:34of excessive daytime sleepiness,
06:36so you would not be able to call that
06:38insufficient sleep and you could
06:40because you can have long you know,
06:42short sleepers,
06:43long sleepers,
06:43but it has to have some type of
06:46daytime sleepiness,
06:47symptoms and most of the time this is
06:49going to be due to shortening of the
06:51duration of sleep that's that's occurring
06:53on most days for at least three months.
06:56And then of course there's other
06:58criteria in terms of how we're
07:00measuring the curtailed time,
07:01whether that's through sleep
07:03logs or tiger fee,
07:04but overall you know.
07:05And obviously you have to exclude
07:07that it's not going to be a result
07:09of other entities as mentioned here.
07:14So one distinction that
07:15I kind of wanted to make,
07:17especially as you delve into some of
07:19the data is is really differentiating
07:22between insomnia and insufficient sleep.
07:24So when you have insomnia,
07:26you can end up having overall you know,
07:29sleep deprivation, but when you when you
07:31qualify this into different categories,
07:34there are distinctions that are needed.
07:37So insomnia really refers
07:38to the inability to sleep,
07:41and that could be both in terms
07:42of the total length of sleep.
07:44Which are getting or the quality of sleep.
07:46But there is the opportunity to sleep there.
07:48So most insomniacs we know will be in
07:50bed for prolonged periods of time,
07:52tossing and turning.
07:53So they are giving themselves
07:55the opportunity to sleep,
07:56but but it's the actual issue with either
07:59falling asleep or maintaining sleep.
08:02Whereas insufficient sleep really
08:03is a shortening,
08:05it's it's more of a behavioral component
08:07where you're decreasing the length of
08:09total sleep that you're allowing yourself,
08:12or there's other issues that are causing.
08:14Arousals and we'll get into that
08:15into a little bit more detail,
08:17so this kind of little picture
08:18here shows a lot of the sleep
08:20deprivation is going to be a little
08:22bit of behavioral by choice,
08:24whereas insomnia is is more of the inability.
08:30So how much sleep do we really need?
08:32And that's kind of a a hallmark question
08:34to ask because as we are taking care
08:36of patients in our clinical practices,
08:39you know we often ask them what
08:40time are you going to bed?
08:41How long does it take you to fall asleep?
08:42What time are you waking up in the morning?
08:44Are you feeling refreshed?
08:45Are you still feeling sleepy?
08:46Are you feeling tired?
08:47You know what's your app worth?
08:49So that's you know,
08:50we get that kind of objective data from then.
08:52But how do we interpret that?
08:54And and really,
08:56there isn't any great data to suggest
08:58a finite number of hours or minutes.
09:01We'll, we'll lead to you know,
09:03this being a normal quantity
09:05of sleep for that individual,
09:07so there's a few substitutes that that
09:09can be used to determine what is the
09:11amount of sleep and a person will need,
09:14and that may become the normal for them.
09:16So if you allow someone to kind of
09:19sleep and then wake up spontaneously,
09:21that duration may constitute what the
09:24normal sleep quantity is for that person.
09:27Also, if you have them sleep at
09:29different durations, so one day.
09:31One day they sleep six hours 789 et cetera.
09:35And then in the morning you're again
09:37asking them for subjective information.
09:40How alert do they feel?
09:41How refreshed,
09:42whether sleep and then you know how
09:44are they able to carry out the day
09:46feeling alert when they have these kind
09:48of boring and monotonous situations?
09:50Are they nodding off during you know?
09:52Zoom conferences and things of that nature
09:55or they've dozing off during meetings,
09:57but there is a little bit of a consensus
10:00that that suggests that most adults.
10:02Report that if they are able to
10:04get anywhere from 6 to 8 and some
10:06will say 6 to 9 hours of sleep,
10:08that's considered kind of the the
10:10norm in terms of a population study.
10:12But we know that there's long
10:14sleepers and short sleepers.
10:15People who function really well
10:17with less than six hours of sleep
10:19and then others who need 10 hours
10:21of sleep to kind of have their
10:24day going and feeling alert.
10:26So this is one of the slides
10:28that kind of looks at what is
10:32considered the recommended sleep
10:34duration for different age groups,
10:36and it starts with a newborn and progresses
10:39all the way through an older adult.
10:41But you can see that there's
10:43there's such a wide range.
10:44There's there's a recommended portion.
10:46Then there's also maybe appropriate portion,
10:49and then there's not recommended,
10:51so you can see you know,
10:53even starting over the newborn 14 to
10:5417 hours is kind of the recommended.
10:56Time,
10:57but from 11 hours all the
10:5919 hours may be appropriate,
11:02so the entire range may be appropriate
11:06and and then obviously outside of that
11:08meeting you know can be less or or more,
11:10but this this this.
11:11This range really kind of exceeds
11:13and goes to all the way through
11:15the different age
11:16groups, even into the older adults
11:19and we see a gradual decline in
11:21what the recommended sleep time is,
11:24what a lot of this variation
11:25and what may be appropriate.
11:27Continues to make it difficult for us to
11:31finitely define what someone may need,
11:34so this is good for a reference,
11:37but it's going to be very individualized
11:38when it comes to patients.
11:43So some of the epidemiology
11:45data and what's out there.
11:47So more than 1/3 of of adults in
11:49the US report that they have issues
11:52falling asleep or staying asleep,
11:55or they're not getting enough sleep.
11:57The initial slide had mentioned 70%
11:59having some type of sleep problem,
12:01and it's almost you know,
12:0240% of males having some insomnia complaints.
12:0530% of female having insomnia
12:07complaints and and this is where it's
12:09really important to kind of hone out.
12:10Is it really due to insufficient
12:12sleep from rehearsal?
12:13Aspect is more insomnia,
12:15but there is some data that suggests
12:18that if 1/3 of adults report
12:21having less than 7 hours of sleep,
12:23they had slightly more difficulty
12:25with concentration compared to their
12:27counters that that we're getting
12:28anywhere from 7 to 9 hours of sleep,
12:30and you can see the difference
12:32between 29 and in the group that
12:34was getting Leslie versus 19.
12:36So it seems that less than 7 hours and
12:39better through the of the population and
12:42adults have some concentration issues.
12:45Now there is groups that are more prone,
12:47so if you're Hispanic, black Americans,
12:50American Indian Alaskans,
12:51Native Hawaiians, and Pacific Islanders,
12:53this group tends to have higher
12:55complaints of insufficient sleep.
12:57So that's this is kind of something to
13:00consider when we see our patient population.
13:03Then,
13:03as well as we'll talk about the
13:05kind of U shaped curve in terms of
13:07what you know more and and less
13:09sleeping and what that results in.
13:11But is also thought that
13:13blacks versus whites,
13:14the black population has higher prevalence
13:16of short and long sleep duration,
13:19and especially those with
13:21low socioeconomic statuses.
13:22In terms of the prevalence of getting
13:24less than six hours of sleep,
13:26again,
13:26a lot of studies will use six
13:28hours is kind of the cut off,
13:29some will define it as less than 7 hours.
13:32The six hours is generally an
13:35acceptable total sleep time for for,
13:38for nocturnal sleeping is considered.
13:40That's probably the on the lower end,
13:42but we see that as as as time has
13:45progressed from the 70s till the early 2000s,
13:48more of the population is getting less sweet,
13:51and so the prevalence overall
13:54sleep deprivation has increased
13:56over this time frame.
13:57And then there's also a meta analysis
14:00that looked at children or almost 700,000.
14:03Children in over 20 countries
14:05and what they found is again,
14:07this is reported data and from
14:09from the studies then what they
14:11found is that over the last century
14:14per year children are getting .75
14:17minutes less of sleep.
14:19So over over over a span of a century,
14:21that's 75 minutes overall,
14:23which you know which is an hour and
14:2515 minutes less that children are
14:27getting and we we wonder if this is,
14:30you know, playing a role in higher diagnosis.
14:33And more prevalence of ADHD.
14:36You know more antidepressants
14:38being used in children?
14:40Increased prevalence of of psychiatric
14:42illnesses that were that were also seeing?
14:45Because we know that there
14:46is great data to suggest
14:47that when there is sleep deprivation,
14:49a lot of these mood factors
14:51and psychiatric illnesses.
14:53Prevalence is also goes up.
14:57So sleep deprivation really like like
14:59we mentioned earlier is is can be
15:02an issue with both the quantity of
15:04sleep and then the quality of sleep.
15:06So this is a little bit interesting
15:09that we again when you define
15:11what is normal for one person.
15:13So if someone sleeps 8 hours a day and
15:16the next day they get 8 hours is a norm.
15:18If one day they sleep 7 hours,
15:21is that going to result in them having
15:23any type of change in their performance
15:25in terms of daytime sleepiness?
15:27Et cetera, but what they really
15:30found is that if you reduce that
15:33total number of sleep hours,
15:35as long as it's not fall below 6 hours,
15:38there was no clear change in terms of
15:41performance or subjective sleepiness,
15:43and that's kind of where the six
15:46hour mark or six hour total sleep
15:49time may become relevant here.
15:51Similarly, if when you start to
15:54look at vigilance testing,
15:55there is a a decrease in in in your.
15:58Performance if you're sleeping less
16:00than your normal time, but again,
16:03if you maintain it above 6 hours.
16:05So if you're maintaining between 6:00 to
16:079:00 hours your your you can adapt to that,
16:09so you'll have this decrease
16:11in in in in response times,
16:13but you can adapt to that and and as
16:15long as you remain over 6 hours you
16:17are able to cope with that just fine.
16:19So something to kind of add to
16:23where the six hour is is is coming
16:26from for the lower threshold.
16:28Now the quality of sleep is is also
16:30going to be playing a big role here,
16:33so we know even from our sleep
16:35disorder breathing that a number
16:37of arousals that are occurring and
16:40how we quantify those can lead
16:42to these complaints of excessive
16:44daytime sleepiness and performance.
16:46Now sleep disorder breathing
16:48could be a very poor correlation
16:50in terms of the actual Hird.
16:52Whatever you want to look
16:53at and the symptoms.
16:54But there is data suggest
16:56that as few as five arousals.
16:58Per hour can lead to daytime sleepiness and
17:01and and decrease in performance overall,
17:04so this was a study done where 11 young
17:08adults and probably not the most ethnic
17:11ethnically combining study at this point.
17:14But they had eleven young subjects
17:16who were subject to brief awakenings
17:19through an audiometer that kept kind of
17:22waking them up so they were connected
17:25to EG and for two consecutive nights.
17:28They had these frequent arousals
17:30and then two nights where they had
17:32undisturbed recovery sleep and what
17:34they really found is that the the
17:36the the the nights that they were
17:38having these persistent arousals.
17:41They had a severe reduction in their
17:43slow week slow way where they're deep
17:44sleep and their REM sleep and then
17:46overall their total sleep time was
17:48cut down by one hour and they tested
17:51them again for their performance,
17:54their mood, their assessed,
17:55they're having daytime sleepiness
17:57and all that seemed to have gotten
17:59worse so they had more
18:00sleepiness. You know, irritability.
18:02There were not as sharp in terms
18:05of their response time and their
18:06their level of of decrease was very
18:09similar to that of someone who's who's
18:11getting a total sleep over a chronic
18:13period of time of 40 to 64 hours.
18:16So there's there's good data suggest
18:18that when you have interruptions that
18:20can that can lead to symptoms of sleep
18:24deprivation and then affect your performance.
18:27So this was an older slide,
18:29but I think it it's a great way to kind
18:31of see what happens if you're on call
18:33and you're getting frequently paged
18:35or you're getting you know messages
18:37that you have to respond to when you
18:39look at the normal sleep architecture
18:41on the on the the graph above,
18:44you can see the the cycling through
18:45the different stages.
18:46You can see that there's REM
18:48periods that are getting enlarged
18:50so good sleep architecture here,
18:52whereas if you see that if you're
18:54constantly getting paged and awakened
18:56you're really having and this is again.
18:58You know older slide with
18:59stage three and four,
19:00but you're really having a reduction
19:01in your slow wave sleep and then your
19:04REM periods are also being cut down,
19:06and that's probably a reason why
19:08you're having a change in your
19:11alertness and and your response time.
19:13And then of course,
19:14if this is someone who's on call and
19:17then has to go from morning rounds,
19:18they're not going to be feeling
19:20very refreshed.
19:21That alertness may not be there,
19:23and I have data later on coming to go over
19:26the exactly what the some of the changes are.
19:30So there I I wanted to just kind of.
19:33Go over some of the the different
19:36changes and different structures that
19:38happen in acute sleep deprivation.
19:40There's cognitive as being one of the
19:43the prominent ones where alertness and
19:46vigilant testing can really be affected.
19:48So even within that one to two day period,
19:51you can have leaders who are going
19:53to take much longer to respond,
19:55respond to stimuli.
19:56They're really going to have poor
19:58performance when it comes to doing
20:00tasks that require sustained attention,
20:02so especially if you if we're looking at
20:04occupation of patients who are working with.
20:06Heavy machinery or dangerous machinery,
20:09if they're really having sleep deprivation,
20:11they're at higher risk of making errors.
20:13If you look at kind of logical reasoning.
20:16Even complex,
20:17just subtraction tasks.
20:18All these will be affected,
20:20and then being able to carry out
20:23multiple tasks simultaneously,
20:24or something that's complex.
20:26A complex nature all all
20:28becomes affected here.
20:29Now there's also imaging data to suggest that
20:33when you do have acute sleep deprivation.
20:37If you look at functional Mris,
20:38there is decreased activity in the frontal,
20:41parietal attention networks,
20:43and so you see that there really is
20:46a even a organic change that we can.
20:49We can clearly see on imaging there.
20:51Now there's data that that have
20:54looked at police officers that
20:56looked at healthcare workers
20:58and and and what they found is that
21:00when you had medical interns working,
21:03these frequent shifts for more than 24 hours,
21:06there was a higher prevalence of
21:08diagnostic errors. And and and,
21:10and negligent mistakes that were being made.
21:12And as you as we kind of keep it
21:15within the healthcare network,
21:16we see that even GI physicians,
21:19if they were on call the night before,
21:21and they had to perform some type of
21:24an emergent procedure the next day if
21:26they were doing routine colonoscopies,
21:28they actually had a lower detection
21:31rate for adenomas compared to those who
21:34were not on call or were not awakened.
21:36So there is, you know this this this.
21:39Definable entity of having cognitive
21:42impairment when you have acute
21:45acute sleep deprivation.
21:48In terms of the mood this is,
21:50you know, no news to most of us
21:51that you're gonna have a poor mood.
21:53You can be very irritable along with
21:55the daytime sleepiness, low energy,
21:57decreased libido, poor judgment.
22:00You're kind of a little bit more energy,
22:01psychological dysfunction and and
22:03and one of the good things about
22:06the mood manifestations is that as
22:08soon as your your sleep is restored
22:10or that acute deprivation is is,
22:13you're paid back your sleep,
22:14that there,
22:15the mood component improves quite quickly.
22:19Now Microsleep is is is an interesting
22:21concept that I kind of came across.
22:24This is intrusions of sleep within
22:26your periods of wakefulness,
22:28and they last for a few seconds,
22:30especially if you're not being
22:32constantly stimulated or you're
22:34doing something that may now require
22:37a persistent need for attention.
22:39So one of the great examples that
22:41I saw is that if you're driving
22:43in your sleep deprived and you're
22:45driving on the highway at 60 mph,
22:48if you have 3 seconds.
22:49Microsoft period,
22:50your car will travel 250 feet so you
22:54can imagine in 250 feet if there if
22:56there's any changes in the road.
22:58If it curves or a car in front of you stops,
23:00you're really going to have a poor
23:03response time in terms of responding
23:05to that change and and This is why
23:07we see that with sleep deprivation
23:09there is much,
23:10much higher incidences of of car
23:13motor vehicle accidents and injury
23:16and then same thing with vigilance,
23:17testing and performance.
23:18There is much more.
23:20Inconsistent results and unreliable results.
23:22So not only are they not accurate,
23:25they're also not consistent,
23:27so it's kind of very staggered and
23:29and and in very different places.
23:31Now,
23:31if you take these same patients
23:33who have sleep deprivation and do
23:35a psychomotor vigilance testing
23:36and what they're doing is,
23:38they're every six to 10 seconds.
23:40They're sending some type of a visual
23:42stimuli at random 6 to 10 intervals
23:44over a span of 6 to 10 minutes,
23:47and what they're what they're asking you
23:48to record your response time when you do.
23:51Acknowledge a stimulus has been
23:52reported and So what they found,
23:54what they found is that when
23:56you have the sleep
23:56deprivation, not only is there a
23:58delay by more than 500 milliseconds
24:00of of responding to the stimuli,
24:02but there's much more errors.
24:04You're so you're not accurately
24:06reporting the stimuli,
24:07but you're also having a
24:08delay in your response time.
24:11Now, chronic sleep deprivation.
24:14Again, this is a little bit more
24:16difficult to define in terms of changes,
24:19but again, there is great data to
24:22suggest that as the the the almost
24:25daily basis of having less than needed
24:28sleep for optimal function occurs,
24:30you can take all those effects
24:32from sleep deprivation,
24:32including the mood etcetera.
24:34Functioning and kind of enhance that
24:37even further, and so you're really going
24:40to have poor alertness persistent.
24:42Daytime sleepiness you're in.
24:43Your cognitive function is going to decline.
24:46He spoke about the increased risk of
24:48accidents and deaths and that kind of goes,
24:50you know, hand in hand,
24:51we know there's great data suggests
24:52when you have sleep, disorder,
24:53breathing, and and obviously that goes
24:55on for years before being diagnosed,
24:58a lot of the times they're at
24:59higher risk of having accidents.
25:01And then, of course,
25:01there's going to be a lot of negative
25:03effects on your on your physical health,
25:05so you know,
25:06excessive daytime sleepiness is
25:08reported as one of the most common
25:10reasons for having car crashes.
25:12And over half of the fatal truck
25:15crashes in the US and then occupational
25:17errors over a long period of time.
25:19There's a cohort study that looked
25:21at police officers almost 5000 police
25:23officers and found that you know,
25:26within their subjective responses,
25:28at least 40% of them had some
25:32type of sleeping disorder.
25:33The most common again was
25:34sleep apnea in them.
25:35But again,
25:36all these sleeping issues overall can
25:38result in having sleep deprivation,
25:40and then have both.
25:43Neurocognitive and and amongst other changes.
25:47So when you look at cardiovascular
25:49morbidity and things of that nature,
25:51I think this concern may
25:54be some motivational.
25:56Pointers that we can use towards our
25:58patients who are having symptoms
26:00of sleep deprivation may have the
26:02daytime sleepiness and this may help
26:04them get a little bit more motivated,
26:06especially if they have a lot
26:08of medical comorbidities.
26:08So there is an American Heart
26:10Association has recognized that when
26:12when patients have sleep restriction
26:14that it does have an adverse effects on
26:16their their cardio metabolic profiles,
26:19so they tend to have higher blood pressures.
26:21They're having poor dietary habits,
26:24so they have more glucose,
26:26higher glucose, or insulin.
26:28Resistance,
26:28they tend to have less physical activity,
26:31more weight gain, and then they're smoking.
26:34Cessation rates are much,
26:35much lower,
26:36and so a lot of the data for each one
26:39of these particular entities had a
26:41hazard ratio anywhere from 1.07 to 1.12,
26:44so shows that much much higher
26:46incidence of having these entities
26:48occur when you have sleep deprivation,
26:51and then the normal population there is
26:54recorded increase in inflammatory markers.
26:55CRP is one of them,
26:57but you're a lot of the interleukins.
26:58Are are elevated,
27:00there is decreased response to vaccination.
27:03So if you're looking at titers
27:06after vaccinations,
27:06those that have sleep deprivation tend to
27:09have less amounting over mean response,
27:11and then they have looked at
27:13population studies and and
27:15seeing what is the all caused mortality?
27:17And it really comes out to a U shaped
27:20curve where people were getting less than
27:22six hours or more than 10 hours tend
27:24to have a higher all caused mortality,
27:27whereas in between that time.
27:29It's it's more normalized.
27:31Again, that's that reflects
27:33the general population.
27:35It's not going to be something that's
27:37applied to every single person as we
27:39know there is short and long sleepers.
27:44So sleep rebound. It's it's another
27:47interesting phenomenon that occurs,
27:49and this really refers to when you're
27:52you're you're paying back your sleep debt.
27:55It's much easier to do so after an
27:58acute phase where it's one to two
28:01days and you haven't slept well.
28:03Whether you're on call,
28:04you know we all have things that need
28:06to get done traveling, et cetera.
28:08But once you do get that sleep.
28:12The appropriate amount of sleep and
28:14you're able to repay that debt back.
28:15A lot of the acute effects do get better,
28:19so a lot of the things that we spoke
28:22about in the acute sleep deprivation
28:23in terms of mood and response time.
28:26All that gets better relatively quickly,
28:29and just similar to what we saw
28:30in terms of the sleep architecture
28:32changes when you're having the acute
28:35sleep interruptions you're having less
28:37of the slow wave and the REM sleep.
28:39So as you rebound and get more sleep,
28:41you're able to fall asleep.
28:43Masterseal sleep onset latency is
28:44is short and you're able to get
28:47more slow wave or deep sleep.
28:48You're going to be paying back
28:50your your REM deficit as well,
28:52so we tend to see more slow wave and
28:55REM sleep as as the rebound periods
28:58occur from from acute sleep deprivation.
29:01Like I said,
29:02a lot of the cognitive impairments
29:03that were that were often seeing
29:05from acute supervision gets, gets,
29:07gets better and and so does the mood.
29:10And so I think this is.
29:11This is some of the subjective things
29:15that we can bring to our patients and
29:18and especially if they're coming in
29:21complaining of daytime sleepiness in
29:23our pediatric patients about irritability.
29:26Their performance in school,
29:27whether they're having behavioral issues,
29:29acting out, you know,
29:30in their in the classroom.
29:32Are there in their in their schools?
29:34You know, we we,
29:35we have some evidence to suggest that
29:37if they are able to kind of go back
29:39and and and increase their total sleep time,
29:43some of these things can be
29:45reversed for improvement purposes.
29:49So how do we really evaluate our
29:51patients when we're we're assessing
29:54for sleep deprivation?
29:55It's it.
29:56It kind of goes hand in hand with what
29:58we're doing for our initial evaluations,
30:00whether we're assessing for sleep,
30:02disorder, breathing,
30:03insomnia,
30:03but few things that you know you
30:06really want to hone in on is what
30:09their habitual sleep time is.
30:10If they're clearly telling you they're
30:13having symptoms of daytime sleepiness,
30:15but they're only getting less
30:16than six hours of sleep, at least.
30:18Then putting sleep deprivation or
30:21insuffient behaviorally induced
30:22insufficient sleep is going to be
30:24on your differential there.
30:26Yes,
30:26you still want to make sure there's
30:27no sleep disorder, breathing,
30:28and other things,
30:30but if you're having daytime
30:32sleepiness with less than six hours,
30:34it it becomes part of a differential.
30:36Here you also want to look for any
30:38shift work shift workers in your
30:40in your population,
30:41because as you're kind of going
30:43back and forth between
30:45trying to keep their.
30:46Normal hours for their family and then
30:48they have to work certain amount of
30:51days that constant shift and and changes
30:53in their sleeping pattern can result
30:55in them having insufficient sleep.
30:56And then you really want
30:58to rule out insomnia.
31:00Movement disorders like we spoke about,
31:02and that's where the insomnia component
31:05is going to help you determine.
31:08What the treatment modality will be?
31:10Because for insomnia we know about the
31:12things that we need to focus on and
31:14we'll get into the treatment next,
31:16which will be slightly different.
31:18You also want to look at circadian
31:21rhythm disorders sometimes.
31:22If they are,
31:23we know in the adolescent population
31:25they can have a delay phase,
31:26and then they have to wake up
31:29early for school and that may be
31:31something that's that's driving their
31:33their overall sleep deprivation.
31:35So if they're going to bed later
31:37and they just can't fall asleep.
31:38Earlier than they have to get
31:40up in the morning.
31:41They're going to be cutting their
31:43total sleep time less so they can
31:45have an overlap between a delayed
31:47phase disorder and and and then
31:49resulting in insufficient sleep from
31:50behaviorally not getting enough sleep.
31:53Mental illnesses are also going
31:55to be a big component if you're
31:58having mood disorders,
31:59they're more likely having insomnia,
32:01especially if they're depressed.
32:03But there are.
32:04There are spectrums of depression
32:06where they have less of of a need for.
32:09Or you know, manic phases.
32:10They're not sleeping as much and so
32:13kind of becomes a vicious cycle of,
32:16you know,
32:16being manic,
32:17not wanting to get enough sleep
32:18and then becoming sleep deprived,
32:20which further drives the mania.
32:22Medications are also important.
32:24There are medications that make you sleepy.
32:26And then there's also kind of
32:28stimulants that are being used.
32:29We're seeing a lot more ADHD medications
32:32being used in the younger population,
32:35and so the timing of the medication
32:37if they're taking their stimulant.
32:39Much later in the evening portion,
32:41that's going to make it harder
32:42for them to sleep,
32:43and then again reduce their total sleep time
32:45and then can lead to sleep deprivation.
32:48Sleep state misperception is another one.
32:52Kind of goes hand in hand with some
32:55of the insomnia by our DOXIL insomnia,
32:57where they may report that they're you know,
32:59only getting a few hours of sleep,
33:00but then when you give them a tiger fee
33:03or you actually put them in the sleep lab,
33:06you know there's a misperception
33:07in terms of what is reported and
33:10what the actual sleep time is.
33:12Sleep Diaries are are are going to
33:14be kind of important here and again,
33:16they're subjective.
33:17They're prone to having a degree of
33:20of error in terms of how much is.
33:22Accurately being recalled,
33:23but there are a great way of starting
33:25to assess the total sleep time
33:27that someone is getting, and again,
33:29if they persist in less than six hours,
33:32you can start thinking.
33:33Is this more behaviorally induced
33:36insufficient
33:36sleep? While you're excluding other causes,
33:39your your Pittsburgh sleep quality index
33:41will help you assess if they are really
33:43having issues with their quality of life.
33:45Sleep quality as you're kind of delve
33:48into your differential and then you
33:50can use actigraphy to really assess
33:53as a surrogate of how much total
33:55sleep time they may be getting.
33:59So how do we? How do we improve the
34:01the total sleep time that's going
34:03to be the main therapy in terms of
34:06sleep deprivation is just being able
34:08to give yourself more time to sleep.
34:11Now that's kind of easier said than
34:14being done and and there really isn't
34:16a lot of great evidence to suggest
34:19that one therapy or one combination
34:22of therapies work better than another.
34:24It kind of logically makes sense
34:26that if you're asleep.
34:28The price you should be getting more sleep
34:30and so you should just get more sleep.
34:32Now you know you say that to a
34:34patient and you know there will
34:35be a million and one excuses.
34:37Oh well, you know.
34:38Have kids take care of I have work I
34:40have to balance this and I want to watch
34:42you know a little bit of TV so you know what.
34:44What can we use to kind of motivate
34:46our patients when we're trying to help
34:48them increase their total sleep time
34:50and what works what does not work.
34:53And one thing is that we really want to
34:55try to avoid medications and these patients.
34:58We don't want to give them
34:59a sleep aid and say, well,
35:00I know you're only getting
35:02six hours of sleep,
35:02but this will help you get,
35:04you know fall asleep delivered faster
35:06and give you 30 extra minutes etcetera.
35:09So it's it's really going to come down
35:12to having the opportunity to go to sleep
35:14and so you you want to tell them that
35:17you want to dedicate this much time,
35:19you know to go to sleep and
35:20and and stay asleep.
35:22Most patients who have both acute and.
35:24Chronic sleep deprivation is don't
35:26really have an issue falling asleep,
35:28so they're sleep onset.
35:29Latency tends to be normal
35:31versus your insomniacs,
35:32which you know they can have their
35:34own set of issues with the the
35:36sleep on set and sleep maintenance.
35:38But sticking to a regular schedule,
35:40so you really wanna start to
35:42normalize their sleep schedule,
35:44have a have a consistent sleep
35:46time and wake up time.
35:47Give themselves adequate number
35:48of hours of sleep.
35:49So if they're getting sick so you can
35:51try to increase it by one hour and
35:53then see if that makes a difference.
35:55And and oftentimes if you say well,
35:56one hour may not be a lot.
35:58But if you look at it over a week,
35:59that's seven.
35:59If you look at it over a year,
36:01this becomes hundreds of hours of sleep
36:03and and if you've been doing that for years,
36:06you can imagine that your sleep that has
36:08accumulated for such a long period of time.
36:10Sleep hygiene is going to be
36:12also another component you know.
36:13We often are engaged with technology,
36:15so if you're on your phone, you know.
36:18Engaging in social media,
36:19etcetera.
36:20You may not even realize how much
36:22time has gone by and that has cut
36:24down to your time that you could
36:27have been sleeping so kind of doing
36:29some little bit of stimulus control,
36:31being able to relax yourself down before
36:33sleeping so that you're actually able
36:36to fall asleep relatively quickly.
36:38We'll we'll be part of it.
36:40Nice saw me there can be overlaps
36:43between sleep deprivation and insomnia
36:46and and that's where you're CBT.
36:48I and other things that we do during
36:50insomnia management can can play a role.
36:53We spoke about kind of adequate
36:54time to sleep, so really allocating
36:55yourself on that that period.
36:57And one interesting thing is,
36:58especially as as you have young
37:00kids in the in the home with
37:03the frequent arousals at night,
37:04having partners to kind of switch off so
37:07that the total sleep time may be adequate.
37:09This is where daytime.
37:11Gaps or they called cat naps may
37:13help so that over a period of 24
37:15hours you're able to at least provide
37:18yourself with more total sleep
37:19time that may not be cumulative,
37:21but at least it's additive and
37:23that's much better,
37:24so adequacy will be much better
37:26than overall sleep deprivation.
37:27Another thing for pertaining to more
37:30of the shift workers is is taking
37:32a nap before their shift can reduce
37:35some of the cognitive impairments,
37:37and some of those errors that we've
37:38spoken about and then other stuff is,
37:40is really maintaining healthy.
37:418 exercise you want to make
37:43sure there's nothing else that's
37:45contributing there as well,
37:46and there is little bit of
37:48evidence that it's not.
37:49It's not like there's our
37:51randomized control trials.
37:52Look at bright light exposure in the morning.
37:54It kind of makes sense that you
37:56are going to be more alert as
37:58you're having bright light,
37:59and so you're allowing yourself
38:01to entrain the circadian rhythm.
38:03So when you combine,
38:04it's going to be a combination of
38:06all these things to really help
38:07you increase the total sleep time,
38:09but a lot of this is going to
38:11be motivation of the patient.
38:12To generate with the with the
38:15assistant of their provider.
38:16To allow themselves the opportunity
38:18to get more sleep,
38:20and then if they are having issues with
38:22falling asleep or maintaining sleep now,
38:24you've kind of shifted gears from
38:26just insufficient sleep towards
38:28more towards an insomnia and that
38:30that becomes its own separate well.
38:32So I wanted to just kind of change
38:35gears and and go over some of the fun facts.
38:38And as I was kind of going through
38:41sleep deprivation and and looking
38:42at some of the prevalence data,
38:44what happens to it?
38:45There's some cool things that kind
38:47of came across which made sense,
38:49and then at the same time it's,
38:51you know,
38:52just kind of some information
38:53that we can carry with us.
38:55And so one of the fun facts is
38:58that about 12% of of people will
39:01dream in black and white.
39:03And this before the invention of color
39:05television, this was closer to 75%.
39:07So help us reflect,
39:09you know how much of our dreams
39:11or or or or subconscious things
39:13come from our
39:14environment and things that we do.
39:17And so if you're you know, watching
39:20or you're engaging in certain things,
39:22your your daily life and all that
39:23stuff will get tied into your sleep.
39:24So this is where stressors and
39:26anxiety really play a role in
39:28your sleep quality and and and.
39:30And this is just one example
39:32of the environmental factors.
39:34Tying into our our sleep as well.
39:38So men tend to have longer
39:39circadian clocks than women.
39:40It's also by it's just by 6 minutes,
39:42but that's kind of interesting.
39:43You know they can stay up.
39:44I guess a little bit longer.
39:45They'll be a little bit more delayed.
39:48I think sleep boosting immunity.
39:49We're pretty well aware of that.
39:50So really,
39:51if you're chronically sleep deprived,
39:53it's through.
39:56Community compromised that you're
39:58you're going to sepsis and then you die.
40:00From that perspective,
40:0315% of population sleepwalks
40:04the National League Foundation,
40:05which I you know I don't see.
40:07We don't that we see that much sleeping,
40:08sleepwalking, parasomnias,
40:09but they are quite prevalent
40:11and this includes the the the
40:13the pediatric population,
40:14which is what the group that is
40:17more prone to having this they
40:19knew a new bed can increase your
40:21sleep time by 42 minutes,
40:22so that's kind of interesting.
40:23It may be more of a placebo effect.
40:25Maybe it's more comfortable.
40:27Mattress it's you understanding.
40:28Oh I'm,
40:29I'm getting this more comfortable
40:30bed so it's going to help me sleep
40:32better and so you're able to stay more
40:34or or you're just enjoying the fact
40:36that it's a new bed so you want to kind of,
40:37you know,
40:38enjoy this new entity but a new bed can
40:40increase your sleep time by you know.
40:42So several several minutes there.
40:45One thing that we sometimes
40:47hear is is you know,
40:49I I I sleep in one position and I sleep
40:51like that throughout the entire night.
40:52I don't wake up at all so no one
40:55sleeps throughout the night.
40:56There's we,
40:56we know that there's several arousals
40:59that occur during the night,
41:00but most most people are doing that
41:02are not able even able to recall that.
41:04That could be a toss a little turn,
41:07you know,
41:07very brief arousal that may not
41:09even be registered as an arousal
41:12in the morning consciously.
41:14So another interesting fact is that.
41:16Our our sense of smell is really
41:19decreased during sleep and this
41:21was one of the reasons smoke
41:23detectors were created.
41:24Is that if there's a fire or or
41:26carbon dioxide and other things that
41:27that are occurring at night time
41:29because of this decrease in your smell,
41:31that's going to help you become
41:33alerted to to the the fire
41:36that's maybe happening there.
41:38In terms of sleep deprivation,
41:40we know you know how long can
41:42someone go without without sleep.
41:43So an average person can survive about 10
41:45days without sleep and then at that point,
41:48not only are they having all those
41:50cognitive behavior and mood issues going on,
41:53but they start to have immune
41:55issues and there's multi organ
41:56failure starts to go down and they
41:58they die from severe sepsis.
42:00There is a Guinness World Record
42:03of 449 hours so that was 18 days,
42:0621 hours and 40 minutes.
42:08And the the recording was stopped
42:10at that time due to risk of having
42:14further health issues at that point.
42:16So the last thing I'll kind of end off
42:19our talk with is is fatal familial insomnia.
42:23And the reason I kind of tagged
42:25this towards the end of it is,
42:26is there such a wide range of
42:29onset for fatal familial insomnia?
42:31There's sporadic cases.
42:32Obviously it's not a sonal,
42:34autosomal dominant brown
42:35disease of the brain,
42:37so it's going to have a
42:39lot of familial patterns,
42:40but the early portions or early
42:43disease states were familiar,
42:45family fatal familial insomnia
42:47is going to mimic sleep
42:50deprivation and insomnia overlap.
42:52So I thought it might be an
42:54interesting thing to add on here.
42:55So like I said, it's a pre disease.
42:57It's it's a protein that has a
42:59mutation and sleep issues really
43:01start very gradual and and they're
43:03going to start to mimic this acute
43:05and chronic sleep deprivation.
43:07The onset is anywhere from
43:08the age of 13 to 60,
43:09with an average being around 50 years
43:11of age and the the pathophysiology
43:13is a little bit unclear.
43:15But what they believe is that this
43:17protein mutation is going to lead
43:19to poor decrease glucose intake in
43:21the thalamus and then the single
43:23cortex which is our areas that.
43:25Control some of the sleep
43:27and alertness portions,
43:28and so you're really depriving
43:30those cells they're undergoing
43:31kind of atrophy and and and,
43:33and possibly dying,
43:34and so you're knocking those
43:37centers out and then as they're
43:39sleep deprivation increases,
43:41the increases are not able to sleep,
43:43and they're going to have you know some
43:45issues with the commercial insomnia,
43:47but both sleep onset and maintenance,
43:50leading to both hallucinations,
43:51the confusional slate and then death
43:54usually occurs anywhere from 6 to 36 months,
43:57so you can see you know it's.
43:59So the fatal disease on the average
44:01survival was about 18 months from this
44:04symptom initiation and there really
44:06isn't any great treatment options,
44:09it becomes more of a palliative approach.
44:12There are studies have looked at
44:14using sleep AIDS barbiturates but
44:16has not panned out in terms of
44:18being able to increase sleep time
44:21or giving giving them more deeper
44:22REM sleep and and allowing their
44:25overall progression to be delayed.
44:27So it's it's, it's quite.
44:29The deadly disease if it once
44:33it is diagnosed there.
44:35Now back in 1998,
44:36there was 40 families that were
44:38known to have a genetic mutation,
44:40and so you know it's not a social dominance.
44:42It's going to be occurring in the
44:44in the various generations now,
44:46but in 2016 they also had about
44:4824 sporadic cases and and then you
44:51can see in this functional PET
44:52scanning that you know if you look
44:55at control patients versus those in
44:57the early portions of their disease
44:59process versus a laid you really
45:01having decreased uptake in the
45:03installments in the in the singular.
45:05Regions,
45:05and that's going to be really
45:08leading to your inability to sleep
45:10and then moving forward towards
45:13the the fatal component,
45:15so that's what I have so far and I'll be
45:18happy to take any questions at this point.
45:26So that was a fantastic discussion
45:30on very important topic and I love
45:33your approach about looking at
45:36chronic versus acute and and kind
45:38of honing in on some ways for sleep
45:42extension do is anybody well let's
45:44I'm going to look into the chat,
45:45but otherwise feel free to unmute
45:49yourself and ask a question.
45:52Let me just take a look at
45:53some of the chat here.
45:58So, so this is a common thing we're asked by.
46:02I've had actually patients ask me this.
46:04This is my. Are you aware of studies that
46:07compare 7 hours of sleep compared to two
46:09periods of four and three hours of sleep
46:12using PBT or other alertness measures?
46:16So I don't think they're they're been
46:18data to kind of cause you to or or
46:20allow you to have sleep restrictions.
46:22At that point. We know that sleepiness
46:25symptoms can definitely occur,
46:26but there as there is data that have looked
46:29at patients who have fragmented sleep,
46:31and we know that even six hours
46:34of consolidated sleep is going
46:35to be better than four hours plus
46:37two hours of fragmented sleep.
46:39But I'm not aware of anything that
46:42compares them head-to-head in terms of,
46:43you know, having less daytime sleepiness
46:46complaints or affecting their mood.
46:48But you you can imagine your sleep
46:50architecture is going to be affected,
46:51especially if you're cutting your sleep less.
46:53You're going to be having less deep sleep
46:56or slow wave sleep and less REM sleep.
46:58Yeah,
46:58this is an interesting question,
46:59probably about maybe eight years ago or so.
47:02I had a very smart adolescent who was
47:04telling me that why do we have to have
47:07you know 7-8 hours of wall at one spot?
47:09What about splitting it up and and he said
47:12that I guess Albert Einstein was famous
47:15for sleeping just a few hours at a time.
47:18That you wouldn't sleep
47:19for a long period of time.
47:20And but, uh, I don't know if anyone I've
47:22at the time I was interested in that.
47:24And I looked and at that time there was no
47:26specific research data on that question.
47:29I don't.
47:29I'm not sure if anything has been looked at,
47:32you know since that time, but you know,
47:34it is kind of difficult for most people
47:37to kind of break up their sleep like that,
47:40whereas you know standard because you
47:42also have that circadian aspect, right?
47:44So you have a circadian aspect may
47:46make it more difficult to sleep.
47:49At a different time period,
47:51so that could also play a role,
47:53but that is an interesting thought.
47:54I'm not aware of anything specifically
47:55that has looked at that,
47:57but there may certainly be.
47:59OK, we have, uh,
48:01do you know if men are more likely to be
48:04delayed or women more likely to be advanced?
48:07And I'm not gonna touch that one.
48:08I assume it means these circadian rhythm,
48:12although you can interpret
48:13it many different ways.
48:14So I think I just found that the
48:17circadian overall is slightly increased
48:19in males by by a few minutes,
48:22so they're going to vary by age.
48:24I don't know if they vary
48:26extremely by gender themselves.
48:28I think as you kind of progress in age,
48:31that's you're going to be shifting
48:33more towards an advanced.
48:35Sorry for more from an
48:36delayed phase to an advanced.
48:38Delay advanced fees afterwards,
48:39but I'm not quite sure if one has
48:41more prominence over the other.
48:44Yeah, I I. I never even knew that
48:46fact that before you presented it.
48:48So that's very, very interesting,
48:50you know, sort of gender
48:52differences in circadian biology.
48:54OK, any ideas for motivating people
48:56to make sleep a higher priority when
48:58they feel that they're too busy?
49:02I think this is where
49:03you're really gonna say.
49:04You know it's it's it's
49:06quantity versus quality,
49:07and so if you're our are,
49:09you know you're busy you're you're
49:11trying to do all these things,
49:12but you may be less efficient
49:14with the time that you have.
49:16So if you have two hours of
49:19of really inefficient time,
49:20that may be worse than an hour
49:22and a half of very efficient time,
49:24so I think it really if you motivate them,
49:27you want to tell them that you're
49:29going to be cognitively improve.
49:30You're going to be more alert.
49:32You're going to have less chances of making.
49:34Issues with tasks are able to clearly
49:37multifunction and multitask better
49:38with without sleep deprivation,
49:40so that's going to help you function better,
49:43and that and and then and most of
49:44the time you're busy because you're
49:46trying to achieve certain things,
49:47and so if you motivate them that
49:50this will help yield a better
49:52overall performance,
49:53and that may help them motivate
49:55to get more sleep.
49:57Yeah, this is always the tough thing
49:59to do right when you have someone who
50:01has insufficient sleep and they tell
50:03you that all these things going on
50:05and you know trying to convince them
50:06they're gonna feel so much better.
50:08And generally what I what I do is I try
50:10to say try to aim for at least 30 minutes
50:13more sleep per per night and and that's in.
50:16Some studies show that that may be enough to
50:19make an important difference in in patients,
50:22but it's one of those things.
50:24Just like anything,
50:25whether it's weight loss or stopping.
50:27Smoking or they just it really.
50:30It requires a lot of
50:31motivation and and so forth,
50:33but there's no magical.
50:34That's why one of the things we were
50:37talking about was looking at the studies
50:39about sleep extension and any sort of
50:42evidence based strategies for sleep
50:43extension that could be applied to a
50:46population or an individual subject.
50:49And you know the studies that
50:50we looked at right there.
50:52Many of them show that they're
50:54very effective in in in a
50:56research population of motivated.
50:58Patients to increase their total sleep time
51:00by just giving them more opportunities.
51:02Sleep in a very controlled environment.
51:04But how do you translate that into
51:06kind of the real world setting where
51:08we have all of the distractions that
51:11people have and I wish somebody would,
51:13you know,
51:13come up with an app that kind of
51:16helps track your sleep and give
51:17you pointers and and it can show
51:20that it helps with sleep extension,
51:22but we haven't really seen that just yet,
51:24so that may be a great opportunity
51:26for for future research.
51:28Uh, also depends on the outcome of interest.
51:31You know, I know a lot of
51:32times I'll talk to, you know,
51:33either college students or graduate students,
51:35and you know an outcome of interest
51:37is for example, academic performance.
51:38And there's a whole literature on
51:40academic performance in terms of either
51:42how much sleep that the individuals
51:44get or how variable sleep gets and how
51:46that actually improves test scores.
51:48And you know GPA, and so you know.
51:51Sometimes when you present enough
51:53data in the sphere that people are
51:55interested in that can break that shrink.
51:57But I agree, it's it's a really hard.
51:59Problem because people feel like
52:00they're functioning OK.
52:01Going back to David Dinges's
52:02old work that you know,
52:04you can show clear cut worsening Pvt.
52:07But people don't perceive that necessarily.
52:10So it really takes.
52:11I think a lot of education.
52:14Alright, absolutely great, great
52:16comments. Let's see here but but.
52:23Let me see if I'm just go down and
52:25make sure I got everything here.
52:27There's one more that says the
52:29medical intern in the 24 hour
52:31call was interesting, so I can.
52:32I can send a link to the article
52:33that I that I used to the group
52:35chat group after the presentation.
52:38OK, yeah that that the medical literature
52:42is very interesting regarding to.
52:45To you know, in terms of what data
52:47they had or there's one study that
52:50showed that if you know where the
52:52interns were up for more than 24 hours,
52:55there was more mistakes.
52:57There was more medical errors
52:59and that led to the restriction
53:02on the work hours for interns,
53:04and that's why you know a lot of residency
53:07programs had a completely revamp.
53:09How they were doing things in terms of
53:12ICU intern call, but subsequent studies.
53:15Actually showed that it didn't
53:16make a difference if they chose,
53:18uh, you know, uh,
53:20the standard versus modified schedule.
53:23So there's a lot of conflicting
53:26sort of data on on that.
53:28And you know,
53:29the one thing that in terms of work hours,
53:31you know when we went from the unlimited
53:34work hours to the 80 hour work week?
53:36You know,
53:37pretty much the data did show that you
53:39know trainees were getting more sleep,
53:41but it wasn't a huge boost,
53:43but there was definitely some some
53:45some boost.
53:45There,
53:46and, uh,
53:46so certainly you know from a training
53:49perspective via our work week is
53:51is helpful to allow for sleep,
53:53but also it turns out that you
53:55know there's not as much of robust
53:57improvement because now you have
53:59time to go to the bank or to do
54:01this or socialize or whatever.
54:02So there's always these sort
54:04of competing interest.
54:05And then there's the one question about this.
54:09The Vinci approach to sleep.
54:11I don't know what that means.
54:12Have you heard of that before Arman?
54:16I
54:16think that was a comment
54:18to a previous comment.
54:20I'm not sure if that's
54:21an actual question.
54:21Is there a question?
54:23That might. That might be
54:24no, no. I was just mentioning that.
54:28That that the intermittent
54:30sleep strategy that's used for,
54:33for example, for performers
54:35that have to go long distances,
54:37they're on sailboat races where they've
54:40been able to do reasonably well with.
54:45As far as alertness with short bursts
54:48of like 45 minutes of sleep every
54:50three hours or something like that.
54:54OK interesting yeah.
54:57Got it, I have but I.
54:59I wonder if anybody could comment on this.
55:02I've always been intrigued by
55:05the the recovery from
55:07acute sleep deprivation.
55:09I think of. I'm from San Diego,
55:11so I think of Randy Gardner,
55:13who in the 1960s set the record as
55:16a 17 year old high school student.
55:18I think he had 11 days in a row and
55:21actually Dement was able to study him and
55:24recover his sleep after 11 days.
55:27On the first night he slept for 16 hours.
55:30On the second night he slept for
55:32about 9 1/2 hours and by and by the
55:34third night he was not not sleeping any
55:38longer and it appeared that you know
55:40he was back back home.
55:42I wonder if anybody has
55:45any comments about that.
55:46Yeah, that's interesting.
55:47Umm, what do they teach
55:49you about recovery sleep?
55:51So your your your total sleep time
55:52is definitely going to be increased
55:54or sleep latency is decreased.
55:55More slow, more RAM,
55:56but it's it's not going to be enough
55:59unless you have really change your
56:01circadian rhythm and gone differently.
56:03If you're once you start paying back,
56:05it's not going to be.
56:07You know it's not going
56:08to be your your everyday.
56:09You'll be sleeping multiple hours more
56:11eventually as you normalize your sleep,
56:13you're going to start to pay back that
56:15debt very slowly, so it's a sharp.
56:17Decline your initially.
56:17You're going to replace some
56:19of that deprivation quickly,
56:20but then after that starts to taper
56:22pretty pretty quickly afterwards.
56:24As long as you're getting
56:25sufficient hours of sleep.
56:26Yeah, I think the study showed that slow
56:29wave sleep is sort of preferred that
56:32that that it's actually increased very.
56:35You know, sort of at first during
56:37the recovery sleep and then R.E.M.
56:39Rebound actually happens.
56:41You know 24 to 36 hours later you'll have a
56:45REM rebound period to replace that REM sleep.
56:49And, uh, but you're right.
56:50I think that patients or subjects can
56:53actually recuperate fairly quickly after
56:56a long period of sleep deprivation,
56:58usually within three days or so.
57:02And and that's you know the other interesting
57:04data on acute sleep deprivation is,
57:06uh, you know,
57:07they've looked at patients that
57:09are subjects that are more than
57:1124 hours or actually more than
57:1330 hours of of sleep deprivation,
57:15and they put him in a drive simulator,
57:17and basically they performed equally to
57:19those people who were legally intoxicated.
57:22So the thought is that after
57:24about 30 hours of sleep,
57:26total sleep deprivation you,
57:27it's it's like your own legally
57:29intoxicated in terms of the
57:31least of your performance on a.
57:32On a drive simulator and then you know,
57:36with chronic chronic partial
57:38sleep deprivation,
57:39you know the way I describe it to
57:40patients is that I say it's sort of
57:42like having a credit card balance
57:44and just paying the minimum payment.
57:45You just continue to accumulate that
57:48and accumulate that and and then
57:50there was actually some interesting
57:52studies looking on recovery sleep.
57:54So for example,
57:55let's say you work Monday through
57:56Friday and you're sleep deprived
57:58Monday through Friday.
57:59And then you try to make it up
58:01on the weekend on Saturday.
58:02And Sunday,
58:03can you sort of normalize with that sleep
58:06deprivation Monday through Friday with,
58:08you know,
58:09sleep extension on the weekends.
58:11And it turns out that it definitely
58:13helps compared to people who are
58:14sleep deprived 7 days of the week,
58:16but you don't actually get to that level.
58:18That if you're well rested for
58:19seven days of the week and they
58:21looked at PT testing and other
58:23type of neurocognitive testing.
58:24So trying to catch up on the weekends like
58:27many of us will try to do can be helpful,
58:30but not really get you
58:31back to a fully rested.
58:32Tested state so it's better to to to have,
58:35you know,
58:35sort of normal sleep period that you need.
58:37You know seven days a week rather than
58:39trying to catch up and then lastly,
58:41naps are something that a lot of people
58:44use to kind of help manage sleep deprivation.
58:46And there's a whole science behind naps,
58:49right?
58:50And This is why we tell our
58:51patients don't nap past 7:00 PM.
58:53But since past 3:00 PM,
58:55try to keep your naps to 30 minutes or
58:57less so you don't end up getting into
58:59slow wave sleep and becoming groggy
59:01and you know there are some jobs.
59:03Would actually encourage people to nap
59:05during work during you know protected
59:08time for optimizing performance.
59:10So anyway, very interesting.
59:12Do we have any last questions?
59:15Oh, there's.
59:20Let's see, so there's one
59:23less you have to balance.
59:24Reducing sleep debt for
59:26shifting circadian rhythm.
59:27If you're prone to the delay,
59:28that was just one comment that Theresa had.
59:31OK. Well, thank you so much.
59:34I think we're perfectly on time.
59:35We're gonna finish now and have a
59:37great rest of the week everyone.
59:40Thanks everybody for joining.
59:41Have a great week.