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But now the day was come, the day, the hour; Now, frowning, smiling, for the hundredth time, The nurse, that ancient lady, preached decorum; And, in the lustre of her youth, she gave Her hand, with her heart in it, to Francesco. There around 90 distinct sleep disorders; most are marked by one of these symptoms: excessive daytime sleepiness, difficulty initiating or maintaining sleep, and abnormal events occurring during sleep.
The cumulative long-term effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. After decades of research, the case can be confidently made that sleep loss and sleep disorders have profound and widespread effects on human health. This chapter focuses on manifestations and prevalence, etiology and risk factors, and comorbidities of the most common sleep conditions, including sleep loss, sleep-disordered breathing, insomnia, narcolepsy, restless legs syndrome, parasomnias, sleep-related psychiatric disorders, sleep-related neurological disorders, sleep-related medical disorders, and circadian rhythm sleep disorders.
Sleep loss and sleep disorders are among the most common yet frequently overlooked and readily treatable health problems.
It is estimated that 50 to 70 million Americans chronically suffer from a disorder of sleep and wakefulness, hindering daily functioning and adversely affecting health and longevity NHLBI, Questions about sleep are seldom asked by physicians Namen et al. For example, about 80 to 90 percent of adults with clinically significant sleep-disordered breathing remain undiagnosed Young et al.
Failure to recognize sleep problems not only precludes diagnosis and treatment—it also precludes the possibility of preventing their grave public health consequences.
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The public health consequences of sleep loss and sleep-related disorders are far from benign. The most visible consequences are errors in judgment contributing to disastrous events such as the space shuttle Challenger Walsh et al. Less visible consequences of sleep conditions are far more prevalent, and they take a toll on nearly every key indicator of public health: mortality, morbidity, performance, accidents and injuries, functioning and quality of life, family well-being, and health care utilization.
Some of these consequences, such as automobile crashes, occur acutely within hours or minutes of the sleep disorder, and thus are relatively easy to link to sleep problems. Others—for example, obesity and hypertension—develop more insidiously over months and years of chronic sleep problems. Although there are around 90 distinct sleep disorders, according to the International Classification of Sleep Disorders AASM, , most are marked by one of these symptoms: excessive daytime sleepiness, difficulty initiating or maintaining sleep, or abnormal movements, behaviors, and sensations occurring during sleep.
The cumulative effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. This chapter focuses on the most common sleep conditions, including sleep loss, sleep-disordered breathing, insomnia, narcolepsy, restless legs syndrome RLS , parasomnias, sleep-related psychiatric disorders, sleep-related neurological disorders, sleep-related medical disorders, and circadian rhythm sleep disorders.
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The manifestations and prevalence, etiology and risk factors, and comorbidities for each condition are briefly described. There is a large body of data on these disorders, in part because they encompass the most frequently cited sleep disorders or they carry the greatest public health burden. As such, the committee chose to focus primarily on these disorders. Sleep loss generally, in adults, refers to sleep of shorter duration than the average basal need of 7 to 8 hours per night.
The main symptom of sleep loss is excessive daytime sleepiness, but other symptoms include depressed mood and poor memory or concentration Dinges et al. Chronic sleep loss, while neither a formal syndrome nor a disorder, has serious consequences for health, performance, and safety, as described in Chapter 4.
Sleep loss is a highly prevalent problem that continues to worsen in frequency as individuals grow older. Recent studies find that at least 18 percent of adults report receiving insufficient sleep Liu et al. Historically, there have been a limited number of nationally representative surveys that provide reliable data on sleep patterns in the population. Based on these data, it has been estimated that the percentage of men and women who sleep less than 6 hours has increased significantly over the last 20 years Figure CDC, More than 35 years ago, adults reported sleeping 7.
Percent of adults in the United States who usually slept 6 hours or less a night. Adolescents also frequently report receiving insufficient sleep. Contrary to public perceptions, adolescents need as much sleep as preteens.
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A large survey of over 3, adolescents in Rhode Island found that only 15 percent reported sleeping 8. The optimal sleep duration for adolescents, about 9 hours per night, is based on research about alertness, sleep-wake cycles, hormones, and circadian rhythms Carskadon et al. Among adolescents, extensive television viewing and growing social, recreational, and academic demands contribute to sleep loss or sleep problems Wolfson and Carskadon, ; Johnson et al. The causes of sleep loss are multifactoral.
Unfortunately, available epidemiological data are not sufficient to determine the extent to which sleep loss is caused by pathology versus behavioral components. The increase in sleep loss is driven largely by broad societal changes, including greater reliance on longer work hours, shift work, and greater access to television and the Internet. About 20 percent of workers are engaged in some kind of shift work Monk, , of whom there is a growing number of night shift workers suffering chronic sleep loss and disruption of circadian rhythms Harma et al.
One indication of the growing trend is the number of adults departing for work between midnight and a. A greater prevalence of insomnia also may contribute to the rise in sleep loss, but probably to a lesser extent than do occupational or lifestyle changes.
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Adults are sleeping less to get more work accomplished and are staying up later to watch television or use the Internet NSF, b. In the past 10 or more years, research has overturned the dogma that sleep loss has no health effects, apart from daytime sleepiness. The studies discussed in this section suggest that sleep loss less than 7 hours per night may have wide-ranging effects on the cardiovascular, endocrine, immune, and nervous systems, including the following:.
Many of the studies find graded associations, insofar as the greater the degree of sleep deprivation, the greater the apparent adverse effect although the difference may not reach statistical significance. Another common finding is the relationship that adverse effects occur with either short or long sleep duration, as compared to a sleep time of 7 to 8 hours. This type of association is often described as a U-shaped relationship. It should be noted, however, that the majority of these studies are observational in nature, and thus definite causal inferences cannot be made. In the discussion that follows, and wherever possible, potential physiological mechanisms behind epidemiological associations and that support the plausibility of a true causal relationship are noted.
When a person sleeps less than 7 hours a night there is a dose-response relationship between sleep loss and obesity: the shorter the sleep, the greater the obesity, as typically measured by body mass index BMI —weight in kilograms divided by height in meters squared. Although most studies were cross-sectional, one prospective study was a year cohort study of nearly adults. By age 27, individuals with short sleep duration less than 6 hours were 7.
Another study, a large population-based study of more than 1, adults, found a U-shaped relationship between sleep duration, measured by polysomnography, and BMI Figure Adults who slept 7. The U-shaped association also applies to other health outcomes, such as heart attacks. The impact of sleep loss diminishes with age.
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The study also sought to investigate physiological mechanisms behind the relationship between sleep duration and BMI. Measuring two appetite-related hormones, the study found that sleep insufficiency increased appetite. Sleep insufficiency was associated with lower levels of leptin, a hormone produced by an adipose tissue hormone that suppresses appetite, and higher levels of ghrelin, a peptide that stimulates appetite Taheri et al. Another study—a small randomized, cross-over clinical trial—also found that sleep restriction was associated with lower leptin and higher ghrelin levels Spiegel et al.
The findings suggest that a hormonally mediated increase in appetite may help to explain why short sleep is related to obesity. Curvilinear relationship between BMI and average nightly sleep. Obesity also contributes to obstructive sleep apnea OSA. This most likely occurs through fat deposition in airways, causing them to narrow.
The relationship has been found in well-designed epidemiological studies of young children Locard et al. Taken as a whole, the body of evidence suggests that the serious public health problem of obesity may continue to grow as sleep loss trends continue to worsen. It also suggests that addressing obesity will likely benefit sleep disorders, and treating sleep deprivation and sleep disorders may benefit individuals with obesity Taheri et al. Two large epidemiological studies and one experimental study found an association between sleep loss and diabetes, or impaired glucose tolerance.
Impaired glucose tolerance, which is a precursor to diabetes, is manifested by glucose levels rising higher than normal and for a longer period after an intravenous dose of glucose. In the Sleep Heart Health Study, which is a community-based cohort, adults middle-aged and older who reported 5 hours of sleep or less were 2. Those reporting 6 hours per night were about 1. Both groups were also more likely to display impaired glucose tolerance. Adults with sleep times of 9 hours or more also showed these effects, a finding consistent with the Nurses Health Study.
Adjustment for waist girth, a measure of obesity, did not alter the significance of the findings, suggesting that the diabetes effect was independent of obesity. Sleep duration impacts prevalence of diabetes. NOTE: Data were adjusted for age, sex, race, waist girth, caffeine, alcohol, smoking, and apnea-hypopnea index. The relationship between shorter sleep times and impaired glucose tolerance is also supported by an experimental study in which 11 healthy male volunteers were restricted to 4 hours of sleep for a total of six nights Spiegel et al.