# Presentation: 927069

## Sleep Interventions for Corporate Occupational Health

**Sleep Interventions for Corporate Occupational Health**
**Dr. Larry Clevenger, Director**
**Sandia National Laboratories**
**Health, Benefits and Employee Services**

## Outline

**Sleepy Nation**
**Types and prevalence of sleep disturbances**
**Problems related to sleep disorders**
**Sandia’s Sleep Solutions Program**
**How to manage the risk**

## A Nation of Sleepy People

**A Nation of Sleepy People**

**One in five adults report getting insufficient sleep**
**Problems falling asleep or daytime sleepiness affect 35 to 40 percent of**
**the population**
** **

**More than 50 million Americans suffer from a chronic sleep disorder **

**Notes:**
$150 Billion in list productivity and mishaps  $48 Billion in medical for just drowsy drivers
Indirect Economic Costs of Sleep Disorders Far Exceed the Direct Health CostsThe major financial impact of sleep disorders results from the role they play in motor vehicle accidents, work-related injuries and loss of productivity. Associated Professional Sleep Societies Sleep | 03/01/2006Press Release Results of a study show that the direct health costs of sleep disorders account for only 2 percent of the total cost of these disorders, while the major financial impact results from the role sleep disorders play in motor vehicle accidents, work-related injuries and loss of productivity. The study results appear in the March 1 issue of the journal Sleep. 
The study analyzed the direct and indirect health costs in 2004 for sleep disorders such as insomnia, obstructive sleep apnea and periodic limb movement disorder. The direct health costs include the medical costs attributable to sleep disorders in the development of other conditions such as cardiovascular disease and depression. 
The study shows that the major financial costs of sleep disorders are related to how these disorders affect cognitive and psychomotor function, resulting in accidents and injuries, work absenteeism, and even premature death. 
According to the authors, their results suggest that “too little is being spent on prevention and treatment to reduce the huge tail of indirect cost impacts ... Sleep is underrepresented on national health agendas despite the availability of a range of proven, cost-effective interventions available for management of sleep disorders.” Sleep is the official journal of the Associated Professional Sleep Societies, LLC, a joint venture of the American Academy of Sleep Medicine and the Sleep Research Society. Go online to www.journalsleep.org for more information. 

## Sleep Deprivation
Insomnia
Sleep Apnea
Restless Leg Syndrome (RLS)

**Sleep Deprivation**
**Insomnia**
**Sleep Apnea**
**Restless Leg Syndrome (RLS)**

**Common Sleep Disorders**

**Notes:**
Prevalence and risk factors
Sleep Deprivation
Shift work
American Life Style
50-70 million Americans with Chronic Sleep Disturbances
Insomnia 30% of population experience about 10-15% chronic
Medical illness. 
Psychiatric illness. 
Medication and drugs. 
Other sleep disorders. Sleep apnea, nocturnal myoclonus, periodic leg movements in sleep, phase advance sleep disorder, phase delay sleep disorder, sleep state misperception and nightmares. 
Poor sleep habits. 
Situational factors.
Other common characteristics... 
Chronic sinus congestion
Deviated septum
Long face – high hard palate
If you have insomnia, then you are not alone. It is a common sleep disorder. About 30% of adults have symptoms of insomnia. Less than 10% of adults are likely to have chronic insomnia. It is more common among elderly people and women. Some medical conditions cause insomnia, or it may be a side effect of a medication. 
Obstructive Sleep Apnea  8% of population
Family history (2-4 times increased risk) 
Overweight and obesity, especially central obesity 
Large neck circumference (>17 inches in men, >16 inches in women) best predictor
Male sex 
Advancing age 
African American, Pacific Islander, or Mexican 
Smoking and alcohol use 
Craniofacial abnormalities -Deviated septum - Crowded oropharynx
Hypothyroidism 
Acromegaly 
Adenotonsillar hypertrophy (in children) 
OSA can occur in men and women of any age, but it is most common in obese, middle-aged men. There is a strong relationship between weight and OSA. Your neck gets thicker as you gain weight. This increases the level of fat in the back of the throat, narrowing the airway. With more fat in the throat, your airway is more likely to be blocked.  People with OSA are often obese and have a neck size of more than 17 inches. Many people with OSA also have high blood pressure. Children with large tonsils may also have OSA. 
Restless Leg Syndrome (RLS) 5% of population
Family history
Although symptoms can start at any age, older people may be more likely to have severe symptoms. 
RLS is more common during pregnancy. 
It may also appear in people who have another medical problem, such as anemia or kidney problems. (important to check for low Ferrtin levels)

## Sleep disturbance is a complex process which often involves both psychological and physical components

Additionally, the tendency for sleep deprivation and disturbances is often a result of our culture and environment  

**Sleep disturbance is a complex process which often involves both psychological and physical components**
**Additionally, the tendency for sleep deprivation and disturbances is often a result of our culture and environment**

**Nature of Sleep Disturbance**

**Notes:**
Neglecting one of these essential components may lead to outright treatment failure or to less than optimal treatment outcomes.

## Physical Components

**Oxygen Levels**
**Nasal Airflow**
**Allergies**
**Co-morbidities**
**Neurological conditions**

**Notes:**
Some Examples of the Physical Components...
When breathing is disrupted for whatever reason it can effects our O2 levels.  Appropriate O2 levels are needed for good quality sleep.

If you are unable to breath well through your nose it is highly likely that you have a physical reason for not sleeping well.  

Allergies, in addition, can create breathing problems.

Neurologic – Alzheimer's, Parkinson’s disease
Chronic Pain – osteoarthritis, rheumatoid, fibromyalgia
Cardiovascular – CHF, dyspnea, nocturnal angina
Endocrine/ metabolic – Menopause, Thyroid disease
Genitourinary – BPH, incontinence
Gastrointestinal – GERD
Pulmonary – COPD, Asthma, Sleep Apnea, obesity-hypoventilation syndrome
Psychiatric – bipolar, anxiety disorders, posttraumatic stress disorder etc...

Finally body movements during sleep can be a problem for some.  RLS and PLMD

## Learned Behaviors
Beliefs and Attitudes
Emotional Distress
General Stress
Personality Styles
Psychological Disorders

**Learned Behaviors**
**Beliefs and Attitudes**
**Emotional Distress**
**General Stress**
**Personality Styles**
**Psychological Disorders**

**Psychological Components**

**Notes:**
Some Examples of the Psychological Components... 
Things that get in the way of a good nights sleep. 

Learned behavior – for example you get into the habit of using time in bed to worry

Beliefs and attitudes – for example, the believe that if I can’t sleep, I need to spend more time in bed trying to sleep

Emotional distress/ General Stress/ - how well you cope with stressors may effect your sleep

Personality styles/ psychological disorders – if you are predisposed to depression and/ or anxiety this may further aggravate your insomnia  

## Environmental/Cultural Factors

**Sleeping is a waste of time**
**Too much to do and not enough time **
**Sleep is overrated**
**I’ll get plenty of sleep when I’m dead**
**I get more work done because I have more awake time**

**Notes:**
you know you’re an insomniac when...
Add some jokes here about late night web surfing and informercials 

“Thomas Edison invented the light bulb because he thought sleep was a waste of time. But he was a 10-hour sleeper -- six hours a night and two, two-hour naps during the day.” Mark R. Rosekind, PhD
“Not getting enough sleep impairs our work performance, increases the risk for injuries and makes it more difficult to get along with others. Without sufficient sleep it is more difficult to concentrate, make careful decisions and follow instructions, we are more likely to make mistakes or errors, and are more prone to being impatient and lethargic. Our attention, memory and reaction time are all affected. But while we may recognize these symptoms, we do not always associate them as being symptoms of sleep loss.” 
Mark R. Rosekind, PhD
Dr. Rosekind is President and Chief Scientist of Alertness Solutions, a California-based company that provides consulting, education, and training services to companies, government agencies and organizations concerned with fatigue management. 
Formerly, Dr. Rosekind directed the Fatigue Countermeasures Program at NASA's Ames Research Center, where he developed important operational guidelines, safety procedures and investigation methods that established a new standard and remain in use. 
Prior to his NASA work, Dr. Rosekind directed the Center for Human Sleep Research at the Stanford University Sleep Disorders Clinic.

## How much sleep do we need?

**How much sleep do we need?**

| Age | Hours of sleep needed |
| --- | --- |
| 0-3 months | 15-17 |
| 3-18 months | 13-15 |
| 4-12 years | 10 |
| Teens | 8 1⁄2- 9 1⁄2 |
| Adults | 7-9 |

**Notes:**
National Sleep Foundation 

Although each person has an individual sleep need, most adults require an average of seven to eight hours of sleep each night to feel alert and well rested. Studies show that at least one in five adults reports getting an insufficient amount of sleep. 

## Impairment of alcohol vs. sleep loss

**Impairment of alcohol vs. sleep loss**

| 
Sleep loss | Alcohol Equivalent | 
Alcohol dose |
| --- | --- | --- |
| 8 hours | 10-11 beers | 0.190 |
| 6 hours | 7-8 beers | 0.102 |
| 4 hours | 5-6 beers | 0.095 |
| 2 hours | 2-3 beers | 0.045 |

**In New Mexico it is illegal to drive with the breath alcohol concentration of .08**

**Notes:**
Would we send drunk people to work??

Roehrs T et al.  Sleep. 2003

## Accidents\near misses
Depression
High blood pressure
Cardiovascular risk
Diabetes
Weight management
Quality of life
Lost Productivity

**Accidents\near misses**
**Depression**
**High blood pressure**
**Cardiovascular risk**
**Diabetes**
**Weight management**
**Quality of life**
**Lost Productivity**

**Consequences of Sleep Deprivation**

**Notes:**
Related problems... $150 Billion in list productivity and mishaps
Sleep deprivation is a common result of occupational demands such as rotating-shift work schedules and lifestyle choices that prevent an individual from getting sufficient sleep. While daytime sleepiness is the most common effect of sleep deprivation, data report that sleep loss can have severe effects on performance, including poor memory and concentration, impaired cognitive performance, increased errors and slower reaction times. 
The consequences of sleep deprivation are a real risk for the more than 20 million Americans who have rotating-shift work schedules such air traffic controllers. Sleep deprivation significantly increases the risk of motor vehicle accidents as well as work-related injuries and accidents. One reason these accidents occur more frequently is that sleep-deprived people often underestimate their levels of sleepiness and functional impairment. 
"Studies have shown that chronically sleep deprived people believe that they have adapted to their lack of sleep while actually their test performances continue to deteriorate," said Michael H. Silber, MBChB, president of the American Academy of Sleep Medicine. 
Depression – so closely linked with insomnia difficult to tell chick vs egg.  Clinical depression often proceeded by several months of insomnia.
HTN – strong correlation with sleep disordered breathing
CVD – snoring alone, without any diagnosis, increases risk of stoke
Diabetes – high fasting blood sugar levels seen with poor sleep
Wt management – less sleep results in higher levels of appetite hormones
Sleep deprivation often results in a decreased energy to do what you love –

## Accidents related to sleep deprivation

**Accidents related to sleep deprivation**

**Chernobyl **
**Three-mile island**

**Comair Flight 5191**
**Exxon Valdez**

**Notes:**
Chernobyl Nuclear Disaster - April 25, 1986
Another meltdown disaster, this time in the Ukraine and again linked to sleepiness. A shutdown and test of reactor #4 was to take place at 1 A.M. Things went awry when several safety features were turned off, and the rest, as they say, is history. According to Jennifer Rosenberg, Your Guide to 20th Century History, "Itis estimated that the radiation from the Chernobyl disaster was 100 times more powerful than the bombs dropped on Hiroshima and Nagasaki. Thirty-one people died shortly after the explosion, but thousands more will die from the long-term effects of radiation." 
Three Mile Island - March 28, 1979
The nuclear accident at Three Mile Island occurred between midnight and three A.M. when night workers tend to be the drowsiest and was caused by a serious lack of judgment. A cooling malfunction caused a meltdown that destroyed the #2 reactor. Although some radioactive gas was released, luckily, no injuries or health problems ensued. 
Exxon Valdez Oil Spill
When the Exxon Valdez went aground off Alaska, first reports said the accident was caused by a drunken captain. Later investigation, however, suggested that the captain had turned over command to his first mate who was extremely sleep deprived. He had slept only six hours in the previous 48. The cleanup of the spill cost more than two billion dollars and the damage to the environment was tremendous. 

Comair/Delta Air Regional Flight 5191 Airplane Accident in Lexington, Kentucky, August 2006
The crash of Comair Flight 5191 highlights the potentially devastating consequences of sleep deprivation. American Academy of Sleep Medicine AASM | 09/01/2006The National Transportation Safety Board's announcement that the sole air traffic controller on duty the morning of the crash of Comair Flight 5191 was functioning on only two hours of sleep highlights the potentially devastating consequences of sleep deprivation, the American Academy of Sleep Medicine said today. 
"Education of workers, employers and regulatory agencies regarding sleep needs and the effects of loss of sleep is essential to maintain public safety," said Michael H. Silber, MBChB, president of the American Academy of Sleep Medicine. 
Sleep deprivation is a common result of occupational demands such as rotating-shift work schedules and lifestyle choices that prevent an individual from getting sufficient sleep. While daytime sleepiness is the most common effect of sleep deprivation, data report that sleep loss can have severe effects on performance, including poor memory and concentration, impaired cognitive performance, increased errors and slower reaction times. 

Other plane crashes
On October 23,2001, the National Transportation Safety Board concluded that mistakes by a fatigued cockpit crew caused the 1999 crash of an American Airlines jetliner in Little Rock Ark, killing 11 and injuring 105 passengers. Studies by NASA and the Battelle Memorial Institute have concurred with pilot unions that a pilot should not be on duty more than 12 hours. Incidentally, by the time the ill-fated plane neared Little Rock, the crew had been on duty for about 13 1/2 hours. Malnic, Eric. "Crew Fatigue Cited in Fatal 1999 Crash of Jetliner in Ark." Los Angeles Times. Oct.24, 2001, A28.

## Accidents related to sleep deprivation

**Accidents related to sleep deprivation**

**Driver sleepiness is related to one in five serious car crash injuries**

**Notes:**
How about the everyday accidents...
Driver sleepiness is related to one in five serious car crash injuries.
$ 48 Billion spent on drowsy drivers

Other examples...
Nearly fatal incident of electrician working long hours – review resulted in limit on amount of hours on shift and between shifts as well as several other safe guards to the procedures to limit chance fatigue related of errors  

$150 Billion in list productivity and mishaps

Work related auto accidents – drug testing indicated.  Screen for sleep deprivation or sleep disorder indicated?

## Sleep Solutions Program 

**Sleep Solutions Program **

**Annual guest speaker**
**Directorate buy-in/promos**
**Four-week insomnia class **
**Individual consultations and sleep assessments**
**Organizational presentations on sleep disturbances**
**Limited case management **

**Notes:**
The Preventive Health Sleep Solutions Program strives to help employees improve sleep disturbances.  The program includes the following components:    

Annual guest speakers from the community. Sleep medicine doctors in the community offer 1 hour presentation during lunch hour – usual attendance 50-200 past topics include: Travel and sleep, Sleep Apnea, Impact of Poor Sleep on Learning, Mood, and Conduct in Kids.  This not only is a great way to increase awareness it also gives us an opportunity to develop relationships with our community providers.

Four-week educational class on insomnia.  We offer one or two times a year on average about 50-75 attend each year.  Contractors may attend. 

Individual consultations – “sleep assessments”.   We offer one on one appointments to employees -with about 100-150 individuals being assessed annually.   
Organizational presentations on request – organization are often able to count presentation toward there required safety meetings

Referral for the class and one-on-one appointments come from other health care providers working in the clinic, former clients and also, many are self-referred from our Preventive Health newsletter. 

Limited case management.  Health educator assists clients as needed in accessing various community resources and benefits. 

## Provides information on:

Common sleep disturbances 
Sleep hygiene
Stimulus control therapy
Relaxation techniques
Cognitive behavior therapy
Medications, diagnosis and treatment for sleep disturbances

**Provides information on:**
**Common sleep disturbances **
**Sleep hygiene**
**Stimulus control therapy**
**Relaxation techniques**
**Cognitive behavior therapy**
**Medications, diagnosis and treatment for sleep disturbances**

**Insomnia Class**

**Notes:**
The sleep solutions insomnia class has three major objectives.  
Participants will learn... 
some of the potential causes of their sleep problems
some techniques to improve their sleep quality
of other resources that are available to help treat their sleep problems

The class includes information on sleep hygiene, stimulus control therapy, relaxation techniques, sleep disordered breathing, medications, diagnosis and treatment of sleep disturbances and cognitive behavior therapy.  

A health educator teaches the majority of the information and a physician attends on session to discuss medications with participants.  
Class is follow up with a one on one meeting to see how much success employee is having with techniques and assistant is provided in accessing other providers and resources.  PCP, Sleep medicine specialists, ENT, allergists, physiologists etc. 

## Most helpful behavior changes

**Survey says:**
**Not watching the clock**
**Get up at the same time everyday**
**Don’t lose sleep over losing sleep**

## Improvement from 4.9 to 3.8

p < .001

N = 50

**p < .001**
**N = 50**

**Quality of sleep**

**Ranked 1- 8**
**Extremely Good**
**Very Good **
**Good  **
**Adequate  **
**Fair  **
**Poor **
**Very Poor **
**Extremely Poor **

**Notes:**
FY04 data 130 surveys sent  34% returned

## Insomnia Sleep Index

**Bastien CH, Vallieres A, Morin CM.**Validation of the Insomnia Severity Index as an outcome measure for insomnia research. **Sleep Med. 2001; 2:297-307. **

**Describes proclivity toward insomnia**
**Improvement from 12.95 to 8.75**
**N = 44**
** ****where < 10 is non-clinical insomnia**
**p < .001**

**Notes:**

There are a number of insomnia questionnaires, one of the more popular of which is the Insomnia Severity Index. It is reliable and valid and has 7 items that use a 5-point Likert-style scale. Scores can range from 0 to 28, with a cutoff score of 10 suggesting the presence of clinical insomnia. The questionnaire has 3 questions assessing the severity of insomnia and 1 question each assessing satisfaction with current sleep pattern, sleep interference, "noticeability" of sleeping problem to others, and concern about sleeping problems.

Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297-307. 

## Epworth

**self-administered questionnaire provides a measurement of the subject's general level of daytime sleepiness**
**Improvement from 11.4 to 9.2**
**N=44**
**Where > 10 is excessive daytime sleepiness**
**p < .001**

**Johns, Murray W. (1991)**"A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale"** *****Sleep***** *****1991***** (14): 540-5. **

**Notes:**
The Epworth Sleepiness Scale developed by researchers in Australia and is widely used by sleep professionals around the world to measure sleep deprivation. 

A new method for measuring daytime sleepiness: the Epworth sleepiness scale.Johns MW.Sleep Disorders Unit, Epworth Hospital, Melbourne, Victoria, Australia.The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.PMID: 1798888 [PubMed - indexed for MEDLINE] 

Johns, Murray W. (1991). "A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale". Sleep 1991 (14): 540-5. 

## What should we do?

**What should we do?**

**Regular screening **
**Encourage work/rest guidelines**
**Teach management about the danger signs**
**Recognize sleep disturbances as a treatable disorder**
**Make it easy to access resources**
**Socialize impact with other health and safety professionals**
**Screen in the case of select near miss and occupational events**