What is Narcolepsy? - Focus on Respiratory Care & Sleep Medicine

Report
Narcolepsy and Other
Hypersomnias
Marietta B. Bibbs, RPSGT
Morton Plant Mease Healthcare
Clearwater, FL
Objectives
Discuss etiology and symptoms of narcolepsy
Discuss causes of excessive sleepiness
Define idiopathic hypersomnia
Describe other causes of hypersomnia
Define the three factors that characterize sleepiness
Demonstrate the dangers of drowsy driving
What is Narcolepsy?
A neurological disorder caused by
deficiency of an excitatory neurotransmitter leading to excessive sleepiness
and other atypical REM-related activity.
It is a chronic disorder characterized by
excessive daytime sleepiness despite a
restful night of sleep, and sudden and
uncontrollable attacks of sleep that are
sometimes accompanied by hallucinations
and sleep paralysis.
Characteristics of Narcolepsy
Excessive sleepiness
with cataplexy
Rapid transition from
wakefulness to sleep
Early onset REM
epochs
Automatic behavior
Narcolepsy
Other Symptoms:
Sleep Paralysis (waking with
inability to move—a frightening
condition).
Hypnagogic hallucinations
(perceptual distortions that seem
real)
Characterizations:
Repeated naps, lasting 10-20
minutes with sleepiness
reappearing in 2-3 hour
repetitious patterns.
Waking up refreshed from naps
Unique Distinctions of Narcolepsy
Inability to consolidate
wakefulness in the day
(and sleep at night)
Cataplexy (loss of muscle
tone in response to
strong, usually positive,
emotions)
Short naps are very
refreshing
Sleepiness returns within
hours after napping
Cataplexy may be localized
or general, and vary from
mild to very disabling.
Clustered cataplexy
episodes may result in
status cataplecticus, lasting
minutes up to an hour
Four Primary Symptoms
1.
2.
3.
4.
Excessive Daytime Sleepiness (with
uncontrollable sleep attacks and automatic
behavior, and the most prominent symptom of
narcolepsy).
Cataplexy (loss of bilateral peripheral muscle
tone).
Hypnagogic Hallucinations (usually occur as
vivid dreams at sleep onset).
Sleep Paralysis (usually occurs at sleep onset).
It is rare for a person to have all four symptoms.
Sleep Attacks of Narcolepsy
Uncontrollable sleep attacks
occur most often in sedentary
situations, but can also occur in
situations where sleep would
normally not occur such as in the
middle of conversation, while
driving, eating, walking, etc.
Narcoleptics can fight sleep
attacks for a while, but eventually
lose the fight and give in to the
urge to sleep.
Cataplexy
The most exclusive feature of narcolepsy.
Cataplexy is always precipitated by powerful
emotion, such as laughter, crying, anger, etc.
It is characterized by a sudden, bilateral loss
of muscle tone in which consciousness and
memory are intact
Respiratory and ocular muscles are not
affected.
Cataplexy
A catapletic attack can last from a few seconds to
several minutes.
The loss of muscle tone in cataplexy can be very mild
(jaw dropping, slurred speech) to a complete
collapse in which the person can fall to the ground.
Strong emotion can sometimes precipitate episodes
of cataplexy that occur in succession, called status
cataplecticus).
Onset and Diagnosis
Early adolescence is the peak
age of onset for narcolepsy,
but it can have onset in early
childhood and adulthood.
Can be diagnosed with a
good sleep and family history
of narcolepsy.
Diagnosis confirmed by
polysomnography and MSLT.
Diagnosis
Clinical findings and characteristic features of
polysomnography are key in the diagnosis of
narcolepsy
The Multiple Sleep Latency Test (MSLT)
confirms the diagnosis and the severity of
excessive sleepiness.
Automatic Behavior in Narcolepsy
Performing a routine
task automatically
without conscious
awareness. The
narcoleptic patient
continues to perform
the task while falling
asleep (microsleep) and
without memory of
performing the action.
Nocturnal Sleep Disturbance
Narcoleptic patients fall asleep easily, but often
complain of trouble staying asleep during the night,
despite the fact that they may experience sleepiness
and fall asleep repeatedly during the day.
Narcoleptics don’t sleep more than normal people
over the 24-hour cycle, but they do have frequent
awakenings or excessive shifts to stage N1.
Diagnostic Criteria…..
Narcolepsy with Cataplexy
Narcolepsy without Cataplexy
Narcolepsy Due to Medical
Conditions
Diagnostic Criteria….
A complaints of excessive daytime sleepiness
occurring daily for at least 3 months.
EDS cannot be explained by another sleep
disorder, medical or neurological disorder,
medication use or substance use.
A definite history of cataplexy (sudden and
transient episodes of loss of muscle tone
triggered by emotions).
Diagnostic Criteria…..
Confirmation of the disorder through multiple
sleep latency testing (MSLT).
The MSLT results in a mean sleep latency less
than or equal to 8 minutes with two or more
sleep onset REM periods (SOREMPS) observed
following sufficient nocturnal sleep of a minimum
of 6 hours.
The Stanford Sleepiness Scale and Epworth
Sleepiness Scale can be used to aide in the clinical
diagnosis of Narcolepsy.
Other Diagnostic Tools
HLA typing can be used since there is a strong
correlation of narcolepsy in individuals with
cataplexy when human leukocyte antigen typing is
positive for DQB*0602 or DR2.
HLA Typing
Although the test can be used to confirm narcolepsy
diagnosis, it is not very useful in ruling out
narcolepsy.
If presence of DR2 or DQB1*602 are positive, this
does not directly indicate narcolepsy, but indicates
that the person has a genetic predisposition to
develop the disease.
HLA typing assists in determining the risk level in
families of narcoleptic patients.
Almost all narcoleptic patients will have presence of
HLA-DR2 and DQ1.
In narcoleptics with cataplexy, 90-100% of them will
have the DQB1*602 allele regardless of their race .
Developments on Narcolepsy
The etiology of narcolepsy is now better understood,
and the pathophysiology of narcolepsy is recognized
and linked to defects in the orexin (hypocretin)
neuropeptide system resulting in impaired control of
sleep and wakefulness.
Most cases of narcolepsy in humans have been
associated with low or absent cerebrospinal fluid
levels of hypocretin.
The Orexin Connection…
Patients who have
Narcolepsy with cataplexy
are associated with loss of
approximately 50,000100,000 hypothalamic
neurons containing Orexin.
Hypocretin (Orexin) levels
in CSF <= 100 p/mL.
The Orexin Connection…
The discovery that
orexin/hypocretin dysfunction
causes narcolepsy indicates a
major role for this system in sleep
regulation and integrating
metabolic, circadian and sleep
debt .
When orexin A/hypocretin-1 is
administered, it promotes
wakefulness, increases body
temperature, and elicits a strong
increase in energy expenditure.
Narcolepsy Research
When a person is sleep
deprived, transmission
of orexin A/hypocretin1 increases and it is
now thought that this
system is more
important in the
regulation of energy
expenditure than in
food intake.
Narcoleptic patients
who are deficient in
orexin/hypocretin have
increased obesity rather
than decreased BMI, as
would be expected if
orexin/hypocretin were
primarily an appetite
stimulating peptide.
Differential Diagnosis
Patients with symptoms of narcolepsy without
cataplexy should be distinguished from those with
narcolepsy.
When narcolepsy is suspected, but cataplexy is NOT
present, other disorders with similar symptoms
should be ruled out. These include:
idiopathic hypersomnia
obstructive sleep apnea
periodic limb movement disorder/restless legs syndrome
depression
inadequate sleep secondary to medical disorders or medications
Differential Diagnosis
Patients with Idiopathic
hypersomnia will not have the
REM related features of
narcolepsy (sleep paralysis,
hypnagogic hallucinations or
three out of five REM onset
periods during MSLT).
Patients with OSA will not
wake from naps feeling
refreshed, but narcoleptic
patients will feel refreshed
following naps.
Differential Diagnosis
There is a group of patients with all the symptoms of
narcolepsy, including HLA-DR2 positivity, along with
two or more sleep-onset REM periods during MSLT,
and may also have hypnagogic hallucinations and/or
sleep paralysis but they DO NOT have cataplexy.
These patients may be classified as having
narcolepsy, essential hypersomnia, primary
hypersomnia, ambiguous narcolepsy or atypical
narcolepsy.
Polysomnographic Features
Sleep latency of less than 10 minutes.
Sleep onset REM period (occurring within 20 minutes
after sleep onset).
Hypnagogic hallucinations or sleep paralysis
associated with sleep onset REM.
Increased N1 sleep.
Sleep disturbance with frequent awakenings.
Polysomnography in the Narcolepsy Diagnosis
Patient must be free of drugs that influence
sleep, particularly REM sleep, for at least 15
days.
Patient must have an established sleep/wake
schedule for 7 days, which can be
accomplished through sleep logs.
Polysomnography should be performed on
the night immediately before the MSLT in
order to rule out other disorders that could
have similarities to narcolepsy.
Polysomnography in the Narcolepsy Diagnosis
The PSG should consist of EEG (frontal, central,
occipital derivations), EOG, EMG (chin, tibialis),
respiratory (airflow and effort), ECG, and oximetry.
The recording should reflect the patient’s normal
bedtime and wake time.
Patients SHOULD NOT be awakened during the last
REM period of the morning.
Differential Diagnosis
 When
other sleep
disorders are present,
such as apnea, periodic
limb movement
disorder, it is more
difficult to confirm a
narcolepsy diagnosis.
Multiple Sleep Latency Testing
An objective measure of excessive
sleepiness.
A MSLT is positive for narcolepsy when:
there is presence of thee or more sleep onset REM
periods during five nap opportunities
sleep latencies are <10 minutes, typically below 5
minutes
A good sleep-wake schedule and good
sleep hygiene are essential for MSLT
accuracy.
MSLT vs MWT
The MSLT is used to measure sleepiness.
The MWT (maintenance of Wakefulness test) is used
to measure alertness—ability to stay awake.
The MSLT is the gold standard for confirming the
narcolepsy diagnosis.
The MWT is often used to assess the level of
alertness after treatment for sleep disorders, such as
sleep apnea.
The MSLT
Measures the physiological tendency to
fall asleep since the tendency to fall
asleep increases as physiological
sleepiness increases.
To measure physiological sleepiness,
alerting factors must not be present.
The test is based on the hypothesis that
sleep latency is a reflection of the degree
of sleepiness.
MSLT Protocol
Five nap opportunities performed in two-hour
intervals.
Four nap opportunities are only reliable if the patient
has two sleep onset REM periods during the first
four naps.
The first nap opportunity should begin 1.5 to 3 hours
after the patient is awakened from the night’s sleep.
Tests should always be performed immediately
following polysomnography in the sleep center.
MSLT Protocol
REM suppressing medications should be
discontinued two weeks prior to the test.
Drug screening may be performed in some cases to
rule out pharmacologically induced sleepiness.
Tests should be performed by experienced
technologists.
MSLT Protocol
In order for the MSLT results to be valid, the patient
should have a minimum of 6 hours of sleep during
polysomnography .
MSLT should not be performed following split-night
polysomnography, but it can be performed following
full-night PAP titration.
MSLT Protocol
The testing environment
should be standardized in
order to obtain valid test
results.
Sleep rooms should be
dark and quiet and
temperature should be
set to the patient’s
comfort.
MSLT Protocol
Smoking should cease at least 30 minutes prior to
each nap.
Vigorous physical activity should be avoided on the
day of the test, and stimulating activities should be
discontinued 15 minutes prior to start of each nap.
Caffeinated beverages and exposure to bright
sunlight should be avoided during testing.
Meals should occur at least 1 hour prior to the first
test and after termination of the second noon trial.
Recording Montage
Standard recording procedures for PSG should be
followed, with electrode derivations including,
central, occipital and frontal leads.
EOG mental/submental EMG and EKG is also
recorded.
The patient should use the restroom (if indicated)
prior to the start of each test.
The patient should remain out of bed and refrain
from sleeping between naps.
MSLT Recording Procedure
Standardized physiological calibrations should be
performed before each nap opportunity:
“Lie quietly with your eyes open for 30 seconds”
“Close both eyes for 30 seconds”
“Without moving your head, look to the right, then left, then right, then left”
“Blink your eyes slowly 5 times”
“Clench or grit your teeth tightly together”
Following physiological calibrations, the patient
should be instructed:
“Please lie quietly, assume a comfortable position, keep your eyes closed and
try to fall asleep”
MSLT Recording Procedure
Turn lights off immediately after instructions are
given.
Determine sleep onset latency:
The time from lights out to the first epoch of ANY stage of sleep
The epoch counted as sleep onset must have 15 seconds of cumulative sleep in
a 30-second epoch.
If no sleep occurs during a nap opportunity, the sleep latency
is counted as 20 minutes
REM sleep latency:
Calculated from the first epoch of sleep to the first epoch of REM sleep
regardless of intervening sleep or wake stages
MSLT Recording Procedure
When sleep onset occurs during a nap opportunity,
the recording should continue for 15 minutes after
the first epoch of sleep. Calculate 15 minutes using
“clock time”, not by sleep time.
The 15-minutes of recording allows for occurrence
of REM sleep.
In calculating mean sleep latency, ALL naps are
included, even the ones in which there is no sleep
occurrence.
MSLT Recording Procedure
End the nap after 20
minutes if no sleep
occurs.
End the nap after 15
minutes of “clock time”
sleep following sleep
onset.
The following data is
reported:
the start and end times
latency from lights out to the
first epoch of sleep
number of sleep onset REM
periods
Mean sleep latency,
calculated from data of all
naps
The Danger of Hypersomnia and
Drowsy Driving
 Almost
Home
Hypersomnias of Central Origin
Not due to a Circadian Rhythm
Sleep Disorder, Sleep Related
Breathing Disorder, or Other
Cause of Disturbed Nocturnal
Sleep.
HYPERSOMNIAS
Primary complaint is daytime sleepiness.
Cause is NOT one of those previously listed.
Subjective measures of EDS:
Epworth Sleepiness Scale, MSLT, MWT
12 Disorders in the one category
Narcolepsy is described in this category
With cataplexy
without cataplexy
46
What is Sleep?
Sleep is a reversible state of
decreased consciousness that is
recurrent and associated with
characteristic biophysiologic
alterations.
Sleep is a very complex
amalgam of physiological and
behavioral processes.
Sleep is a process, unlike
coma, this is physiologic,
recurrent and reversible.
Sleep Medicine—Accepted Facts
Sleep is necessary for healing and recovery.
When sleep is abnormal, there can be
psychological and physical illness and even
death.
Treating sleep disorders improves physical
well-being and can be instrumental in treating
medical and psychiatric illness.
Why is sleep important?
Restorative to mind and body
Essential for physiological functions
Hormone secretion
Growth and “Maintenance”
Essential to maintain proper mental processes
Memory – both long and short term
Decision making
Socially acceptable personality traits
Sleep Requirements
Average adults require about 8 hours of sleep
regardless of environmental or cultural differences.
People who sleep less than 4 hours or more than 9
hours have increased risk for coronary artery
disease, cancer and stroke.
Whether a person is a “long” sleeper or a “short”
sleeper is most likely determined by heredity.
Long sleepers spend more time asleep but have less
deep sleep and more stage N2 sleep than do short
sleepers.
Behavioral Characteristics of Sleep
Sleep must have these four behavioral characteristics:
Minimal movement
A typical sleep posture (e.g., for humans, lying
down; for bats, hanging upside down)
Reduced responsiveness to external stimulation
(moderate noises don't awaken you)
Quick reversibility of reduced responsiveness to
relatively intense stimulation (distinguishing sleep
from other states like death or coma).
Circadian and Homeostatic Factors
Sleep and wakefulness are controlled by homeostatic
and circadian factors.
Duration of prior wakefulness (homeostatic factor)
determines timing, duration and characteristics of
sleep.
There are two highly vulnerable periods of
sleepiness: 3:00-5:00 a.m. and 3:00-5:00 p.m.
Circadian and Homeostatic Factors
Subjective Sleepiness – a person’s perception of
sleepiness—depends on environmental factors such
as environment and ingestion of coffee or other
caffeinated beverages,
Physiological sleepiness depends on homeostatic
and circadian factors.
Homeostatic factors refer to a period of wakefulness
and sleep debt. After prolonged wakefulness, there
is an increased tendency to sleep.
Circadian Rhythm Sleep Disorders
Circadian Rhythm Sleep Disorders
May arise when physical
environment is altered
relative to internal
circadian timing or
circadian timing system is
altered relative to the
external environment
 Includes maladaptive
behaviors
 Entire section < 20 pgs

55
Circadian Rhythm Sleep Disorders
General Criteria
Recurrent or persistent pattern of sleep disturbance
due primarily to:
Alterations of the circadian timekeeping system
Misalignment between endogenous circadian rhythm and
exogenous factors that affect the timing or duration of sleep
Leads to insomnia, EDS or both.
Associated with impairment of social, occupational or
other functioning.
Chronobiology & Circadian Rhythms
Circadian rhythms exist independent of
environmental stimuli.
Studies from as far back as 1731 have shown that if
humans are isolated from environmental cues, like
time and light, they have free-running rhythms.
The circadian cycle in humans is approximately 25
hours instead of 24-hours day-night cycle.
Chronobiology & Circadian Rhythms
Environmental cues of light and darkness
synchronize or entrain rhythms to the daynight cycle but the existence of
environmental-independent rhythms suggest
that the human body has an internal
biological clock.
This biological clock is located in the
suprachiasmatic nuclei of the hypothalamus
above the optic chiasm.
Circadian and Homeostatic Factors
Recovery from sleep debt is not linear; thus there is
no exact number of hours of sleep required to repay
sleep debt, but the body needs adequate restoration
of slow wave sleep.
Sleep/wakefulness and the circadian pacemaker are
interrelated, but the neurological basis of this
interaction is unknown.
Understanding Sleep Wake Cycles
Why Sleep Matters
Sleep Hygiene
Fatigue Countermeasures
It’s In The News
Big Time, All the Time
Sitcoms
Evening news
Game shows
Reality shows
Newspapers
Magazines
Movies
Sleep/Wake Regulators
Homeostatic Drive
Your body’s sleep savings account
The more sleep you get, the more likely you are to be fit for
duty (remain alert).
The greater your sleep debt is the more likely you will
fall asleep unintentionally.
Not always noticeable to you or others
Sometimes not “all of you” but just your brain!
The less sleep you get, the more likely you are to fall
asleep during your scheduled wake time (like at work
or driving).
Circadian Rhythms
Influenced by:
Light
Regularity of wake time
Age
SLEEP BASICS
CIRCADIAN RHYTHMS
Clock dependent alerting
The 24 hour cycle
20 m inutes
E nough sleep, regu la r sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
E nough sleep, irregu la r sleep
Acceptable
N ot enough sleep, regu la r sleep
10 m inutes
Gray Zone
N ot enough sleep, irregu la r sleep
5 m inutes
Bad, Not good,
Dangerous 
0 m inutes
7am
9
11
1p m
3
5
7
9
11
1am
3
5
Good Sleep Hygiene
What you need to do to maintain the sleep
regulators:
Refers to the practice of getting enough sleep at the right
times and with regularity
Prevents some sleep disorders
Improves efficacy of treatment for other disorders
Protects against or aids treatment for some non-sleep
disorders:
Asthma, diabetes, CHF, psych, GI
Risks Associated with Sleepiness & Fatigue
Safety
A sleepy workforce = increased safety violations,
accidents and workman’s comp claims
Production
Decreases with a sleepy workforce
Quality
Decreases with a sleepy workforce
Litigation
Shared employee/employer responsibility for
sleepiness related accidents, errors
At work and on the way to and from work
Risks Associated with Fatigue
Work environment
A well slept workforce is
happier, more pleasant, less
angry, works better as a
team
Health & Well-being
Degrades in proportion to
sleepiness
Risks Associated with Fatigue
Mental
& Physical
Performance
Poor integration of
information &
decision making.
Critical & lateral
thinking difficult.
Decreased long &
short term memory.
Risks Associated with Fatigue
Mental
& Physical Performance
Difficulty focusing, young children become
distracting, hyperactive.
Physical performance can decrease by as
much as 30%.
This is where you are
most productive
Clock dependent alerting
20 m inutes
E nough sleep, regu la r sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
E nough sleep, irregu la r sleep
Acceptable
N ot enough sleep, regu la r sleep
10 m inutes
Gray Zone
N ot enough sleep, irregu la r sleep
5 m inutes
Bad, Not good,
Dangerous 
0 m inutes
7am
9
11
1p m
3
5
7
9
11
1am
3
5
SLEEP Now – Eight
continuous hours in a 10-11
hour opportunity.
Clock
Dependent
Alerting
Pick the best “body clock” time.
20 minutes
Time it
takes to
fall
asleep
The Way it
Should Be!
Enough sleep, regular sleep
Enough sleep, irregular sleep
Acceptable
Not enough sleep, regular sleep
10 minutes
Gray Zone
Not enough sleep, irregular sleep
Bad, Not good,
Dangerous 
5 minutes
0 minutes
7am
9
11
1pm
3
5
7
9
11
1am
3
5
Sleep Debt
8 hours per night X 5 nights = 40 hours
Add up the last 5 nights,
40 or more GREAT
38 or less you’ve got a sleep debt
36 or less, you would do poorly on performance
tests
How do you fix it?
SLEEP BASICS
Pick a night & SLIP IN THE DIP !
CIRCADIAN RHYTHMS
The 24 hour cycle
20 m inutes
E nough sleep, regu la r sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
E nough sleep, irregu la r sleep
Acceptable
N ot enough sleep, regu la r sleep
10 m inutes
Gray Zone
N ot enough sleep, irregu la r sleep
5 m inutes
Bad, Not good,
Dangerous 
0 m inutes
7am
9
11
1p m
3
5
7
9
11
1am
3
5
Work With Your Body Clock for NAPS
Clock dependent alerting
The 24 hour cycle
20 m inutes
E nough sleep, regu la r sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
Good
Good
Time
E nough sleep, irregu la r sleep
For
Time
Acceptable
A
N ot enough sleep, regu la r sleep
For
10 m inutes
Nap
A
Gray Zone
Or
N ot enough sleep, irregu la r sleep
Early
Nap
To
5 m inutes
Bad, Not good,
Dangerous 
Bed
0 m inutes
7am
9
11
1p m
3
5
7
9
11
1am
3
5
The first night you stay up late and sleep
in, body rhythm starts to shift
20 minutes
Time it
takes to
fall
asleep
The Way it
Should Be!
Enough sleep, regular sleep
Enough sleep, irregular sleep
Acceptable
Not enough sleep, regular sleep
10 minutes
Gray Zone
Not enough sleep, irregular sleep
Bad, Not good,
Dangerous 
5 minutes
0 minutes
7am
9
11
1pm
3
5
7
9
11
1am
3
5
This is where you will
be most productive
Body Rhythm Time
20 minutes
Enough sleep, regular sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
First Class
or Start
Work
Enough sleep, irregular sleep
Acceptable
Not enough sleep, regular sleep
10 minutes
Gray Zone
Not enough sleep, irregular sleep
5 minutes
Bad, Not good,
Dangerous 
0 minutes
7am
9
11
11am
7am
1pm
3
5
7
9
11
11pm
Clock time
1am
3
5
This is where you want
to work and drive
Clock dependent alerting
20 m inutes
E nough sleep, regu la r sleep
Time it
takes to
fall
asleep
The Way it
Should Be!
E nough sleep, irregu la r sleep
Acceptable
N ot enough sleep, regu la r sleep
10 m inutes
Gray Zone
N ot enough sleep, irregu la r sleep
5 m inutes
You can startBad,
yourNot
daygood,
at
Dangerous
Anytime you wish as long
as
You have acclimated your
Body clock to it
0 m inutes
7am
9
11
1p m
3
5
7
9
11
1am
3
5
What about sleeping in on days off to lower sleep debt?
OK if less than 2 hours or it’s the ONLY choice to
make up sleep debt.
Prefer you SLIP IN THE DIP one night then sleep in
a little on days off.
Watch out for shift workers….. Bed time MUST be
regular
They tend to go home in am and sleep when nothing else is
going on...sometimes going to be right away others late AM
Avoid exposure to light as much as possible
IS FATIGUE REALLY AN ISSUE?
Typical attributes of sleepy people
Anxious
Inaccurate
Immoral
Bewildered
Confused
Hostile
Over-confident
Angry
Absenteeism
Chronic illnesses
Hormone imbalances
 pain thresholds
Vision problems
Depression
Personality changes
Aggressive behaviors
HOW BIG IS THE PROBLEM?
We are poor judges of our degree of sleepiness.
We are poor judges of our degree of alertness.
As high as 75% of the population is chronically sleep
deprived.
Adults require 8+ hours of sleep to maintain
performance and memory functions surveys indicate
most get far less
As much as 1/3 of the population has untreated sleep
apnea.
Most of this population drives!
Facts About Sleepiness
1.
2.
3.
4.
The effects on driving are similar to driving drunk !
The leading cause of sleepiness is self imposed sleep restriction.
Sleepiness is accumulative.
Performance falls off dramatically after 12 hours of work.

66 truck drivers were tested for sleepiness after 3 nights with
8 hours of sleep
OK = 15-20 minutes
Borderline = 5-10 minutes


5% were OK
45% borderline
Acceptable = 10-15 minutes
Pathologically sleepy = < 5 minutes
13% acceptable
37% pathologically sleepy
(82% still shouldn’t be driving !!!!!!)
How Do I know…..
if I’m Not As Alert As I NEED To Be?
Dozing off while engaged in an activities such as
reading, watching TV, sitting in meetings or sitting in
traffic.
Slowed thinking and reacting.
Difficulty listening to what is said or understanding
directions.
Frequent errors or mistakes.
Narrowing of attention span, missing important
changes in a situation.
How Do I know…..
if I’m Not As Alert As I NEED To Be?
Poor judgment in complex situations.
Difficulty coming up with a new approach to a problem
when the old approach is not working.
Depression or negative mood.
Impatience or being quick to anger.
Frequent blinking, difficulty focusing eyes, heavy
eyelids, long blinks.
Signs of Fatigue While Driving
Difficulty focusing, frequent blinking, or heavy eyelids.
Daydreaming; wandering/disconnected thoughts.
Trouble remembering the last few miles driven;
missing exits or traffic signs.
Yawning repeatedly or rubbing your eyes.
Trouble keeping your head up.
Drifting from your lane, tailgating, or hitting a
shoulder rumble strip.
Feeling restless and irritable.
Microsleeps
People don’t have to LOOK sleepy to make mistakes.
The brain can take short “naps” even in the middle
of performing a task.
Normally habitual safety procedures can be
eliminated to get to the end goal of the task.
Safety procedures can be performed
“automatically” without thought or recognition of
warnings.
Fatigue Management
Reduce sleep debt before beginning duty.
Screen for and treat OSA.
Education
sleep in synchrony with physiological dips.
Drive in synchrony with your alertness peaks.
Naps.
Caffeine.
Alerting Medications as a last resort.
Prevent Drowsy Driving—Fix Your
Sleep Debt
Try to be in bed and get up at the times you will be
sleeping and awakening when on the road
For at least 3 days
Keep your sleep debt to a minimum
No sleep debt if you can
Have white noise, ear plugs, eye covers packed!
Start duty period at usual wake time
Drowsy Driving & Hours of Service
Calculate your sleep debt
If it is more than 1 or 2 hours……….
You need to make up your debt BEFORE you drive, the
greater the debt the higher your risk!
(Go to sleep early – slip in the dip!)
Near-Misses Predict Accident Risk
If you’ve ever had a near miss, you’re at risk!
Reducing your sleep debt, may reduce your risk
Powell et al; Sleep 2007, 30(3)331-339
Fatigue Management with Naps
By modeling the effectiveness of naps as a
countermeasure to driver sleepiness and accidents,
professional shift-work* drivers adopting prophylactic
naps can reduce the risk of accidents during night
work.
Driving any time outside your normal waking hours can be considered shift
work.
*
Sleep 2004;27(7):1295-1302.
Fatigue Management with Naps
Ten minutes is better than 30 minutes.
Immediate & sustained recovery in alertness, mood, &
performance ..a safe way to get to your rest stop
Establish rest period protocols.
when, where, how
Rest Periods are not a substitute for adequate sleep.
Change social view of naps.
Let Sleep Work for You !
MAKE
SLEEP
A
PRIORITY!

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