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Almost 20 percent of all serious car crash injuries in the general population are associated with driver sleepiness, independent of alcohol effects. Further, sleep loss and sleep disorders have a significant economic impact.
The high estimated costs to society of leaving the most prevalent sleep disorders untreated are far more than the costs that would be incurred by delivering adequate treatment.
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Hundreds of billions of dollars a year are spent on direct medical costs associated with doctor visits, hospital services, prescriptions, and over-the-counter drugs. Compared to healthy individuals, individuals suffering from sleep loss, sleep disorders, or both are less productive, have an increased health care utilization, and an increased likelihood of accidents.
The public health consequences of sleep loss, night work, and sleep disorders are far from benign. Each of these incidents not only cost millions of dollars to clean up, but also had a significant impact on the environment and the health of local communities.
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Less visible consequences of sleep conditions take a toll on nearly every key indicator of public health: mortality, morbidity, performance, accidents and injuries, functioning and quality of life, family well-being, and health care additional contribution from sleep income. Drawing on the available body of evidence, the chapter then describes the economic impact of sleep loss and sleep disorders.
The deficits include attention, vigilance, and other measures of cognition, including memory and complex decision making.
This section addresses sleep loss and then turns to sleep-disordered breathing and other sleep disorders. Sleep Loss Affects Cognitive Performance Sleep loss had been largely dismissed as the cause of poor cognitive performance by early, yet poorly designed, research.
The prevailing view until the s was that people adapted to chronic sleep loss without adverse cognitive effects Dinges et al. More recent research has revealed sleep loss-induced neurobehavioral effects, which often go unrecognized by the affected individuals.
The neurobehavioral impact extends from simple measures of cognition i. Involuntary microsleeps occur. Attention to intensive performance is unstable, with increased errors of omission and commission. Cognitive slowing occurs in subject-paced tasks, while time pressure increases cognitive errors. Response time slows. Performance declines in short-term recall of working memory.
Performance requiring divergent thinking deteriorates. Learning acquisition of cognitive tasks is reduced. An increase in response suppression errors in tasks requiring normal primarily prefrontal cortex function.
Bagley The publisher's final edited version of this article is available at Sleep Med See other articles in PMC that cite the published article. Abstract Objectives Children in families of low socioeconomic status SES have been found to have poor sleep, yet the reasons for this finding are unclear. Presleep worries and home environment conditions were assessed with questionnaires.
The likelihood of response preservation on ineffective additional contribution from sleep income is increased. Compensatory efforts to remain behaviorally effective are increased.
Although tasks may be done well, performance deteriorates as tasks duration increases Durmer and Dinges, Attention and reaction time are altered by experimental sleep loss, which leads to cumulative, dose-dependent deterioration of attention and reaction time Figure Deterioration is measured in part using the psy chomotor vigilance task PVTa test that requires continuous attention to detect randomly occurring stimuli and that is impervious to aptitude and learning effects.
In one study 48 healthy subjects were randomized to 4, 6, or 8 hours time in bed for 14 days Van Dongen et al. Investigators found a dose-dependent effect, which increased over time Figure A.
Performance deficits in individuals who slept 6 hours or less per night were similar to those observed in individuals after two nights of total sleep deprivation. Most striking was that study subjects remained largely unaware of their performance deficits, as measured by subjective sleepiness ratings.
A second study Belenky et al. Subjects were followed for 3 days after the period of sleep restriction, during which time they recovered, but not enough to return to their baseline levels. Imaging studies have demonstrated a physiological basis for cognitive impairments with sleep loss that has been linked with metabolic declines additional contribution from sleep income the frontal lobe of the brain Thomas et al. Although there is not a large body of evidence, associations are also likely between sleep loss and increased risk taking Roehrs et al.
Repeated nights of sleep loss have cumulative cognitive impairment. NOTE: B, baseline day. Sleep Loss in Adolescents and Academic Performance Sleep loss in adolescence is common and grows progressively worse over the course of adolescence, according to studies from numerous countries Wolfson and Carskadon, ; Howell et al. Average sleep duration diminishes by 40 to 50 minutes from ages 13 to Despite secondary options market physiological need for about 9 hours of sleep, sleep duration, across this age span, averages around 7 hours and about a quarter of high school and college students are sleep deprived Wolfson and Carskadon, Research indicates that patterns of shortened sleep occur in the preadolescent period and may be most marked in African American boys, compared to white children or African American girls Spilsbury et al.
The decline in adolescent sleep duration is attributed to psychological and social changes, including growing desire for autonomy, increased academic demands, and growing social and recreational opportunities, all of which take place in spite of no change in rise time for school Figure Wolfson and Carskadon, Furthermore, the need to earn income adds to the burden.
Students who worked 20 or more hours weekly, compared with those who worked less than 20 hours, were found to go to bed later, sleep fewer hours, oversleep, and fall asleep more in class Millman et al. Sleep loss affects alertness, attention, and other cognitive functions in adolescents Randazzo et al. Most studies attempting to link the two are cross-sectional in design, based on self-reporting of grades and sleep times, and lack a control for potential confounders Wolfson and Carskadon, An association between short sleep duration and lower academic performance has been demonstrated Wolfson and Carskadon, ; Drake et al.
A 3-year study of 2, middle school students did not find that sleep loss resulted in lower academic performance. It only found a cross-sectional association at the beginning of the study. However, by the end of the study, as sleep time worsened, grades did not proportionately decrease Fredriksen et al. A study of the Minneapolis School District, which delayed start times for its additional contribution from sleep income schools additional contribution from sleep income almost 1.
Further, there was a trend toward better grades, but not of statistical significance. The study compared grades over the 3 years prior to the change with grades 3 years afterwards. Much of the difficulty in studying sleep loss and its relation to academic performance stems from multiple, often unmeasured, environmental factors that affect sleep such as school demands, student employment after school, family influences, TV viewing, and Internet access.
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These are set against the rapid developmental and physiological changes occurring in adolescence. Another difficulty is the challenge of objectively assessing school performance Wolfson and Finance option, Additional robust intervention studies are needed to determine the effect of having later school start times on student performance.
However, a confounder to later school start times is the potential onset of sleep phase delay during middle school seventh and eighth grade.
Moving middle school start time early to compensate for later high school start time may be problematic for the middle school children. There have been no studies that have examined effects of early start time on elementary-aged children Wolfson and Carskadon, An alternative to changing the school starting times might be to implement bright light therapy in early morning classes for high school students as a means to change the circadian timing system of these students and thereby enable earlier sleep schedules Wolfson and Carskadon, Long work hours and extended shifts among hospital workers are now known to contribute to the problem.
Medical residents work longer hours than virtually all other occupational groups Steinbrook, During the first year, medical residents frequently work a hour shift every third night i. Two studies found that sleep-deprived surgical residents commit up to twice the number of errors in a simulated laparoscopic surgery Grantcharov et al.
In a survey of 5, medical residents, conducted by the Accreditation Council for Graduate Medical Education, total work time was inversely correlated with reported sleep time. Residents who worked more than 80 hours per week were 50 percent more likely than those working less than 80 hours to report making a significant medical error that led to an adverse patient outcome Baldwin and Daugherty, Earlier attempts to demonstrate patient safety benefits by reducing resident hours were beset by methodological problems Fletcher et al.
Residents are not the only health professionals to report medical errors in association with short sleep. Nurses who completed logbooks recording their schedule length, sleep, and errors, reported 3. Additional contribution from sleep income 40 percent of the nurses reported having hour shifts; and although their sleep duration was not directly studied, the findings suggest that fatigue is a major factor.
Obstructive Sleep Apnea Is Associated with Development, Cognition, and Behavior in Children Children with obstructive sleep apnea OSA often have problems in development, cognition, behavior, and academic performance, according to detailed reviews of the evidence Schechter, ; Bass et al. The risk of neurobehavioral abnormalities in children with severe OSA is about three times greater than in children without OSA Schechter, The contribution of overnight reduction of oxygen levels in the blood hypoxemia in comparison to sleep disruption is unclear.
One study shows an association with the lowest level of oxygen during sleep and scores in arithmetic Urschitz et al. Outcome measures video lessons online earnings in numerous studies include intelligence quotient, learning and vocabulary, attention, symptoms of attention deficit hyperactivity disorder ADHDand academic performance.
For example, two historical cohort studies found decrements in intelligence quotient, impaired learning, and vocabulary in children with polysomnography-confirmed cases Rhodes et al.
A study of younger children with sleep apnea also did not find a relationship with academic performance, after adjusting for the effects of socioeconomic status Chervin et al. The neurobehavioral effects of OSA may be partially reversible with tonsillectomy and adenoidectomy, a surgical procedure that opens the airway. Treatment is related to partial improvement in school performance, cognition, or behavior Ali et al.
A limitation to this work is that it is often difficult to control for the many confounders that influence cognitive function, with a recent study showing that after robustly adjusting for neighborhood socioeconomic status Emancipator et al.
No randomized controlled study has been conducted to address the potential reversibility of cognitive deficits with sleep-disordered breathing; such data would more definitively address this situation. Gozal studied 54 children with sleep-disordered breathing and low school performance.
Half of them underwent surgical tonsillectomy and adenoidectomy to treat OSA. Children undergoing the interventions improved their academic performance, compared to untreated children. One problem with the study design; however, was that surgical treatment was not randomly assigned parents elected whether or not their children could receive surgery. Given the high proportion of children with sleep-disordered breathing, especially in vulnerable groups such as children in minority populations and those born prematurely, there is a large need to address the role of sleep-disordered breathing and its reversibility in these important outcomes.
Sleep-Disordered Breathing and Cognitive Impairment in Adults Several cross-sectional studies additional contribution from sleep income that sleep-disordered breathing in adults is associated with impaired cognitive function Greenberg et al. Cognitive deficits, in turn, partially contribute to poorer work performance Ulfberg et al.
Abstract Introduction: The aim of this article is to investigate the determinants of sleeping patterns in children up to age 9 on a large and geographically homogeneous sample of British children and parents, focusing in particular on the role of economic and social factors, specifically on income. Aims and Methods: The data of this study come from the Avon Longitudinal Study of Parents and Children, a long-term health research project that recruited over pregnant women who were due to give birth between April and December in Bristol and its surrounding areas, including some of Somerset and Gloucestershire. Logistic regression models for the sleep problem dummies and log-linear models for the sleep quantity. Sleep quantity does not vary much and is not sensitive to socioeconomic factors. Conclusion: Exposure to income-related inequalities affects child sleep.
A meta-analysis of the case-control studies found that the magnitude of the cognitive disturbance was greatest in individuals with severe OSA. Cognitive domains most affected were attention and executive function the capacity to plan and organize complex tasks with only milder effects on memory Engleman et al. The meta-analysis also found some cognitive benefit associated with continuous positive airway pressure CPAP treatment.
In a series of randomized, placebo-controlled crossover trials, people with mild OSA exhibited a trend toward better performance.
The failure to detect a robust effect may have been due to the fact that the patients had mild disease, were nonadherent to therapy, or that they had a possibly irreversible component to the cognitive impairment.
The cognitive deficits with sleep-disordered breathing are thought to be related to both sleep fragmentation and hypoxemia Weaver and George, However, one study showed no clear threshold level between level of hypoxia and performance deficits Adams et al. Animal models of chronic episodic hypoxia have led to the hypothesis that cognitive deficits in humans result from injury of nerve cells in the pre-frontal cortex Beebe and Gozal,the area of the brain responsible for problem solving, emotion, and additional contribution from sleep income thought.
Almost 20 percent of all serious car crash injuries in the general population are associated with driver sleepiness, independent of alcohol effects Connor et al.
What keeps low-SES children from sleeping well: the role of presleep worries and sleep environment
Driver sleepiness is most frequently a manifestation of sleep loss, as discussed below, but other sleep disorders, which have lower prevalence, contribute to the problem, including sleep-disordered breathing, restless legs syndrome, and narcolepsy.
The 20 percent figure, cited above, is the population-attributable risk, which is a key public health measure indicating what percentage of car crash injuries, including fatal injuries of passengers, could be avoided by eliminating driver sleepiness. The finding was based on a population-based case-control study in a region of New Zealand in which car drivers and a matched control sample were asked detailed questions about measures of acute sleepiness while driving Connor et al.
The study adjusted for potential confounding factors, including alcohol.
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Crashes examined in this study involved a hospitalization or death. The greatest risk factor for the crashes was sleep loss and time of day driving between a.
Indications are that the public health burden of sleepiness-related injuries is likely increasing, given recent trends in drowsy driving. The National Sleep Foundation found that self-reported drowsy driving has increased significantly over the past years, from 51 percent of respondents in to 60 percent in NSF, Similarly striking was that more than 10 percent of the entire sample reported nodding off or falling asleep while driving at least 1 to 2 days per month.
The impact of driver sleepiness is similar in magnitude to that of alcohol consumption. In actual driving performance on a closed course, sleep-deprived adults performed as poorly as did alcohol-challenged adults Powell et al.
After a night of total sleep deprivation, impairments in lane-keeping ability were similar to those found with blood alcohol content of 0. Fall-asleep crashes have distinct patterns by type, age, and time of day. According to the North Carolina study, fall-asleep crashes are largely off-the-road and at higher speeds in excess of 50 mph Pack et al.
Adolescents and young adults between the ages of 16 and 29 are the most likely to be involved in crashes caused by the driver falling asleep Horne and Reyner, ; Pack et al. They account for about 50 percent of all crashes Horne and Reyner, ; Pack et al. Fall-asleep crashes occur at two periods of day that coincide with circadian variation in sleepiness, in the early morning a. Pack et al. The most common reasons behind fall-asleep crashes are working multiple jobs, night shift work, and sleep duration of less than 5 hours Connor et al.
Sleep apnea accounts for a small, but measurable percentage of motor vehicle crashes, primarily additional contribution from sleep income drivers above the age of 25 Sassani et al.