آیه 9 سوره نبأ - PowerPoint Presentation

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آیه 9 سوره نبأ(وَجَعَلْنَا نَوْمَكُمْ سُبَاتًا)(و خواب را مایه آرامش شما ساختیم )

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Sleep Disorders and Work

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Dr

Hashemi

Occupational Medicine Specialist

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Sleep is the intermediate state between wakefulness and

deathSleepiness is modulated by a circadian rhythmPacemaker to promote sleep at night and wakefulness during the dayThe internal clock is located in the suprachiasmatic nucleus hypothalmus

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Sleep and Performance

Most people most alert at 10 AM-8 PM and most sleepy at 2-4 AMWithin the 24-hour cycle, there are two major nadirs for alertness, during which many people may feel slowed or sleepy: The stronger nadir occurs at night (10 P.M. - 8 A.M., peaking around 4 A.M )The second occurs between 2 P.M. - 4 P.M.

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Sleep and Performance

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Sleep and Performance

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The average amount required is

7 - 8 hours

per 24-hour period

If sleep is curtailed, as frequently occurs with today's societal demands,

sleep loss accumulates

This accumulation can be likened to a

debt

For instance, a person who requires 7 hours of nightly sleep for optimal alertness but only captures 6 hours per night will incur a 5-hour sleep debt by the week's end.

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Sleep and Performance

When the debt is large enough or unmasked by boring or passive tasks, one can no longer maintain wakefulness, and involuntary episodes of sleep will occur. These episodes, called micro-sleeps, may be as brief as 5 to 10 seconds in duration and often go unnoticed.

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Sleep and Performance

Lapses in performance occur at a rate three to 10 times greater in persons who have been awake longer than 14 hoursPerformance deficits also occur in a dose-dependent manner with accumulating sleep loss or “ debt” .Combined with an increasing sleep debt, performance is at its worst during the circadian nadirs.Demonstrate that monotonous work increases the propensity to sleepiness in a setting of sleep loss and long work hours.

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Sleep and Performance

The need for sleep may be unmasked and hard to combat when tasks are long, tedious, or boring. Repetitive tasks increase habituation in a sleepy brain and consequently unmask or augment underlying sleepiness.The fundamental effects of sleep loss permeate all levels of performance and negatively impact the workplace.

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Sleep and Performance

Performance deficits can be subtle and first emerge as lapses, omissions, and cognitive deficits. These may be expressed as slowed or inappropriate Decision makingPerseverationJob performanceThoughtMemorySpeedImmediate and recall memory

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The Cost of Sleepiness to Society

Driver deaths from single vehicle accidents occurring in the early morning hours

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The Cost of Sleepiness to Society

The likelihood of driving while sleepy increased with longer work hours

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The Cost of Sleepiness to Society

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International Classification of Sleep Disorders

Over 80 known sleep disorders Major sleep disorders likely to produce sleepiness among working adults:InsomniaNarcolepsyObstructive Sleep Apnea ( OSA & OSAS )

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Insomnia

Subjective sense that sleep is difficult to initiate or maintain or that sleep itself is non-refreshing.Prevalence :One third of the adult population experiences insomnia Nearly 10% as a chronic problem

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Insomnia

FatiguePerformance decrementsMood disturbancesDecreased worker productivityHigher accident rateIncreased morbidityThe workplace can also be a source of stress, which promotes sleep difficulty especially in women.

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Insomnia

Precipitating factors are generally listed as the 5 Ps:Physical PsychologicalPsychiatricPharmacologicPhysiologic

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Insomnia

Physical : PainIllnessHormonal changesEnvironmental disturbances

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Insomnia

Psychological: Psychological stressors Psychiatric: active psychiatric disease

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Insomnia

Pharmacologic:Side effect of medications prescribed for other illnessesThrough the arousing properties of caffeine and other CNS stimulantsDirect effect of ethanol ingestionIndirectly as rebound effect following withdrawal of CNS depressants initially prescribed as sleep aids

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Insomnia

Physiologic: Circadian change: Jet lag from crossing three or more time zonesRotating shift work

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Insomnia

Diagnosis:Diaries of sleep-wake activityObjective polysomnographyActigraphy (a wrist-worn motion detector)

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Insomnia

Diaries of sleep-wake activity

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Insomnia

POLYSOMNOGRAPHY

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Insomnia

Actigraphy (a wrist-worn motion detector)

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Insomnia

Treatment:Simple changes in routine, living situation and food intake may be effective. Education regarding the mechanics of sleep (i.e., sleep promoting and interfering behaviors) is important.

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Insomnia

Transient insomnia:Lasting a few days to a couple of weeksAssociated with trans-meridian travel, a brief illness, or a stressful event (next day exam or presentation ) Sedatives/hypnotics can be used as the main therapy Shorter acting benzodiazepines Non-benzodiazepine receptor agonistsNew melatonin receptor agonists

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Insomnia

Short-term insomnia:Lasting several weeks to a monthUsually associated with more traumatic life events Negative (death of a loved one, divorce, or sudden hospitalization) Positive (marriage, job promotion, or birth of a child)Sedative/hypnotic therapy is indicated over the short termBehavioral therapies and education are important to prevent the development of chronic insomnia

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Insomnia

Long-term or chronic insomnia :May last months to yearsThere are well-recognized effective behavioral treatments: Sleep restrictionCognitive therapyRelaxation therapiesStimulus controlBehavioral therapies are typically effective during a 6- to 8-week program Sedative/hypnotic medication should be used as reinforcement for educational and behavioral techniques

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Insomnia

Contraindication:Fragile elderlyPregnant womenThose needing to respond to emergencies in the nightFirefighters PhysiciansNatural products:L-tryptophan (amino acid precursor to serotonin)Melatonin (neurohormone secreted by the pineal gland in the dark)Herbs such as valerian root

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Narcolepsy

Affecting 0.03% to 0.05% of the worldwide populationJapaneseSymptoms are rare in prepubertal children, with onset peaking in the second decade but continuing into the fifth decade of life.Onset appears to be invoked by stressful life occurrences Death of a loved one Divorce

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Narcolepsy

Pentad of primary symptoms: Severe SleepinessCataplexyHypnagogic HallucinationsSleep ParalysisSeverely Fragmented Nocturnal Sleep

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Narcolepsy

Severe sleepinessFrequent sleep attacks during which the person cannot fight sleepCataplexy Reversible motor inhibition, triggered by internal or external emotionally laden stimuli and resulting in partial or complete, sudden loss of muscle tone

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Narcolepsy

Hypnagogic hallucinations Sleep onset-related auditory, visual, or tactile sensations that may be pleasant or frightening, lasting seconds to minutesSleep paralysisCharacterized by areflexia of skeletal muscles, which may be partial or complete, noted at sleep onset or offsetSeverely Fragmented nocturnal sleep

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Narcolepsy

PathophysiologyAutoimmune process that attacks the hypocretin (orexin) system in the hypothalamusHypocretin system is a switch: that is vital to internal monitoring of sleep and wakeHLA DR2 subtypes DR15 (DRB1*1501) and DQ6 (DQB1*0602)

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Narcolepsy

DiagnosisCataplexy may be a pathognomonic featureNocturnal polysomnograms followed by a Multiple Sleep Latency Testing (MSLT)Hypocretin-1 levels of cerebral spinal fluid

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Narcolepsy

TreatmentPharmacologic and behavioral techniquesPharmacologic techniques:CNS stimulants or wake promoters improve the symptoms of daytime sleepinessAntidepressant drugs (TCAs and SSRIs)Gamma-hydroxybutyrate (sodium oxybate)Certain jobs for which a person with narcolepsy is unfit: Occupations requiring long periods of driving Monotonous attention to critical dials and gauges.

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Obstructive Sleep Apnea

The most common disorder resulting in daytime sleepiness among adult workersOSAS is characterized by repetitive episodes of cessation of airflow during sleep, which result in brief arousalsRisk factors:ObesityPost-menopausal

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Obstructive Sleep Apnea

PathophysiologyActual cessation (apnea) or the reduction of airflow for brief periods (10 to 60 seconds)Changes in muscle toneRedundant tissueEnlarged tonsils and adenoidsAnatomically small airway passageChanges in the arousal threshold occurring with the ingestion of alcohol or sedating drugsBrief events of apnea can result in significant oxygen desaturations

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Obstructive Sleep Apnea

SymptomsSporadic snoring, excessive sleepiness, and restless sleepBed partners are usually sensitive to a marked worsening of nocturnal symptomsCardiovascular consequences: hypertension, arrhythmia, and strokesloss of memory, irritability, depression, and impotence

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Obstructive Sleep Apnea

TreatmentContinuous positive airways pressure device (CPAP)

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Obstructive Sleep Apnea

TreatmentSurgical :Uvulopalatopharyngoplasty (UPPP)Laser-assisted UPPP (LAUP)Dental devices

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Obstructive Sleep Apnea

TreatmentBehavioral techniques :Weight loss Position changes during sleep

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Sleep Disorders and Work

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Apneic and narcoleptic individuals account for 71% of all sleep-related accidents

In

European countries a patient with

untreated OSAS

is considered

unfit to

drive

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