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114/30 Campbell Street BLACKTOWN NSW 2148 ABN: 51 138 032 014 Phone: + 61 2 9920 1968 Fax: + 61 2 9672 3884 E-mail: admin@sleep.org.au Web: www.sleep.org.au Submission by the Australasian Sleep Association to the Inquiry into Sleep Health Awareness in Australia by The Standing Committee on Health, Aged Care and Sport.
WHO WE ARE The Australasian Sleep Association (ASA) (https://www.sleep.org.au/) is the peak scientific body in Australia & New Zealand representing clinicians, scientists and researchers in the broad area of Sleep.

Our vision is the provision of world standard research, education and training, and establishment of clinical standards to ensure clinical best practice in sleep medicine resulting in an informed community with healthy sleep practices.
Our mission is to lead and promote sleep health and sleep science in Australia and New Zealand and to facilitate the professional development of its members by providing education and training, fostering research and establishing clinical standards within the field.

The ASA congratulates the Federal Government for calling this inquiry.

By doing so it is showing international leadership in considering, at a National level, the huge public cost of inadequate sleep and sleep disorders.
Australia has, rightly, devoted considerable resources to promoting two important pillars of good health - dietary choices and physical activity.

The scientific evidence is clear that sleep health is a third, extremely important pillar of good health.

Unfortunately, to date its importance has been unrecognised and grossly underestimated and its promotion under-resourced.
We have noted that when speaking to many politicians and their staff in the lead up to this Inquiry that consideration of these issues has strong support across all political parties.

The ASA would also like to thank the House of Representatives Standing Committee on Health, Aged Care and Sport for inviting it to the public hearing on November 30th and looks forward to answering any questions it might have at this time.
-1- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 OVERVIEW Sleep is a fundamental biological need, which is essential for physical and mental recuperation.

Poor or inadequate sleep, including sleep disorders, has a major detrimental impact on our physical and mental health and well-being.

The function of every cell in the human body changes when we sleep, so having insufficient or poor quality sleep impairs the function of every cell.
Not only do we become irritable, tired and depressed, but cognition is impaired, particularly memory and decision-making; we are at increased risk of accidents on the road, at home and in the workplace; performance and productivity are reduced; marital and familial disharmony is increased and libido is reduced; there is a greater risk of cardiovascular diseases, including hypertension, stroke, heart attack and arrhythmias; the prevalence of obesity and diabetes is increased; there is a greater risk of dementia with more rapid progression of the disease; and the prevalence of some cancers may be increased.
Yet despite this, at least 4 out of 10 Australian adults report insufficient sleep on a regular basis (daily or several days per week), with young adults being disproportionately affected.1 Children are particularly at risk, with most adolescents not having sufficient sleep on school nights, which significantly affects concentration and learning.
More than 1.5 million Australian adults, 9% of the adult population, suffer from sleep disorders with a further 5.9 million having excessive daytime sleepiness or insufficient sleep2.

Sleep Disorders are highly prevalent in Australian Society, particularly so in disadvantaged populations.
Sleep disorders are linked to chronic disease including mental health disorders, are associated with increased workplace and road traffic accident risk, and have a profound negative impact on an individual’s quality of life.

A huge current challenge in dealing with the health burden of sleep disorders is the lack of an appropriately trained health workforce, particularly in the setting of primary care.
Similarly, there is much we still have to learn about the mechanisms underlying sleep disorders, how best to manage complex sleep disorders, and how to tailor treatments to an individual’s disease – these are all issues that can be addressed by Australia’s sleep research sector, which already has a strong international reputation, but which is being challenged by inadequate funding.
The independent report on the economic cost of inadequate sleep in Australia, ‘Asleep on the Job’, by Deloitte Access Economics2 concludes: “A concerted national approach is required where inadequate sleep is seen as the vast, varied and costly problem that it is, and addressed by influencing behavioural change and increasing awareness of sleep conditions and their treatment.” Improving sleep health in Australia requires a major preventative health intervention equivalent to those that tackled our high smoking rates or reduced our high incidence of skin cancer through changing behaviours.
There is ample -2- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 evidence that sleep is as important for health as good nutrition and regular exercise.

Indeed, sleep should be seen as the third pillar of good health, alongside diet and exercise.

KEY RECOMMENDATIONS RECOMMENDATION #1 There is an urgent need for the development of a comprehensive sleep health promotion campaign, rolled out across Australia.
The aim would be to improve sleep health through promoting behavioural change and increase awareness of sleep-related conditions.

The campaign would be informed by current best practice in behaviour change to maximise motivational components and will learn from other successful Australian health campaigns such as “Quit” and “Slip, Slop, Slap”.

Such a campaign would provide evidence-based information to ensure Australians can better manage their sleep health and the sleep health of their children.
It would include resources to: • Deliver strong sleep health messages through media outlets that reach metropolitan, rural and remote areas of Australia; • Educate primary and secondary students and their parents about the role of sleep in enhancing memory, mood and learning and improve management of their personal sleep habits to maximise mental health and performance; • Inform people in the workforce about sleep health strategies that will improve their workplace safety and health, and reduce absenteeism and presenteeism; and • Increase sleep-related understandings of older Australians, and their carers, about cognitive and behavioural changes that can help improve their sleep, reduce dependence on sleep-inducing medication and improve their mental wellbeing, including decreasing the impact and rate of progression of dementia.
RECOMMENDATION #2 There is an equally urgent need for the development of a national school education program on sleep health.

In addition to a call for a community-wide sleep health education program (Key Recommendation #1) the ASA acknowledges that school-aged children are a special case that warrants specific, targeted sleep health education.
This is because poor sleep and daytime sleepiness have repeatedly been associated with obesity and reduced school performance; specifically with inattention, poor memory, behavioural problems, low mood, irritability, emotional instability, low self-esteem and hyperactivity in school aged children.
Further, teaching school-aged children about the importance of good sleep and how to improve their sleep will improve the likelihood of good sleep patterns into -3- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 adulthood.
The Middle School years are a particularly at-risk time for school children as it coincides with the usual end of parent-set bedtimes and the onset of puberty, when physiological and social changes are known to delay bedtimes and disrupt sleep with the use of social media.

It is essential, therefore, to develop and implement a Federally-funded National School Education Program on Sleep Health.
Such a program would educate an entire generation of school children about the importance of sleep health, which is a life-long asset that may reduce Australia’s very high rates of inadequate sleep (and its sequelae such as reduced work safety and performance, higher obesity risk and poorer mental health).

Sleep education programs have been developed and evaluated in Australia and many other countries around the world (e.g.
USA, Brazil, Italy, New Zealand) and have been shown to improve sleep health knowledge, and significantly increase weeknight and weekend sleep duration.

RECOMMENDATION #3 Development of an education and training program for primary healthcare providers.

With the raised awareness of the importance of good sleep, there will be a great demand for healthcare professionals to manage sleep disorders and assist with improving sleep behaviours.
It is neither appropriate nor feasible for sleep physicians to manage this, rather there will need to be a training program to upskill primary healthcare providers - in particular, general practitioners, psychologists, nurses, pharmacists and dentists.

Sleep medicine in the medical curriculum, either undergraduate or post-graduate, with many training programs having fewer than 2 hours of sleep medicine teaching.
is currently not adequately covered General Practitioners (GPs) are well-positioned to efficiently and capably identify and manage patients with uncomplicated obstructive sleep apnoea (OSA), but the current level of knowledge of sleep disorders, practices and attitudes in primary care is not known.
This includes the prevalence of OSA in primary care, impact of sleep disorders on community health, referral patterns for sleep disorders management in primary care, extent of inappropriate prescribing of sedative-hypnotics for insomnia (the BEACH study3 suggests up to 90% of patients presenting to a GP with insomnia symptoms are prescribed sedative hypnotics), as well as an assessment of the barriers/enablers to increased involvement of GPs in sleep disorders management in primary care.
The ASA proposes a two-step process to upskill GPs in the treatment of sleep disorders: 1.

Assessment of current knowledge levels.

A formal assessment of current status needs to be undertaken.

This will determine the level of training required to enable GPs to achieve the appropriate level of competency in sleep medicine and to inform the content of the course.
This could be achieved utilizing data currently available in -4- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 the NPS Medicine Insight program, with surveys and/or focus groups of GPs and other relevant primary care health professionals and of patients' experiences, attitudes and service preferences.
Such an assessment will also provide the opportunity to work with the Royal Australasian College of General Practitioners (RACGP) to determine how sleep education could be embedded in the FRACGP training course, along with a presence on the examination criteria in order to reverse the current widespread lack of knowledge in sleep disorders.

2.

GP education and training is required.


Such a course could be developed and accredited by a joint working party of the ASA and the RACGP and delivered in the form of a College/University-accredited diploma and certificate course.

GPs who have completed the course will be accredited to partner with a sleep physician (preferably in their geographical area) in a hub and spoke model of care.

The model of care will contain pre-defined algorithms with electronic decision making support.
GPs will be supported in the management of uncomplicated sleep-related breathing disorders, with facilitated and supervised access to physician and sleep laboratory support.

Where available, the involvement of a practice/community nurse may be part of a GP model of care for sleep disorders management.

In those practices where nurses are involved, adequate training programs and remuneration for primary care nurses to participate in patient management would be required.
The ASA and RACGP have previously collaborated to produce online sleep modules to educate GP’s on the commonest sleep disorders but much more work is required in this area.

Training programs are also required to upskill psychologists, nurses (both community and hospital-based), pharmacists and dentists.

Psychologists.

Psychologists also receive little education during their postgraduate psychology training in assessing, diagnosing and treating sleep disturbances.
The Australian Psychological Society (APS) and the ASA have collaborated to develop a continuing four module Certificate in Sleep Psychology.

This program is designed to train psychologists in assessing and managing sleep disorders, such as insomnia.

This represents a positive start to meeting the sleep training needs of psychologists, but is inadequate to meet the knowledge required to adequately treat behavioural sleep disorders.
Such training is limited in current University-based undergraduate and postgraduate psychology programs.

However it would be possible to extend and expand the APS/ASA program in order to allow appropriate therapy, for example cognitive behavioural therapy for insomnia (CBT-I), assistance with continuous positive airway pressure (CPAP) adherence, management of circadian rhythm disturbances and sleep hygiene improvement to be delivered by appropriately trained psychologists.
Federal government funding support for the development of such a national program would be required.

-5- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 Nurses.

Limited education is also provided to nurses during their education and training, despite nurses being on the ‘front-line’ in dealing with poor sleep in the hospital-based setting.

Nurses play an incredibly important role in monitoring and maintaining health in the general community and in rural and remote settings.
There is a need to have nurses trained in sleep health in order to promote sleep in their patients, and also deliver behavioural intervention therapies such as CBT.

Research trials have been done to show that with training, nurses can achieve equivalent outcomes to psychologists in the delivery of CBT-I for uncomplicated insomnia4.

A national training program for nurses, focused on sleep health and sleep disorders needs to be developed.
With adequate funding, expertise exists within the ASA and Nurses Federation to develop such a high-impact and cost-effective program.

Pharmacists.

Community pharmacists are highly accessible health care professionals.

While experts in the delivery of pharmacotherapies, they have little training in sleep health or sleep disorders.

Despite this lack of knowledge, many are working in specialised sleep pharmacies which provide CPAP and other appliances for treatment of OSA.
There is a critical need to upskill pharmacists and their staff in sleep health and sleep disorders.

A course called Sleep Apnoea Services for Pharmacists has recently been co-designed by the ASA and Pharmaceutical Society of Australia.

This is a series of 3 online modules, but further training is required for face-to-face sessions in CPAP delivery.
In addition, pharmacists are ideally placed to identify patients with difficult to control hypertension or mental health issues which may be related to inadequate sleep or sleep disorders.

However they require further knowledge and training in order to provide these important services.

Dentists.

The treatment of snoring and OSA has resulted in a relatively new field of Dental Sleep Medicine.
This is a medical field where a dental appliance is used to provide a medical health related outcome and is one of the few areas where a dental appliance is provided, not as a dental device, but as a technique for the management of a medical condition.

Despite many Dentists providing oral appliances for OSA, few have undergone adequate training.

Currently there exists niche industry and private courses and one postgraduate University Course.
The ASA is developing a formal protocol of certification for dentists involved in the clinical field of Dental Sleep Medicine which will allow patients, sleep physicians and other health professionals working in the field of sleep medicine to be able to identify dentists who possess adequate competencies in dental sleep medicine.

This is essential given the integral role of appropriately trained dentists in the multidisciplinary team approach required to successfully treat patients with sleep disorders.
However it is vitally important that dental sleep medicine be included in the primary dental degree.

-6- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 RECOMMENDATION #4 Development of guidelines and educational campaigns for improving safety and productivity in the workplace.

In 2000-2001, those who were injured in a workplace accident used $809.9 million of informal care or $2,748 per injured person.

In 2010 prices this would be $3,589 of informal care per person injured.
Applying this cost to the 9,584 people injured in workplace accidents due to OSA or insomnia gives a total cost in 2010 for informal care of $34.4 million.

Shift workers comprise 16% of Australian adults (1.5 million) and are particularly vulnerable to poor and inadequate sleep.

This includes truck drivers, of whom 45% have a sleep disorder causing impaired alertness.

Sleep disorders result in a 50% increased risk of occupational injury, absenteeism and error attributable to fatigue.
Around 20% of fatal road accidents involve driver fatigue and about 30% of severe single vehicle crashes in rural areas involve fatigue (VicRoads Road Accident Facts).

To assist with workplace awareness and management of inadequate and poor sleep, guidelines are required to inform improved rostering practices and work environments, with particular attention to shift work, those with long work requirements and the transport industry.
Workers also require a greater understanding of how to optimise their sleep and thus alertness during their time away from the workplace.

Development of such guidelines should be taken in parallel with educational campaigns aimed at the general workforce.

The ASA recommends the development of: • Guidelines to inform improved rostering practices and work environments.
The ASA membership has expert knowledge on these issues and could work with a broad range of agencies to develop and implement such guidelines.
• Educational campaigns aimed specifically at minimising workplace-related risk of inadequate sleep, including: o Ensuring a minimum of at least six hours of sleep before driving; o Avoiding driving at night, particularly after 1am; o Avoiding any alcohol if at risk of drowsiness; o Stopping driving if aware of signs of sleepiness such as blurred vision or heavy eyelids to have a sleep and/or caffeine; o Seeking medical advice regarding sleep disorders if aware of regular drowsiness while driving.
o Campaigns targeted at high risk groups such as young drivers, shift workers and transport industry.

-7- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 RECOMMENDATION #5 A targeted call for research.

Translational, clinical and basic science research are all needed to develop strategies to improve sleep health and the management of sleep disorders in Australia and worldwide.
While Australian sleep research has led the world in understanding and treating sleep apnoea, this now needs to be extended to other sleep disorders.

Current research investment into sleep health is wholly inadequate, with only 7 NHMRC grants, scholarships or fellowships being awarded nationally per year over the past 3 years.

The Medical Research Futures Fund (MRFF) is an ideal mechanism to fund such focussed research programmes.
Areas of immediate research need include: • Research focused on earlier and more accessible diagnosis of sleep disorders, the physiological predictors and consequences of those disorders, as well as predictors of those at risk of developing complications and development of accessible, evidence-based interventions.

• Health services research into models of care for better coordinated primary care management of clinical sleep disorders (e.g.

OSA, insomnia).
OSA, insomnia).

• Research programs aimed at better understanding sleep health issues in at risk populations including children, the elderly and indigenous populations.

• Basic research to identify the causes and consequences of sleep disorders to identify pathways for much needed new targeted and personalised therapies to more effectively and cost-effectively treat sleep disorders than is possible in current usual care.
• Significant gaps remain in the basic understanding of sensory processing during sleep, brain and cardiovascular system activation responses, and the impacts of sleep disturbances on daytime performance, safety, health and well-being.

New discoveries in these areas will remain critical for efficiently guiding scientific and technological advances directly translatable improved sleep and health outcomes in Australia and internationally.
into • Cross-disciplinary research to understand bidirectional links between inadequate sleep and sleep disorders and other medical conditions in which sleep problems are a feature including mental health disorders, pain and neurodegenerative disorders.
• Research that encourages the use of existing datasets to gain insights into sleep health as a cost-effective way of gaining new insights for population sleep health as such research maximises existing federal investments that have enabled the collection of research cohort data.

• Research and field trials are required to understand how to effectively implement alertness monitoring and detection technology in order to reduce crashes through driver feedback.
These data should be used to identify high risk situations and adjust schedules and implement interventions when drowsiness is detected.

-8- Inquiry into Sleep Health Awareness in AustraliaSubmission 118 • Sleep-specific research fellowships for early and mid-career scientists and clinicians to create career pathways during these vulnerable career stages to expand the sleep research workforce in Australia.
• Enhancement of targeted government and industry partnerships to develop, validate and translate novel discoveries into new diagnostic and treatment devices and sleep health management systems into community and clinical settings, particularly in rural and remote areas.

On behalf of all members of the Australasian Sleep Association Yours sincerely, Peter Eastwood President 1.

Adams RJ, Appleton SL, Taylor AW, Gill TK, Lang C, McEvoy RD, Antic NA.
Sleep health of Australian adults in 2016: results of the 2016 Sleep Health Foundation national survey.

Sleep Health.

2017 Feb;3(1):35-42.

2.

Deloitte Access Economics.

Asleep on the Job.

Costs of Inadequate Sleep in Australia.

Canberra: Deloitte Access Economics, 2017.

3.

Miller CB, Valenti L, Harrison CM, Bartlett DJ, Glozier N, Cross NE, Grunstein RR, Britt HC, Marshall NS.

Time Trends in the Family Physician Management of Insomnia: The Australian Experience (2000-2015).

J Clin Sleep Med.
J Clin Sleep Med.

2017 Jun 15;13(6):785-790.

4.

Espie CA, MacMahon KM, Kelly HL, Broomfield NM, Douglas NJ, Engleman HM, McKinstry B, Morin CM, Walker A, Wilson P. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice.

Sleep.

2007 May;30(5):574-84.

-9- Inquiry into Sleep Health Awareness in AustraliaSubmission 118