1 سمینار اختلالات خواب، تشخیص و درماندکتر لیبا رضایی دکترای تخصصی کاردرمانی، استادیار دانشگاه علوم پزشکی کرمانشاه

2 معرفی برنامه اهمیت موضوع :اهمیت آشنایی با علم خواب (sleep science) در سلامت کارکنان مشاغل بهداشتی اهمیت آشنایی با علم خواب به منظور مدیریت بهتر فرآیندهای درمانی در مشاغل مختلف درمانی توجه به علم خواب در توانبخشی (Rehabilitation)

3 What is sleep? Sleep is a dynamic and regulated set of behavioral and physiological states during which many processes vital to health and well-being take place.

4 About Sleep We spend 1/3 of our lives asleepSleep is an active process No organ or regulatory system “shuts down” Slight decrease in metabolic rate Some brain activity increases during sleep Delta Waves Many parts of the brain are as active as awake periods At least 2 hours of dream state per night Specific hormones increase during sleep Growth hormone Melatonin Specific cues exist for regulation of sleep

5 Developmental Patterns of SleepAll aspects of sleep behavior across the lifespan demonstrate a large degree of variability among individuals and across cultures Sleep patterns are shaped by intrinsic biological processes and psycho-social factors such as cultural norms, family values, school, and work.

6 Sleep Across the Life Span

7 How much sleep do we need?Infants Toddlers Pre School School Age 10-11 Teens Most adults need 7 ½ -8 hours to function well About 10% require more or less sleep Pregnant women need more sleep

8 Sleep and Occupational therapySleep was put to rest when the 2002 AOTA Practice Framework categorized sleep as an activity of daily living (ADL), which should be considered a performance area of occupation (AOTA, 2002). In subsequent versions of the practice framework, the importance of sleep was further strengthened by shifting sleep from the category of ADL to that of an occupation in itself (AOTA, 2014). The AOTA (2012) statement on occupation and sleep highlights that “restful and adequate sleep provides the foundation for optimal occupational performance, participation, and engagement in daily life” (p. 2).

9 خواب و شرایط خاص خواب در مشاغل دارای شیفت کاری خواب در زنانخواب و شرایط خاص خواب در مشاغل دارای شیفت کاری خواب در زنان خواب در سالمندان

10 خواب و سایر اختلالات خواب و درد خواب در اختلالات طیف اوتیسمخواب در اختلالات طیف اوتیسم خواب در ADHD خواب در کودکان فلج مغزی خواب در بیماری های نورولوژیک خواب در بیماری های روانپزشکی خواب در بدخیمی ها خواب در بیماری های مزمن

11 Sleep and work performance

12 The Effects of Sleepiness & FatigueImpaired reaction time, judgment & vision Problems with information processing & short-term memory Decreased performance, vigilance & motivation Increased moodiness & aggressive behaviors Increased “microsleeps” – brief (2/3 seconds) sleep episodes Sleepiness negatively affects mood, judgment, reaction-times, attention, vigilance, vision, short-term memory, and motivation—similar to alcohol. Sleep loss makes it easier to fall asleep at inappropriate times, affecting a worker’s ability to perform safely.1 It is important to for you to remember that a person does not have to fall asleep at the wheel to be a danger to themselves and others. Just being tired or drowsy can significantly impair your performance. 70% to 90% of industrial and transportation accidents are due to human error.2-3 References: 1. Dinges, DF. The Nature of Sleepiness: Causes, Contexts, and Consequences. In: Albert J. Stunkard & Andrew Baum (Eds.) Perspectives in Behavioral Medicine: Eating, Sleeping, and Sex. Hillsdale, N.J. Erlbaum; 1989: 2. Heinrich, H. Industrial accident prevention (4th edition). New York: McGraw-Hill 3. Nagel, D. Human error in aviation operations. In: E. Wiener and D. Nagel (Eds.) Human Factors in Aviation. San Diego: Academic Press. 1988;

13 Effects of Sleepiness on WorkWhen sleepy, people report having difficulty with: Concentration-68% Handling stress- 65% Listening-57% Relating to others-38% Solving problems-57% Decision making-56% According to the National Sleep Foundation’s 2000 Sleep in America Poll, more than one-fourth of adults (27%) say that they are sleepy at work 2 days per week or more. The majority of Americans say that being sleepy makes work tasks more difficult including: making decisions, listening, concentrating, solving problems, handling stressful situations, and relating to coworkers. There was not a significant difference in the responses from day workers compared to shift workers on these questions. References: National Sleep Foundation. Sleep in America Poll: Washington, DC Source: NSF 2000 Sleep In America Poll

14 Work Problems Due to SleepinessLate to work—14% Stay home from work—4% Fall asleep at work—7% Make errors—19% Get injured—2% In addition to functioning at work, sleepiness creates a number of other work-related problems, such as these: 14% of adults say that they are occasionally or frequently late to work due to sleepiness. 4% of adults say that they have not gone to work due to sleepiness. 7% of adults say that they have occasionally or frequently fallen asleep at work. 19% of adults report that they occasionally or frequently make errors at work due to sleepiness. And 2% of adults say that they have suffered an injury that they attribute to sleepiness. References: National Sleep Foundation. Sleep in America Poll: Washington, DC Source: NSF 2000 Sleep In America Poll

15 Sleep-Related Fatigue CostsSleep-related fatigue costs for US businesses have been estimated at $150 billion a year for: Absenteeism Workplace accidents Lost Productivity Although the complete economic impact of sleep disorders and sleep loss is difficult to discern, the available data demonstrates the high burden that inadequate sleep has on the economy. With the average age of the population rising, incidence of sleep disorders is likely to rise, leading to increased costs. In fact, compared to healthy individuals, individuals suffering from sleep loss, sleep disorders or both are less productive, have an increased health care utilization, and an increased likelihood of accidents. Reference: Sleep Disorders Create Growing Opportunities for Hospitals, Health Care Strategy Management. 19(2): In Sleep Disorders and Sleep Deprivation, An Unmet Public Health Problem. Institute of Medicine (2006).

16 Sleep Loss and Work Related InjuriesHighly fatigued workers are 70% more likely to be involved in accidents. Workers with chronic insomnia have higher rates of accidents. Those who report disturbed sleep are nearly twice as likely to die in a work – related accident. According to several large scale research studies, sleep-related fatigue is an independent risk factor in work-related injuries and fatalities. For example, one study on hospital residents found that doctor’s working over 80 hours per week were 50% more likely than those working less than 80 hours to report making a significant medical error that led to an adverse patient outcome.1 Reference: Sleep Disorders and Sleep Deprivation: An Unmet Public Health Burden. Institute of Medicine (2006) pp Baldwin DC Jr, Daugherty SR Sleep deprivation and fatigue in residency training: results of a national survey of first-and second-year residents. Sleep: Journal of Sleep Research & Sleep Medicine 27(2):

17 Catastrophes Due to FatigueUnion Carbide chemical plant in Bhopal Chernobyl Three Mile Island Exxon-Valdez The negative public health consequences of sleep loss and sleep related disorders are enormous. Some of the most devastating human and environmental health disasters have been partially attributed to fatigue-related performance failures, sleep loss, and night shift work related performance failures. This includes: The tragedy at the Union Carbide chemical plant in Bhopal, India: the nuclear reactor meltdowns at Three Mile Island and Chernobyl; and the grounding of the Exxon Valdez oil tanker. Reference: Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (2006) pp

18 The Consequences of Sleep Deprivation on the HighwayOne of the most serious consequences of sleep deprivation is driving drowsy – leading to injury, and possibly, death.

19 When “9:00 to 5:00” Isn’t an OptionSleep Strategies for Shift Workers A shift worker is anyone who follows a work schedule that is outside of the typical "9 to 5" business day. In the past few decades the United States has become increasingly dependent upon shift workers to meet the demands of globalization and our 24-hour society. From a competitive standpoint, shift work is an excellent way to increase production and customer service without major increases in infrastructure. According to the Bureau of Labor statistics, millions of Americans are considered shift workers, including doctors and nurses, pilots, bridge-builders, police officers, customer service representatives and commercial drivers. However, while shift work does create potential productivity advantages, it also has many inherent risks. Some of the most serious and persistent problems shift workers face are frequent sleep disturbance and associated excessive sleepiness.

20 The Perils of Shift WorkDepression Stress & anxiety Divorce Increased smoking More errors & accidents Digestive & gastrointestinal problems Cardiovascular disease Higher cholesterol Possible Carcinogen* I want to take a moment to talk about shift workers. Unfortunately, when it comes to sleep, most shift workers don't get enough. When shifts fall during the night (11 pm-7 am), the worker is fighting the natural wake-sleep pattern. It may be hard to stay alert at night and just as hard to fall asleep and stay asleep during the day. Night workers get less sleep than daytime workers do, and the sleep is less restful. Sleep is more than just "beauty rest" for the body; it helps restore and rejuvenate the brain and organ systems so that they function properly. Research has shown that a chronic lack of sleep and working the night shift harms a person's health, on-the-job safety, task performance, memory and mood. The shift worker faces special problems in trying to maintain family relationships and social and community ties. It becomes difficult to balance work, sleep and personal time. Due to their schedule and need for sleep, a shift worker often misses out on family activities, entertainment, and other social interaction. That is why it is important for a shift worker to talk with family members and friends about his or her concerns. Remember that sleep loss and feeling at odds with the rest of the world can make you irritable, stressed and depressed. *World Health Organization (WHO) Report 2007.

21 Annual Economic Impact of Sleep Problems Due to Late ShiftsReduced Manufacturing productivity – 50B Increased motor vehicle accidents – 5.7B Increased industrial accidents = 4B Increased accidents, injuries, and deaths at work – 2.5B Increase in other medical and psychiatric illnesses – 2B Personnel turnover and retraining – 1B Total economic impact in billions – 65.2 The indirect costs associated with sleep loss and sleep disorders result in billions of dollars of annual expenditures, including costs associated with illness-related morbidity and mortality, absenteeism, disability, reduction or loss of productivity, industrial and motor vehicle accidents, hospitalization, and increased alcohol consumption. As shown in the slide above, sleep problems relating to workers inability to adjust to late shifts are estimated to be at minimum over $60 billion. Reference: Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine Report. (2006) p.190.

22 A Closer Look at Nurses 74% of nurses work 12 hour shiftsOn average, over 15% of nurses fall asleep on the job in a thirty day period. Nurses working 12 hour shifts report 3.3 more errors per shift than nurses working 8 hour shifts Nurses working 12hr shifts have higher absenteeism rates than nurses working 8 hour shifts Less than one-quarter of the full-time hospital staff nurses in the US work traditional 8-hour day, evening and night shifts. Most hospitals in the US now schedule nurses for 12 hour straight day or night shifts, with the night shift usually starting at 7:30 pm and ending at 7:30 am. In addition, nurses rarely get to leave work at the end of their scheduled shifts and work on average an hour extra for every shift worked. A large, nationally representative research study found that working a 12 hour shift is associated with shortened sleep times, decreased alertness on duty, and an increased risk of making an error. References: Rogers et al (2004) The Working Hours of Hospital Staff Nurses and Patient Safety, Health Affairs. Scott et al (2006) The Effects of Critical Care Nurse Work Hours on Vigilance and Patient Safety, American Journal of Critical Care.

23 Shift Work: Promoting Alertness at WorkTake short breaks Use the buddy system Exercise on breaks Use caffeine as a tool not as a crutch Schedule demanding tasks when you are most alert Share ideas with others in the same position Eat healthy With around-the-clock activities, our 24/7 society can keep us from allocating enough time for sleep or put us on irregular schedules. Feeling sleepy is a common experience for many of us. The body never adjusts to shift work! Working non-traditional schedules increases your risk for on-the-job accidents and car crashes. The following are tips for shift workers to remain alert on the job: 1. Take short breaks throughout the shift. 2. Try to work with a "buddy." Talking with co-workers can help keep you alert. And co-workers can be on the lookout for signs of drowsiness in each other. 3. Try to exercise during breaks. Use the employee lounge, take a walk, shoot hoops in the parking lot, or climb stairs. 4. Try to eat three normal meals per day. Eat healthy snacks, avoiding foods that may upset your stomach. 5. If you drink a caffeinated beverage (coffee, energy drinks, tea, colas), do so early in the shift, e.g., before 3 am for the night worker. Do not overuse caffeine, so it will be more effective when you really need it. 6. Don't leave the most tedious or boring tasks to the end of your shift when you are apt to feel the drowsiest. Night shift workers hit their lowest period around 4 am. 7. Exchange ideas with your colleagues on ways to cope with the problems of shift work. Set up a support group at work so that you can support and learn from each other.

24 Shift Work: Promoting Sleep at HomeLIGHT Darken the bedroom & bathroom Install light blocking & sound absorbing curtains or shades Wear eye shades Wear dark sunglasses on the drive home SOUND Wear ear plugs or white noise machine Install carpeting & drapes to absorb sound Unplug the telephone & publicize your work schedule to family & friends It is often difficult to get quality sleep during the day and support from others is important. There are several steps a shift worker can take to successfully fall asleep and stay asleep. The key is to make sleep a priority! Set the stage for sleep even though it might be broad daylight outside. Prepare your body and mind for sleep. Wear wraparound dark glasses on your way home from work if you are on the night shift to keep morning sunlight from activating your internal "daytime" clock. Follow bedtime rituals and try to keep a regular sleep schedule—even on weekends. Go to sleep as soon as possible after work. At home, ask family and friends to help create a quiet and peaceful setting during your sleep time. Have family members wear headphones to listen to music or watch TV. Ban vacuuming, dish washing, and noisy games during your sleep time. Put a "Do Not Disturb" sign on the front door so that delivery people and friends will not knock or ring the doorbell. Schedule household repairs for after your sleep time.

25 Sleep and women Women experience more sleep problems than menA woman’s overall health affects her ability to sleep well As women progress through different life stages, changing biology affects their ability to get a good night’s sleep

26 Different Life Stages Respondents were asked about the quality and quantity of their sleep during 5 reproductive stages Women of Childbearing Age Pregnancy Post Partum Perimenopausal Postmenopausal

27 Age-Related Changes in SleepGreater difficulty falling asleep More frequent awakenings Decreased amounts of nighttime sleep, especially deep sleep More frequent daytime napping Increased time spent trying to sleep as sleep become less efficient

28 Age-Related Sleep RequirementsMost older adults require 6 to 10 hours per night Less than 4 hours or more than 8 hours associated with higher mortality rates

29 Psychosocial Problems Associated with Sleep DisturbancesLife stresses combined with Depression Anxiety

30 Psychosocial Influences That May Disrupt SleepSocial isolation Caregiving stress and strain Grief and bereavement

31 Interventions for the Nursing Care Unit/Healthcare FacilityEstablish nighttime routines Reduce noise and light disruption Turn down volume on televisions, radios, and phones Avoid using intercoms and beepers during sleep hours Regulate night lights

32 Interventions for the Nursing Care Unit/Healthcare FacilityOccupy residents during the day Do not put residents to bed immediately after supper If residents are unable to sleep, assist them to move away from those who are sleeping

33 Sleep and pain Chicken or egg? Disturbed sleep chronic Pain

34 Con.. Pain Interferes with Normal SleepThere is the strong relationship between pain, and disturbed sleep. Pain Interferes with Normal Sleep Pain severity was related to fewer hours slept and delayed sleep onset Sleep deprivation lowers the pain threshold Low back pain, fibromyalgia, arthritis

35 Children with Autism have High Rates of Sleep Problems44-89% rates of sleep disturbance in autism spectrum disorders (ASDs) Compared to 20-50% of typically functioning children with sleep disturbances Sleep problems tended to be chronic with low remission rate compared to children without ASD Insomnia is one the most common concurrent problems in children with ASDs

36 Characteristics of Children with ASD and AutismNo correlation between developmental level and sleep problem One study found sleep problems more common in boys than girls More sleep problems with higher level of communication impairment More sleep problems with severity of daytime behavior and diagnosis of comorbid ADHD

37 Effects of Sleep Problems in Children with ASDStress in families and children; families report more daily stress and more intense hassles Parental sleep difficulties Increased daytime behavior problem Higher rates of stereotyped behavior along with higher overall autism severity scores Higher social skills deficits

38 Effects of Sleep Problems (contExacerbation of medical problems such as seizure disorder or gastrointestinal problems In summary sleep problems affect the health and quality of life of children, parents, and others in the family

39 Sleep and ADHD All variety of sleep disorders are more common amongst children with ADHD than healthy controls, controls with other psych illness, and health siblings by 5x The DSM-III considered excessive movements during sleep to be a criterion for hyperactivity in children It is estimated that up to 25% of children with severe sleep problems in infancy will later qualify for a diagnosis of ADH sleep complaint reported in ADHD, bedtime refusal/resistance and/or delayed sleep onset (i.e., time to fall asleep once in bed).

40 ADHD: Clinical PresentationGreater variation in sleep onset time, wake time, and sleep duration Significantly more bedtime struggles with parents Habitual snoring is 3x more common in children with ADHD Greater frequency of PLMD and SDB have also been frequently reported

41 Sleep and cerebral palsyBetween 23 % – 46% of children with cerebral palsy experience sleep problem sleep deficiency affects the child’s physical, emotional and cognitive development and performance, and has been reported to affect caregivers and family who themselves can become sleep deprived the link between chronic pain, sleep, and behavioral problem is important

42 Sleep and cerebral palsy (con..)possible major causes of pain include: musculoskeletal pain (such as hip dislocation or scoliosis) neuromuscular pain (such as muscle spasm) and gastrointestinal pain (such as gastro -esophageal reflux and constipation) dental problems (such as abscesses) Assistive devices

43 Con.. Pharmacological approachNon - pharmacological sleep intervention therapeutic use of activity Sleep hygiene (light, noise, temperature) Massage parent education

44 Sleep and other disordersPatients with CVA, MS, epilepsy, Parkinson disease, cancer, brain tumors, Alzheimer's disease have different kind of sleep disorders. Patient with chronic pain syndromes, Rheumatoid arthritis, fibromyalgia, diabetes, and CRF experience sleep difficulties. Sleep disorders have negative impact on the course of disorders.

45 Sleep and psychiatric disordersMajor depressive disorder, bipolar mood disorders, schizophrenia disorders, substance disorders, PTSD are associated with sleep disturbances. Sleep disturbance may worsen the course of illness, increase risk of readmission, and decrease outcomes of rehabilitation programs.

46 Questions

47 Sleep is a necessary function of lifeMake it Healthy Increase your happiness