By Dr. Elliott Lee, Sleep Specialist at The Royal as presented at our monthly lecture series, Conversations at The Royal.

1. Good Night,
Sleep Tight:
Understanding the
Importance of Sleep
Conversations at the Royal
Elliott Lee MD, FRCP(C)
D. ABPN Sleep Medicine, Addiction Psychiatry
D. Amer Board of Sleep Medicine
Assistant Professor, Royal Ottawa MHC
December 19, 2013

2. Outline
• Functions of sleep
• Factors affecting sleep
- Quantity
- Quality
- Timing
• Is sleep an issue for you?
• Obstructive sleep apnea, Narcolepsy
• How to improve sleep

3. Arianna Huffington, Internet publishing pioneer
President and Editor In Chief, Huffington Post Media Group

4.  Approximately what percentage of our (adult) lives will
be spent sleeping?
A) 20%
B) 25%
C) 33%
D) 40%
E) 50%

5.  Approximately what percentage of our (adult) lives will
be spent sleeping?
A) 20%
B) 25%
C) 33%
D) 40%
E) 50%

6. Why Study Sleep?
 We spend 1/3 of our lives sleeping
 Severe health consequences - DEATH!
 Sleep deprivation costs
$150 BILLION/yr in lost
productivity
(Nat’l Commission on Sleep Disorders, 2003)

7. Functions of Sleep
 Body /brain repair
- Increased resilience to
stress/injury
 Pain Reduction
 Mood regulation
 Diminished anxiety
 Memory and learning
 Immune competence

8. Sleep Characteristics by Stage
 NREM
- Stage N1 + N2
(light sleep)
Motor skill learning?
- Stage N3
slow wave (deep)
Restorative function
Memory
 REM (rapid eye movement)
- Dreaming (85%)
- Memory ?
- Mood regulation ?

9. SLEEP HYPNOGRAM
W
N2
1
N1
N3
REM
1
2
3
4
Hours
5
6
7

10. Sleep factors impacting performance
Sleep Quantity
Sleep Quality
Sleep Timing
(Sleep Inertia)

11.  What is the commonest cause of excessive daytime
sleepiness in the community?

12.  What is the commonest cause of excessive daytime
sleepiness in the community?
Chronic Insufficient Sleep

13. Sleep QUANTITY

14. Sleep Deprivation
 According to the most recent General Social Survey
done by Statistics Canada (2010), 46% percent of
Canadians will cut back on sleep in order to add time
to their days.

15. Sleep Deprivation
 There is a conflict between the biological imperative
for sleep and the social demand for performance. This
poses a fundamental question:
What happens to performance when the pressure for
sleep is increased?

16. Sleep Quantity
 Too little – equivalent to functioning with 0.05 blood
alcohol level (<6 hours)1
 <7 hours – decrements can be seen in performance
 Cognitive function > speed > accuracy2,3
1Williamson
AM and Feyer AM. Occup Environ Med 2000; 57; 649-55
2Koslowsky M and Babkoff H. Chronobiol Intl. 1992; 9(2); 132-6
3Reilly T and Edwards B. Physiology and Behaviour. 2007; 90; 274-84

17. Sleep Disorders Socioeconomic Consequences
 More than 100,000 motor vehicle accidents annually
are sleep-related (US).
 “Toronto syndrome”

18. Psychomotor Vigilance Task (PVT) errors with
cumulative sleep deprivation
Dinges et al Sleep, 1997; 20(4), 267-77

19.  Challenger Disaster
 3 Mile Island
 Chernobyl
 Exxon Valdez
 Medical Errors
 Transportation
Industry

20. Daylight Savings and Traffic Accidents
Coren S. N Engl J Med. 1996 Apr 4; 334(14): 924

21. Sleep Deprivation and Wt gain?
 Women who sleep <5 hours per night, gained 2.5
lbs, cf. to women sleeping 7 hours/night
 Relative risk for obesity (BMI > 30 kg/m2)
5 hour sleepers = 1.15 cf. to 7+ hours
 Studied >68 000 women (Nurses Health Study) for 16
years
 Hormones? Basal metabolic rate?

22. Sleep Deprivation and Children
 Not the same as adults
 May be “hyperactive”
- fidget
- poor attention
- cranky

23. Sleep QUALITY

24. Sleep Quality
 Fragmented sleep
consequences are similar
to sleep deprivation
- ↓ concentration
- ↓ attention
- moodiness/irritability
- ↓ reaction time
- memory impairments
 Causes of fragmented
sleep:
- Temperature
- Light*
- Noise
- Pain
- Anxiety/Stress
- Sleep disorder
- Snoring/Apnea
- PLMs/RLS

25. Sleep TIMING

26. Sleep Control
Process
S(leep)
Process
C(ircadian)

27. Process S(leep)
 Homeostatic control
 “The longer we’re awake, the more sleep debt we
accumulate i.e. the sleepier we become”
 The sleepier we are, the more deficits are seen
 To date, there is no surrogate available for good quality
sleep.

28. Process S(leep)
 Homeostatic control
 “The longer we’re awake, the more sleep debt we
accumulate i.e. the sleepier we become”
 The sleepier we are, the more deficits are seen
 To date, there is no surrogate available for good quality
sleep.

29. Process C(ircadian)
 Sleep tendencies follow a circadian (daily) rhythm
 This is controlled by a central “biological clock”
 Several inputs also influence this clock, especially
- Light
- Melatonin

30. Sleep and Light
11 PM
7 AM
SLEEP
SLEEP
SLEEP

31. Sleep and Light
11 PM
SLEEP
SLEEP
SLEEP
7 AM

32. Sleep and Melatonin
11 PM
SLEEP
SLEEP
SLEEP
7 AM

33. Consequences of Asynchronous Sleep
 Impaired continuity of
sleep
 ↓ alertness
 ↑cognitive errors
 Like “hitting a tennis ball
off the centre of the
racquet” – sleep is not as
efficient, and sleep
architecture is disrupted
 Jet lag, shift work

34.  Who is more likely to do rotating or evening shifts in
Canada, men or women?

35.  Who is more likely to do rotating or evening shifts in
Canada, men or women?
WOMEN

36. Women are more likely to work
rotating shifts or evening shifts
Men
Women
Irregular
25%
Other
13%
Other
12%
Evening
14%
Irregular
35%
Evening
10%
Night
8%
Night
8%
Rotating
41%
Rotating
34%
Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005

37. Shift Work
 International Agency on Research and Cancer (IRAC)
classified shift work as a probable carcinogen in 2007.
 40-50% increase in breast cancer risk with >20-30
years of shift work exposure.
 Melatonin thought to play a key role; reduces estrogen
levels and shown to have anticancer properties.
Megdal et al. Eur J Cancer. 2005; 41: 2023-32
Grundy A et al. Occup Environ Med. 2013; 70: 831-8
Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9

38. Is sleep an issue for you?
 Do you feel satisfied with the quality of your
sleep?
 Do you frequently fall asleep if given a sleep
opportunity (a sleep opportunity is defined as a
quiet, dark environment for at least 10 minutes)?
 Do you usually need an alarm clock to wake you?
 Do you tend to catch up on sleep during the
weekends?
 Once awake, do you feel tired most mornings?
 Do you frequently take naps during the day?

39. Is sleep an issue for you?
 When you can get it, do you consistently sleep
more than 9.5 hours per night?
 Do you feel lethargic or slow throughout the day?
 Do you sleep longer during times of depression,
anxiety and stress?
 Do you snore?
 Do your legs bother you at bedtime, interfering
with your sleep?

40. What Happens at the Sleep Lab…
 ROMHC: 5 bed clinical lab, 4 bed research lab
STEPS:
1) → Referral
2) → Consultation with a Sleep Specialist
3) → Overnight Sleep Study
4) → Data is Analyzed by RPSGTs
5) → Results Appt with a Sleep Specialist

41. How Do We Measure Sleep in the
Laboratory?
 Electrophysiology
 EEG – brainwaves (Central & Occipital Leads)
 EOG – eye movements
 EMG – muscle tone
 EKG – heart
 Breathing:
1)Airflow
& 2) Effort: Thoracic & Abdominal
 Blood oxygen saturation (SaO2)
 Audio-visual recording

46. Obstructive Sleep Apnea (OSA)
 Definition:
The presence of abnormal breathing
disruptions/cessations (apneas) during sleep
 Sleep is disrupted temporarily, usually without recall.
As a result, sleep deprivation and/or excessive daytime
sleepiness occur, usually with snoring at night
 Up to 25% of men and 9% of women are thought to be
affected, with 90% of patients likely undiagnosed1
 50% of snorers are thought to have OSA2
 Strongly associated with cardiac disease
1Young et al. N Eng J Med, 1993; 328(17):
2Lugaresi et al. Sleep, 1980; 3(3-4): 221-4
1230-5

47. Fatal CV events and OSA
Months
Marin JM et al. Lancet, 2005

48. Nonfatal CV events and OSA
Marin JM et al. Lancet, 2005

49. Motor vehicle accidents
Hypertension
OSA Consequences
Impaired
glucose
control
Irritability, mental illness e.g. depression
Heart attack and stroke
Memory problems

50. Treatments for OSA




**Weight loss - ↓ BMI = ↓ RDI
Avoid alcohol consumption and sedative medications
“Snoreball” technique / positional therapy
Upper airway surgery




Tonsillectomy (pediatrics)
Uvulopalatopharyngoplasty (UPPP)
Maxillomandibular Advancement (MMA)
Tracheostomy
 Provent
 Oral Appliances - Mandibular Repositioning Devices
(MRDs), Tongue Retention Devices (TRDs)
 **CPAP – Continuous Positive Airway Pressure

51. OSA and Attractiveness?
 Treatment of OSA with
CPAP has been shown to
improve attractiveness
 Perceived to be
- More alert
- More youthful
- Less forehead creases
Chervin R et al. J Clin Sleep Med, 2013; 9(9): 845-52

52. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from obstructive sleep apnea? (Choose
all that apply):
A
B
C
D
E

53. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from obstructive sleep apnea? (Choose
all that apply):
A
B
C
D
E

55. Narcolepsy
 A pathologic disorder of sleepiness during the day –
key symptom – sleepiness
 May have insomnia at nighttime
 Affects about 1/2000 people
 Very underdiagnosed; difficult to recognize
 80% may have cataplexy, a REM sleep intrusion
phenomenon on wakefulness
 Related to cerebrospinal fluid deficiency of hypocretin
(orexin)

58. Narcolepsy Treatment
SLEEPINESS:
– Stimulants
d-amphetamine (Dexedrine),
methylphenidate (Ritalin)
Novel - modafinil (Alertec / Provigil).
- armodafinil
CATAPLEXY:
– Antidepressants – e.g. venlafaxine
– Sodium oxybate (Xyrem)

59. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from narcolepsy?
A
B
C
D
E

60. All of the following famous people suffer from a
sleep disorder. Which of these famous people
suffers from narcolepsy?
A
B
C
D
E

61. How to Improve Sleep
 Get adequate quantity of sleep (7.5-8.5 hrs)
 Regular sleep/wake times – timing/routine important
 Develop a relaxing pre sleep ritual
- relaxation exercises can be helpful
- avoid stressful/stimulating activities prior to sleep
 Avoiding prolonged naps* in the day
 Bed – only for sleep (and romance!)
 Avoid clock watching
 Rule out sleep disorder, psychiatric disorder

62. How to Improve Sleep
 Sleep Environment
- Avoid environmental disturbances
- Partner/Children
- Roommate
- External noises – phones, texting, external
(white noise generator may drown out)
- Avoid bright light in evenings
- Temperature – slightly cooler (<21-22oC) is better.
drop in temperature facilitates sleep onset
- Bed should be comfortable – consider memory foam
mattresses/pillows; queen or king size beds
Quiet. Dark. Cool. Comfortable.

63. Detriments to Sleep
 Light (evening)
- cell phones, computer
 Stress (cortisol - steroid)
 Caffeine
 Nicotine
 Alcohol
 Marijuana
 Drugs
(Amphetamines, cocaine, opioids*)

64.  Which of the following substances has the highest
amount of caffeine?
A) Red Bull, 250 mL
B) Coca Cola, 1 L
C) Starbucks Coffee, Grande (360 mL)
D) Green Tea, 300 mL
E) Caffeine pill, (200 mg tab)

65.  Which of the following substances has the highest
amount of caffeine?
A) Red Bull, 250 mL
B) Coca Cola, 1 L
C) Starbucks Coffee, Grande (360 mL)
D) Green Tea, 300 mL
E) Caffeine pill, (200 mg tab)

66. Caffeine – a Canadian Love Affair
Starbucks coffee(20 oz)
400 mg
Second Cup coffee (20 oz)
400 mg
Tim Horton’s coffee (20 oz)
270 mg
Instant coffee (8 oz)*
95 mg
Tea (leaf or bag, 8 oz)
50 mg
Mountain Dew (12 oz)
55 mg
Coca Cola (12 oz)
45 mg
Red Bull (250 ml)
80 mg
Sources: National Coffee Association, National Soft Drink Association, Tea Council of the USA, and information
provided by food, beverage, and pharmaceutical companies and J.J. Barone, H.R. Roberts (1996) "Caffeine
Consumption." Food Chemistry and Toxicology, vol. 34, pp. 119-129.

67. Summary
 Sleep is important to consider for performance
 Good sleep can improve performance
- Cognition/memory
- Accuracy
- Speed
- Health/Decrease sick days (immune competence)
- Improve mood, anxiety, resilience
 Sleep variables to consider: Quantity, Quality, Timing
 Rule out sleep disorder
 Details are important; BALANCE – key to success

68. When the time to perform has come, the time to prepare
has past.
Bob Bowman, coach of Michael Phelps

69. Thank You! Questions?

71. Severe OSA, treated with CPAP
10 PM
12 AM
2 AM
4 AM
6 AM

72. Video courtesy of Joe Santos, IOSleep Med

73. Video courtesy of Dr. Viozzi, Mayo Clinic

74. Maxillomandibular Advancement
5 mm
5 mm
+8 mm

76. Mandibular Repositioning Devices (MRDs)
Klearway-
Silencer-
Great Lakes
Orthodontics
Johns Dental
Labs