Poor sleep quality and insufficient sleep of a collegiate student-athlete population.

OBJECTIVE: Poor and inadequate sleep negatively impact cognitive and physical functioning and may also affect sports performance. The study aim is to examine sleep quality, sleep duration, and daytime sleepiness in collegiate student-athletes across a wide range of sports. DESIGN: Questionnaire. SETTING: University setting. PARTICIPANTS: 628 athletes across 29 varsity teams at Stanford University. MEASUREMENTS: Athletes completed a questionnaire inquiring about sleep quality via a modified Pittsburgh Sleep Quality Index (PSQI), sleep duration, and daytime sleepiness via Epworth Sleepiness Scale. Sleep quality on campus and while traveling for competition was rated on a 10-point scale. RESULTS: Collegiate athletes were classified as poor sleepers (PSQI 5.38 ± 2.45), and 42.4% of athletes experience poor sleep quality (reporting PSQI global scores >5). Athletes reported lower sleep quality on campus than when traveling for competition (7.1 vs 7.6, P< .001). Inadequate sleep was demonstrated by 39.1% of athletes that regularly obtain <7 hours of sleep on weekdays. Fifty-one percent of athletes reported high levels of daytime sleepiness with Epworth scores ≥10. Teen student-athletes in the first and second year of college reported the highest mean levels of daytime sleepiness. Greater total sleep time was associated with daytime functioning including lower frequency of difficulty waking up for practice or class (P< .001) and lower frequency of trouble staying awake during daily activities (P< .001). CONCLUSIONS: Collegiate athletes frequently experience poor sleep quality, regularly obtain insufficient sleep, and commonly exhibit daytime sleepiness.

Awareness of sleepiness and ability to predict sleep onset: can drivers avoid falling asleep at the wheel?

OBJECTIVES: Regarding the causes of sleep-related accidents, this study assesses whether individuals can anticipate sleep onset accurately and how individuals acknowledge and use physiological and cognitive cues to make judgments related to sleep onset. METHODS: A group of 41 partially sleep-deprived subjects predicted the likelihood of sleep in 30 consecutive two-minute intervals and noted physiological and cognitive signs of sleepiness, including involuntary eye closure, head-nodding, wandering thoughts, yawns, and instances of sleep, collectively referred to as "sleep complaints". Continuous polysomnographic recording compared these predictions to actual instances of sleep. RESULTS: Subjects varied in their ability to predict sleep onset. For all subjects, the mean prediction of the likelihood of sleep prior to sleep was significantly higher than the mean prediction of the likelihood of sleep prior to intervals in which no sleep occurred (78% vs. 42%; p<.05). However, subjects tended to predict much lower likelihoods of sleep onset before their first sleep event (55%) than before later sleep events. On average, the rate at which subjects reported miscellaneous sleep complaints (such as head-nodding, eye closure, and wandering thoughts) was higher prior to sleep than prior to intervals in which sleep did not occur. CONCLUSION: Subjects who acknowledged a limited number of physiological and cognitive indicators of sleepiness tended to be poor predictors. Subjects whose physiological and cognitive signs of sleepiness failed to provide a strong indication of whether or not sleep onset would occur also tended to be poor predictors. Inability to judge sleep onset and, hence, susceptibility to sleep-related accidents, may be attributable to both a scarcity of meaningful warning signs and a failure to acknowledge the importance of physiological and cognitive indicators.

Short Daytime Naps Briefly Attenuate Objectively Measured Sleepiness Under Chronic Sleep Restriction.

Study Objectives: Napping is a useful countermeasure to the negative effects of acute sleep loss on alertness. The efficacy of naps to recover from chronic sleep loss is less well understood. Methods: Following 2 baseline nights (10 hours' time-in-bed), participants were restricted to 7 nights of 5-hour sleep opportunity. Ten adults participated in the No-Nap condition, and a further 9 were assigned to a Nap condition with a daily 45-minute nap opportunity at 1300 h. Sleepiness was assessed using the multiple sleep latency test and a visual analogue scale at 2-hour intervals. Both objective and subjective indexes of sleepiness were normalized within subject as a difference from those at baseline prior to sleep restriction. Mixed-effects models examined how the daytime nap opportunity altered sleepiness across the day and across the protocol. Results: Short daytime naps attenuated sleepiness due to chronic sleep restriction for up to 6-8 hours after the nap. Benefits of the nap did not extend late into evening. Subjective sleepiness demonstrated a similar short-lived benefit that emerged later in the day when objective sleepiness already returned to pre-nap levels. Neither measure showed a benefit of the nap the following morning after the subsequent restriction night. Conclusions: These data indicate a short daytime nap may attenuate sleepiness in chronic sleep restriction, yet subjective and objective benefits emerge at different time scales. Because neither measure showed a benefit the next day, the current study underscores the need for careful consideration before naps are used as routine countermeasures to chronic sleep loss.

Armodafinil, the R-enantiomer of modafinil: wake-promoting effects and pharmacokinetic profile in the rat.

Modafinil reduces the excessive sleepiness associated with narcolepsy, obstructive sleep apnea/hypopnea syndrome, and shift work sleep disorder. In rats, modafinil promotes dose-dependent increases in wake duration. The wake-promoting activity of the R-enantiomer of modafinil (armodafinil) was evaluated in WKY rats and compared to the classical stimulant, D-methamphetamine. Electroencephalographic and electromyographic signals were assessed via a tethered cranial implant. Body temperature and locomotor activity were assessed by telemetry via intraperitoneal implant. Rats (n=60, 12 per group) were subjected to one of five parallel treatments: armodafinil at 30, 100 and 300 mg/kg i.p.; D-methamphetamine, 1 mg/kg i.p. and vehicle. Armodafinil and D-methamphetamine increased time spent awake relative to vehicle. Armodafinil-evoked increases in wake duration were dose-dependent and proportional to plasma compound exposure. Induction of wakefulness by D-methamphetamine was associated with an approximately two-fold increase in locomotor activity during the 2-h period immediately following administration relative to vehicle. D-methamphetamine also increased body temperature over the same time interval. The dose of armodafinil (100 mg/kg, i.p.) that was closest to D-methamphetamine in its wake-promoting efficacy did not produce changes in either body temperature or the intensity of locomotor activity relative to vehicle. Acute rebound hypersomnolence, characterized by increases in non-rapid eye movement sleep (NREMS) as a percentage of time and NREMS bout duration and by a decreased frequency of brief awakenings following sleep deprivation, occurred following D-methamphetamine-but not armodafinil-induced wake in this rat model which has been shown to be predictive of human drug responses.

Sleep-deprived motor vehicle operators are unfit to drive: a multidisciplinary expert consensus statement on drowsy driving.

OBJECTIVES: This article presents the consensus findings of the National Sleep Foundation Drowsy Driving Consensus Working Group, which was an expert panel assembled to establish a consensus statement regarding sleep-related driving impairment. METHODS: The National Sleep Foundation assembled a expert panel comprised of experts from the sleep community and experts appointed by stakeholder organizations. A systematic literature review identified 346 studies that were abstracted and provided to the panelists for review. A modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting was used to reach consensus. RESULTS: A final consensus was reached that sleep deprivation renders motorists unfit to drive a motor vehicle. After reviewing growing evidence of impairment and increased crash risk among drivers who obtained less than optimal sleep duration in the preceding 24 hours, the panelists recognized the need for public policy guidance as to when it is certainly unsafe to drive. Toward this end, the panelists agreed upon the following expert consensus statement: "Drivers who have slept for two hours or less in the preceding 24 hours are not fit to operate a motor vehicle." Panelists further agreed that most healthy drivers would likely be impaired with only 3 to 5 hours of sleep during the prior 24 hours. CONCLUSIONS: There is consensus among experts that healthy individuals who have slept for 2 hours or less in the preceding 24 hours are too impaired to safely operate a motor vehicle. Prevention of drowsy driving will require sustained and collaborative effort from multiple stakeholders. Implications and limitations of the consensus recommendations are discussed.

History of sleep medicine.

Sleeping and dreaming always have been a fundamental part of human existence. Most early writing on these subjects was almost entirely speculation. During the twentieth century, however, scientific observation and experimentation abounded. This article emphasizes the evolution of the key concepts and research findings that characterize sleep research and sleep medicine, crucial discoveries and developments in the formative years of the field, and those principles and practices that have stood the test of time.

Restless legs syndrome symptoms in primary care: a prevalence study.

BACKGROUND: There are relatively few studies on the prevalence of restless legs syndrome (RLS) in the general population, even fewer that used diagnostic questions covering all 4 essential diagnostic criteria defining the RLS symptom complex, and none that have reported on the 2 RLS phenotypes for patients seen by family physicians. METHODS: To determine the prevalence of the symptom complex, diagnostic for RLS in a primary care patient population, a prospective population-based single-center study was performed. Every adult patient presenting for care in a small rural primary care practice with mostly white patients was surveyed for a 1-year period using a validated RLS diagnostic questionnaire. RESULTS: A total of 2099 patients completed the questionnaire. Analysis revealed that 24.0% of these patients were positive for all 4 of the essential symptoms used to make the diagnosis of RLS and 15.3% reported these symptoms at least weekly. In addition, the RLS symptom complex was reported significantly more often by women than men and, as a whole, patients reporting the RLS symptoms were significantly older than patients without symptoms. The prevalence of symptoms increased with age until about 60 years and then showed a steady decrease thereafter. Further, early-onset RLS was significantly more common in women than men. CONCLUSIONS: A high prevalence of RLS symptoms was observed in this primary care population. This finding supports the need for heightened awareness in both the medical community and general population regarding this disorder, which can often be effectively treated within the primary care practice.

The impact of extended sleep on daytime alertness, vigilance, and mood.

BACKGROUND AND PURPOSE: To measure the effects of prolonged sleep extension on daytime alertness, vigilance, and mood in healthy young adults. Little research has documented the effects of increased sleep on daytime function despite a high prevalence of daytime fatigue and sleepiness in the adult population. Past extension studies report conflicting results with regard to Multiple Sleep Latency Test (MSLT) scores, vigilance, and mood ratings. No study has challenged subjects to maximum sleep extension, defined by an MSLT score of 20. PATIENTS AND METHODS: Fifteen healthy college students reporting minimal daytime sleepiness were allowed to sleep as much as possible during a sleep extension period. MSLT scores, psychomotor vigilance task (PVT) reaction times, and profile of mood states (POMS) ratings were measured at baseline, mid-extension, and end-extension. RESULTS: There was a significant increase in both journal and actigraphy sleep totals during all extension segments (P<0.01). MSLT scores increased significantly from baseline to both mid- and end-extension (P<0.01). Five of eight tabulated PVT measures also improved significantly at mid- and end-extension with respect to baseline (P<0.05). POMS vigor and fatigue scores showed a similar improvement (P<0.01). Seven subjects achieved an MSLT score of 20. Six subjects showed substantial improvements while two subjects obtained relatively little extra sleep and showed little or no MSLT improvement. The maximum extension group displayed exceptional improvements in vigilance and POMS ratings. CONCLUSIONS: Extended sleep leads to substantial improvements in daytime alertness, reaction time, and mood.

Technical protocol for the use of esophageal manometry in the diagnosis of sleep-related breathing disorders.

A time-tested protocol for intrathoracic pressure monitoring during sleep is described. This method of esophageal manometry uses a fluid-filled catheter to measure variations in transmitted intrathoracic pressure with respiration. Esophageal manometry is an invaluable tool for the sleep specialist in the diagnosis of sleep-related breathing disorders, especially for detecting cases of upper airway resistance syndrome and for distinguishing subtle central apneas from obstructive events. The methods for scoring esophageal pressure, the indications and contraindications for esophageal manometry, the use of esophageal manometry as the 'gold standard' for the measurement of respiratory effort, and directions for future research are also discussed.

Symptom-Based Prevalence of Sleep Disorders in an Adult Primary Care Population.

The prevalence of sleep disorders in a primary care physician practice in Moscow, Idaho, was studied between February 7, 1997, and February 6, 1998. This primary care clinic visit population was surveyed for this 1-year period. Every patient above the age of 18 years who visited the Moscow Clinic in this time period was either approached by our on-site researcher during the patient's clinic visit or contacted via mail. Out of a total of 1249 adult patients who met with our on-site researcher during their clinic visit, 962 (77.0%) completed questionnaires and were interviewed for symptoms of sleep disorders. An additional 292 patients completed mailed questionnaires, resulting in a total of 1254 participants in the study. The percentages of patients in our sample reporting symptoms of the following sleep disorders were insomnia (32.3%), obstructive sleep apnea syndrome (23.6%), and restless legs syndrome (29.3%). This study demonstrates the need for heightened awareness and subsequent diagnosis and treatment of sleep disorders in the primary care population.

Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES).

STUDY OBJECTIVE: To determine the neurocognitive effects of continuous positive airway pressure (CPAP) therapy on patients with obstructive sleep apnea (OSA). DESIGN, SETTING, AND PARTICIPANTS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blind, 2-arm, sham-controlled, multicenter trial conducted at 5 U.S. university, hospital, or private practices. Of 1,516 participants enrolled, 1,105 were randomized, and 1,098 participants diagnosed with OSA contributed to the analysis of the primary outcome measures. INTERVENTION: Active or sham CPAP MEASUREMENTS: THREE NEUROCOGNITIVE VARIABLES, EACH REPRESENTING A NEUROCOGNITIVE DOMAIN: Pathfinder Number Test-Total Time (attention and psychomotor function [A/P]), Buschke Selective Reminding Test-Sum Recall (learning and memory [L/M]), and Sustained Working Memory Test-Overall Mid-Day Score (executive and frontal-lobe function [E/F]) RESULTS: The primary neurocognitive analyses showed a difference between groups for only the E/F variable at the 2 month CPAP visit, but no difference at the 6 month CPAP visit or for the A/P or L/M variables at either the 2 or 6 month visits. When stratified by measures of OSA severity (AHI or oxygen saturation parameters), the primary E/F variable and one secondary E/F neurocognitive variable revealed transient differences between study arms for those with the most severe OSA. Participants in the active CPAP group had a significantly greater ability to remain awake whether measured subjectively by the Epworth Sleepiness Scale or objectively by the maintenance of wakefulness test. CONCLUSIONS: CPAP treatment improved both subjectively and objectively measured sleepiness, especially in individuals with severe OSA (AHI > 30). CPAP use resulted in mild, transient improvement in the most sensitive measures of executive and frontal-lobe function for those with severe disease, which suggests the existence of a complex OSA-neurocognitive relationship. CLINICAL TRIAL INFORMATION: Registered at clinicaltrials.gov. Identifier: NCT00051363. CITATION: Kushida CA; Nichols DA; Holmes TH; Quan SF; Walsh JK; Gottlieb DJ; Simon RD; Guilleminault C; White DP; Goodwin JL; Schweitzer PK; Leary EB; Hyde PR; Hirshkowitz M; Green S; McEvoy LK; Chan C; Gevins A; Kay GG; Bloch DA; Crabtree T; Demen WC. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). SLEEP 2012;35(12):1593-1602.

The effects of sleep extension on the athletic performance of collegiate basketball players.

STUDY OBJECTIVES: To investigate the effects of sleep extension over multiple weeks on specific measures of athletic performance as well as reaction time, mood, and daytime sleepiness. SETTING: Stanford Sleep Disorders Clinic and Research Laboratory and Maples Pavilion, Stanford University, Stanford, CA. PARTICIPANTS: Eleven healthy students on the Stanford University men's varsity basketball team (mean age 19.4 ± 1.4 years). INTERVENTIONS: Subjects maintained their habitual sleep-wake schedule for a 2-4 week baseline followed by a 5-7 week sleep extension period. Subjects obtained as much nocturnal sleep as possible during sleep extension with a minimum goal of 10 h in bed each night. Measures of athletic performance specific to basketball were recorded after every practice including a timed sprint and shooting accuracy. Reaction time, levels of daytime sleepiness, and mood were monitored via the Psychomotor Vigilance Task (PVT), Epworth Sleepiness Scale (ESS), and Profile of Mood States (POMS), respectively. RESULTS: Total objective nightly sleep time increased during sleep extension compared to baseline by 110.9 ± 79.7 min (P < 0.001). Subjects demonstrated a faster timed sprint following sleep extension (16.2 ± 0.61 sec at baseline vs. 15.5 ± 0.54 sec at end of sleep extension, P < 0.001). Shooting accuracy improved, with free throw percentage increasing by 9% and 3-point field goal percentage increasing by 9.2% (P < 0.001). Mean PVT reaction time and Epworth Sleepiness Scale scores decreased following sleep extension (P < 0.01). POMS scores improved with increased vigor and decreased fatigue subscales (P < 0.001). Subjects also reported improved overall ratings of physical and mental well-being during practices and games. CONCLUSIONS: Improvements in specific measures of basketball performance after sleep extension indicate that optimal sleep is likely beneficial in reaching peak athletic performance.

The association between obstructive sleep apnea and neurocognitive performance--the Apnea Positive Pressure Long-term Efficacy Study (APPLES).

STUDY OBJECTIVES: To determine associations between obstructive sleep apnea (OSA) and neurocognitive performance in a large cohort of adults. STUDY DESIGN: Cross-sectional analyses of polysomnographic and neurocognitive data from 1204 adult participants with a clinical diagnosis of obstructive sleep apnea (OSA) in the Apnea Positive Pressure Long-term Efficacy Study (APPLES), assessed at baseline before randomization to either continuous positive airway pressure (CPAP) or sham CPAP. MEASUREMENTS: Sleep and respiratory indices obtained by laboratory polysomnography and several measures of neurocognitive performance. RESULTS: Weak correlations were found for both the apnea hypopnea index (AHI) and several indices of oxygen desaturation and neurocognitive performance in unadjusted analyses. After adjustment for level of education, ethnicity, and gender, there was no association between the AHI and neurocognitive performance. However, severity of oxygen desaturation was weakly associated with worse neurocognitive performance on some measures of intelligence, attention, and processing speed. CONCLUSIONS: The impact of OSA on neurocognitive performance is small for many individuals with this condition and is most related to the severity of hypoxemia.

The Apnea Positive Pressure Long-term Efficacy Study (APPLES): rationale, design, methods, and procedures.

STUDY OBJECTIVE: To assess the size, time course, and durability of the effects of long-term continuous positive airway pressure (CPAP) therapy on neurocognitive function, mood, sleepiness, and quality of life in patients with obstructive sleep apnea. DESIGN: Randomized, double-blinded, 2-arm, sham-controlled, multicenter, long-term, intention-to-treat trial of CPAP therapy. SETTING: Sleep clinics and laboratories at 5 university medical centers and community-based hospitals. PATIENTS OR PARTICIPANTS: Target enrollment is 1100 randomly assigned subjects across 5 clinical centers. INTERVENTIONS: Active versus sham (subtherapeutic) CPAP. MEASUREMENTS AND RESULTS: A battery of conventional and novel tests designed to evaluate neurocognitive function, mood, sleepiness, and quality of life. CONCLUSIONS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) is designed to study obstructive sleep apnea and test the effects of CPAP through a comprehensive, controlled, and long-term trial in a large sample of subjects with obstructive sleep apnea.