Sleep - the Great Regulator

4 Questions* every clinician should ask - Every Patient - Every Visit:

  1.   What time do you think you fall asleep?
  2.   How long do you think it takes you to fall asleep?
  3.   What time do you wake up?   
  4.   When you wake up, do you feel rested?

It takes less than 1 Minute to ask/answer these questions.
NOTE:  These 4 Quick Questions are useful for Behavioral Health as well as for visits with physicians, nurse-practitioners, midwives, physician assistants - all healthcare clinicians.

CLINICIANS
1) Calculate Sleep Duration:  from Question#1 (time fall asleep) & Question#3 (time wake up), we can calculate rough sleep duration in hours.
2) Note Delay in Falling Asleep (Question #2):  We can ask ourselves (or our patients), what things are keeping you awake?   The answers often tell us about trauma and past or current adversity.
3) The simple question of whether we feel rested after sleep is key to assessing the health-promoting or disease-associated outcome of a person's sleep. 

IN THE PATIENT RECORD include:
- Sleep Duration (hours)
- Factors for Sleep Delay - in neutral terms 
(Ok to record:  "trouble sleeping due to memories from childhood"; too invasive: "memories of sexual assault").  
- If patient has difficulty falling asleep, record what they did to improve sleep:  OTC meds (Benadryl, Melatonin, etc), alcohol, prescription meds, avoiding coffee, etc.
- Rested - Yes/No.

*  4 Quick Questions about Sleep are adapted from several sleep assessment instruments, including the Pittsburgh Sleep Quality Index - the Gold Standard of Sleep Research.

Sleep Deprivation can have a devastating impact on physical and emotional health

Hundreds of peer-reviewed research studies have shown the profound impact of "short sleep" (chronically less than 6 hours of sleep per night) in the occurrence of many diseases including 
   o  Cardiovascular Disease
   o  Cancer
   o  Autoimmune Disease
   o  Mental Illness
   o  Infertility
   o  More ....... 

RESOURCES

Blackwelder (2021)  Effect of Inadequate Sleep on Frequent Mental Disress  Prev Chronic Dis.  Survey of 270,695 US Adults showed (1) that 13% of participants reported sleeping 6 hour or less per night.  (2) Persons sleeping 6 hour or less were 2.5 times more likely to have frequent mental distress.

Hanlon EC, Van Cauter E.  Quantification of sleep behavior and of its impact on the cross-talk between the brain and peripheral metabolism.  Proc Natl Acad Sci.  2011.   CLASSIC research about how Sleep restriction impairs glucose metabolism and alters the cross-talk between the periphery and the brain, favoring excessive food intake. 

Research has consistently demonstrated that the severity of Traumatic Experience from Discrimination is correlated with Sleep Quality and Duration.  Reasearch also shows that this relationship is DOSE-RESPONSIVE:  the worse a person's experience of discrimination, the shorter the sleep.

The relationship between Discrimination and Sleep Deprivation has been demonstrated for:
        o  LGBTQ+ persons
        o  People of Color - Black, Hispanic
        o  Indigenous People
        o  Immigrants

LINK >> National Sleep Foundation statement on Sleep Health Equity

Resources

Jackson (2017) Determinants of racial/ethnic disparities in disordered sleep and obestiy.  Sleep Health  People of color have historically lived and continue to largely live in disadvantaged, obesogenic physical and social environments, these greater adverse exposures likely negatively affect sleep, resulting in physiological dysregulation. Physiological dysregulation may, in turn, lead to increased obesity risk and subsequent health consequences, which are likely more influential than potential genetic differences in race, a social construct. 

Smith (2019) Racial disparities and sleep among preschool aged children   Sleep Health  Consistent evidence that white, non-Hispanic children were more likely to go to bed earlier and more regularly, have longer nocturnal sleep, and nap less than most racial and ethnic minorities.

Laposky (2016) Reducing health disparities:  the role of sleep deficiency and sleep disorders. Sleep Med.  Insufficient sleep, irregular timing of sleep, poor sleep quality, and circadian disorders 

Chen (2015) Racial/Ethnic Differences in Sleep Disturbances.  Sleep.  High prevalence of sleep disturbances and undiagnosed sleep apea among racial/ethnic miorities may contribute to health disparities.

GUIDELINES from the American Academy of Sleep Medicine:  Sleep for Pediatric Populations.   Children sleeping the recommended hours on a regular basis is associated with better attention, behavior, learning, emotional regulation, and mental ad physical health.  Recommendations of sleep duration range from 12-16 hours for newborns to 8-10 hours for teenagers.

Larson (2021) Parents' Experience of Weighted Blankets' Impact on Children with ADHD and Sleep Problems.  Parents report that children sleeping with weighted blakets (1) achieved satisfactory sleep including improved sleep onset latency, continuity and sleep routines (2) improved relaxation and decreased anxiety (3) improved balance in life, family function and participation in school and leisure.

Frank (2020) The Ontogenesis of Mammalian Sleep Curr Sleep Med Rep. Sleep undergoes dramatic changes during perinatal development - including decreased REM sleep, increase in nonREM sleep and awake time, and appearance of homeostatic and circadian processes from rapid brain development.  Sleep is key to development of functional brain networks and the opening/closing of critical periods of brain plasticity.

Liu (2020) Sleep Training.  Pediatr Ann.  Guidelines for clinicians with basic pediatric sleep physiology, patterns and child development.

Bathory (2017) Sleep Regulation, Physiology and Development.  Curr Prob Pediatr Adolesc Health Care.  Recommendations for pediatric cliicians to assess and counsel families about sleep problems for infants, toddlers, and preschool-age children.

Chaput (2017) Systematic Review of the relationships between sleep duration and health indicators in the early years (0-4).  BMC Public Health.  Short sleep duration is associated with childhood obesity, poorer emotional regulation, impaired growth, and higher risk of injury. 

Sleep and immunity are bi-directionally linked.  Sleep affects various immune parameters including a reduced risk of infection, outcome of infection, and response to vaccination.  Sleep also promotes balance (homeostasis) within the immune system.  Short sleep (consistent sleep of 6 hours or less) is associated with chronic inflammation and the onset of related chronic disease.

RESOURCES

Besedovsky (2019) The Sleep-Immune Crosstalk in Health and Disease.  Physiol Rev.  Comprehensive review of sleep mechanisms, signaling inter-action (crosstalk) between the brain and the immune system, and how prolonged sleep deficiency provokes an inflammatory response associated with diseases such as diabetes and atherosclerosis.

Irwin (2019) Sleep and Inflammation:  partners in sickness and in health.  Nat Rev Immunol.  Sleep enhances immune defenses and signals from immune cells promote sleep.  Chronic social threats drive development of sleep disturbances contributing to immune dysregulation and inflammation.  Discusses potential of improving sleep to mitigate risk of inflammatory and infectious disease.

Park H, Tsai KM, Dahl RE, et al. Sleep and Inflammation During Adolescence. Psychosom Med.  2016

Irwin (2015) Why sleep is important for health:  a psychoneuroimmunology perspective.  Annu Rev Psychol.  Describes the impact of sleep on adaptive and innate immunity and the dynamics of sleep disturbance.  Also provides review of the neuroendocrine and autonomic neural underpinngs linking sleep disturbance and chronic illness including neuropsychiatric diseases.

MEASURING SLEEP CHARACTERISTICS THROUGH WEARABLE TECHNOLOGY

In the past decade, several devices have been developed which measure SLEEP and ACTIVITY. 
These devices are available for the public to purchase - and recently, because of the accuracy of results and ease of use at home, are also used in sleep research.

SYSTEM SCIENCE PERSPECTIVE on SLEEP

ALL complex organisms  (insects to animals to humans) SLEEP.
Why is a process like SLEEP needed for organisms to survive and thrive?

All organisms rely on SLEEP for REGULATION and SYNCHRONIZATION across the system:  from microscopic intracellular processes to whole body processes.

During SLEEP, the Brain is more active than when we are awake.
When we fall asleep, the Brain begins an elaborate set of Brain Wave CYCLES - which scientists call Sleep Cycles of REM (Rapid Eye Movement) and Non-REM (light and deep sleep).

FRACTAL Organization:  all of nature is organized in Fractals. 
A 'Fractal" is a self-similar branching structure - where the particular pattern repeats itself at increasingly bigger (or smaller) levels of organization.
Fractal organization occurs because of repeating (iterative) processes.