SLEEP AND SOCIETY

1. SLEEP AND SOCIETY William C. Dement, M.D., Ph.D., Sc.D Stanford University Center of Excellence For the Diagnosis and Treatment of Sleep Disorders October 1, 2013 Sleep Symposium Las Vegas, NV

2. After the first half century of sleep research, and sleep medicine, America and the world have arrived at a moment of great challenge and opportunity. We know enoughto respond.The challenge: we must change the way society deals with sleep.The opportunity:the entire human race will be lifted to a new level of energy, health, and safety.

3. This presentation will outline… -Why we need sleep-Negative consequences of sleep deprivation and sleep disorders- Failure of effective knowledge transfer-Progress and potential for progress

4. But first… A FewHistorical Highlights

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

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

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

8. Throughout the 1970’s, more than 80 percent of the referralsto sleep disorders centers were patients with obstructive sleep apnea, and most were severely ill. Until 1981 when continuous positive airway pressure (CPAP) and uvulopalatopharyngoplasty (UPPP) treatments were introduced, the only treatment was chronic tracheostomy.Though the results were often miraculous, this treatment wasone of the biggest barriers to expansion of the field. In 1981, there were only 23 fully accredited sleep disorders centers throughout the USA. Today, there are >1000 accredited centers, ~1345 physician specialists who are diplomates of the American Board of Sleep Medicine, and “>15,000 RPSGTs.

9. In spite of this progress, today many Americans and others with sleep disorders continue to be undiagnosed and untreatedor misdiagnosed and mistreated.Thus, in 2013. . .Inadequate and unhealthy sleep remains one of America’s (and the world’s) largest, deadliest, and most costly problems. (USA & Europe not so bad)

10. SOME NEGATIVE CONSEQUENCES

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

12. THE ACCUMULATIONIS CONCEPTUALIZED AS SLEEP DEBT • The cumulative daily hours of sleep less than the mean daily amount needed • ALL lost sleep accumulates as a debt • Sleep debt can only be reduced by getting extra sleep • Sleep debt can accumulate rapidly or very gradually • Most people have a sizable sleep debt.

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

14. FUNDAMENTAL PRINCIPLESAll lost (or frequently interrupted sleep) accumulates as a debt that is only reduced by obtaining extra sleep and/or diagnosing and treating your sleep disorder.The larger your sleep debt…• the more tired you will feel.• the more impaired you will become.• the more likely you are to become drowsy.• the faster you will fall asleep. • the more likely we are to fall asleep and die.

15. ESTIMATED COSTS OF SLEEP LOSS AND SLEEP DISORDERS IN LIVES AND DOLLARS • • ≥50,000 unnecessary deaths/yr • • Countless injuries, disabilities, failures, misery • • Accidents ~$100 billion/yr • Health care ~$300 billion/yr

17. Exxon Valdez 1989 • One of the worst environmental disasters in history. • Cost: over $2 billion clean-up and $5 billion fine for Exxon. • Cause: “Sleep deprivation of the 3rd mate in charge of the bridge” as noted in the NTSB final report.

18. Star Princess 1995 • Grounded near Juneau, Alaska with 1,568 passengers, 639 crew. • Damage to vessel bottom included rupture of oil tanks. • Total cost of repairs - $27 million. • NTSB report concluded: • “The pilot was chronically fatigued as a result of obstructive sleep apnea.” • NTSB recommendations included: • “Advise pilots about the effect of fatigue on performance and about sleeping disorders such as sleep apnea.”

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

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

23. The first aircraft accident where fatigue was specifically identified as the direct cause.

24. VIDEOCHINA AIRLINES

26. RECENT (2000) BUS CRASH WITH IMPORTANT IMPLICATIONS (NOBODY DID ANYTHING!) BUS ACCIDENT WILL BE DESCRIBED

27. IT’S A GOOD THING THIS SLEEPY DRIVER WASN’T DRIVING YOUR CHILDREN’S SCHOOL BUS

29. WHITE PLAINS, NEW YORK JULY, 1994

33. Two photos of worst accident• photo of car• photo of dead little girl

34. Two photos of worst accident• photo of car• photo of dead little girl

36. Other Areas

37. If jurors, judge, and/or lawyers are sleeping, is it a fair trial?

38. PLANT SHUTDOWN COST ~$2 BILLION

39. IOM Report. To Err is Human. 98,000 deaths per year caused by physician error. What percent due to fatigue?

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

43. What is the signal that gets you off the road? Head drop with startle and/or hallucination - 82%THERE MUST BE A BETTER WAY

44. ~100 MILLION AMERICANSCHRONICALLY ILLWITH SLEEP PROBLEMS • 35 MILLION AMERICANS HAVE OSA • 100 MILLION+ HAVE TROUBLESOME SLEEP DEBT

45. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. NEJM. 1993; 328: 1230-1235 Nieto F, Young T, Lind B, Shahar E, Samet J, Redline S, D’Agostino R, Neman A, Lebowitz M, Pickering T. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. JAMA. 2000; 283: 1829-1836 Peppard P, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. NEJM. 2000; 342: 1378-1407.

48. Prevalence of Sleep apnea in Truckers (N = 200; Age = 35 + 9 years; Males = 91%) ODI>5 = 79% AHI>5 = 87% ODI>10 = 46% AHI>10 = 47% ODI>20 = 19% AHI>20 = 21% ODI>30 = 9% AHI>30 = 13% SOURCE: R.A. Stoohs, et.al., Sleep and Sleep-Disordered Breating in Commercial Long-Haul Truck Dirvers, Chest, May, 1995.

49. IGNORANCE IN THE WORKPLACE • In the Trucking Companies Whose • Drivers had Obstructive Sleep Apnea: • Had Ever Heard of Obstructive Sleep Apnea • Or Knew What It Was! • Driver • Manager • Safety Manager • Company Physician Not One

50. In Moscow, Idaho, USA, entire family practice population carefully screenedOSA: 34% males; 19% femalesRLS: 27% males; 31% femalesInsomnia: 30% males; 35% femalesMore than 60% of all patients had oneor more sleep disorders. None identified!