Sleepiness and Human Impact Assessment Sergio Garbarino Lino Nobili Giovanni Costa Editors 123 Sleepiness and Human Impact Assessment Sergio Garbarino Lino Nobili • Giovanni Costa Editors Sleepiness and Human Impact Assessment 123 Editors SergioGarbarino GiovanniCosta Department of Neuroscience, Department of ClinicalSciences Rehabilitation, Ophthalmology, and CommunityHealth Genetics, Maternal and ChildHealth Universityof Milan (DINOGMI), Centre ofSleep Medicine Milan Italy Universityof Genoa Genoa Italy LinoNobili Department of Neuroscience, Centre of SleepMedicine NiguardaHospital Milan Italy ISBN 978-88-470-5387-8 ISBN 978-88-470-5388-5 (eBook) DOI 10.1007/978-88-470-5388-5 Springer MilanHeidelberg New YorkDordrecht London LibraryofCongressControlNumber:2014932217 (cid:2)Springer-VerlagItalia2014 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpartof the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway,andtransmissionor informationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodology now known or hereafter developed. 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While the advice and information in this book are believed to be true and accurate at the date of publication,neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityfor anyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,with respecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) Foreword 1 Excessive daytime sleepiness (EDS) is a common condition worldwide with sig- nificant impact for personal and public health outcomes. EDS is considered to represent a considerable contributing factor towards poorer occupational and social functioning, and is strongly associated with an increased risk for both workplace and road traffic accidents. EDS, reported by approximately 10–25% of the general population, is a defined clinical entity of variable severity. Mild sleepiness can present with symptoms overcome by mild activity or distraction, while more severe forms are characterised by ‘an overwhelming need to sleep, unintended lapses into sleep, amnesia, and automatic behaviour’ (the semicon- scious continuation of activity while drowsy). Concerning pathogenesis, EDS is a common symptom for insufficient sleep, inadequate sleep, intrinsic sleep disorders and many other medical conditions. It is indubitable that we live in a world increasingly filled with multiple, con- tradictory and quickly changing stimuli. The invention of artificial lighting in the nineteenth century improved but modified the lives of people, as well as the later inventionsoftelevision,computerandInternet,allnegativelyrelatedtogoodsleep patterns. In particular, among a range of technologies, interactive technological devices are most strongly associated with sleep complaints. We now have the high-intensity, 24/7world. Itisbecomingevident thatthegreattechnologicaland social changes that now characterize modern life have also contributed to the increasing incidence of insufficient sleep and, consequently, of EDS. What is the cost/benefit ratio for sleep-deprived individuals in terms of physical and psycho- logical health, and social-familial well-being? In the last 40 years sleep medicine has begun to flourish, with greater interest being shown by clinicians in sleep disorders and increasingly larger numbers of research grants being given to study them. These developments have greatly improved our understanding of the reciprocal causal relationship that exists between several sleep disorders and EDS. EDS is the primary complaint in nar- colepsyandotherdiseasesformingagroupnamedhypersomniasofcentralorigin. EDS is often observed in obstructive sleep apnea (OSA), although many subjects do not report the symptom. Moreover, many other medical and neuropsychiatric conditions,usuallycharacterized by reduced total sleeptime or fragmented sleep, v vi Foreword1 may be associated with EDS. Another non-trivial aspect is the EDS related to several medications. This book ‘‘Sleepiness and Human Impact Assessment’’ provides an excellent overviewofthisimportantandcomplexsubjectwithcontributionsofexpertsfrom aroundtheworld.ThepathophysiologicalmechanismsofEDSareexamined,with possible risk factors identified as intrinsic sleep disorders, circadian rhythm dis- orders,extrinsicsleepdisordersandothercontributorylifestyleandhealthfactors. ThisvolumehasalsoattemptedtoaddresstheeffectsofEDSoneverydaylifeand work. It covers important therapeutic considerations and also provides policy and social welfare recommendations. The chapter ‘‘Transport and Communications’’ by Sergio Garbarino and Giovanni Costa underlines the consequences of impaired alertness that may be devastating in all kinds of drivers, truck drivers, pilots, train drivers: in all these individualsfluctuationsinperformancemaypresentsignificantoccupationalsafety hazard.Expertsagreethatthereisnosubstituteforsleep:‘‘Sleepdebtcanonlybe paid back with sleep’’. In the chapter ‘‘Health Impact Assessment’’ by Emanuele Scafato it is clearly reported that the World Health Organization has encouraged health impact assessment as an important method for maximizinghealthpromotionat the local, nationalandinternationallevels.EDScanseriouslydamagethequalityoflifeand human health. Health programs, social and legislative projects that are trying to fight off sleepiness problems, could give us a better quality of life and reduce accidents and errors due to the human factor. This book will continue to enhance the field of sleepiness by allowing the readertobenefitfromthecollectiveexperienceincludedherein,andthusprovidea basis for improving health conditions of individuals as well as those of the community. Luigi Ferini-Strambi President-Elect of World Association of Sleep Medicine Foreword 2 Although an extremely common experience, sleepiness falls into the category of the symptoms and sensations that one should never neglect. In the healthy indi- vidual, sleepiness is the red light telling us that the necessary resources for ade- quate daytime functioning have been exhausted, and that the need for sleep must nowbesatisfied.Overcomingthisbarriereventuallyentailshigherrisksforerrors, lackofvigilanceandimpairedresponsiveness,foronlyafewinstances.Naturally, this is not a problematic situation if you are watching TV in a comfortable arm- chair.However,thiswillquicklybecomeextremelydangerousifyouaredrivinga vehicle on the highway or are at work manipulating dangerous material. And the obvious, most effective and cost-free remedial for sleepiness in the healthy is to stop ongoing activities and get some sleep until capacities are rebuilt. As to prevent daytime sleepiness, sleep hygiene is also paramount. On the other hand, fatigueisaswellacommonlyexperiencedsensationsignallingthehumansystem that some limits are or will be soon be reached, but it is not automatically accompanied by the urge to sleep characterizing sleepiness. In some cases, changing the type of activity can alleviate it. It is necessary to understand the common and distinctive mechanisms underlying these phenomena and how they canimpactnotonlyoneachone’severydaylife,butalsoonthefunctioningofour modern society, that can be viewed as an organized group of individuals con- strainedbyenvironmentalandsocietaldemands,thesedemandsactingthemselves as triggering factors for sleepiness and fatigue. Besides normal to extreme situations encountered by healthy persons, sleepi- ness and fatigue also represent major and invalidating symptoms associated with stress,diseasesandafflictions,eitherasasecondaryresultoftheinabilitytoobtain adequate and restorative sleep at night (e.g. insomnia, sleep apnoea, parasomnia, etc.) or in association with a wide variety of medical conditions ranging from depressiontomultiplesclerosis.Theaetiologyoffatigueandsleepinessinprimary conditionsremainsdifficulttounderstand,andisatopicalfocusforcliniciansand basic researchers all over the world. Disease-related sleepiness and fatigue symptoms have a particularly high societal cost, impairing the individual’s capacity to resume its activities and reintegrate the workplace. It is also a crucial issue to anticipate the conditions in which sleepiness and fatigue will develop to the point of danger and impairment, to improve or build the environmental vii viii Foreword2 conditionsthatwillpreventsafetyandhealththreats,andtocorrectlyandquickly diagnose the individuals that are more at risk than others to develop prejudicing sleepiness and fatigue symptoms. Inallthese respects,abookonsleepinessandhumanimpact assessmentisnot only timely, but also much needed. Of special interest here is the choice of the editors to target this complex problem in a multidimensional way, rather than focusing on single, specialized aspects. Amongst others, the reader will discover the neurophysiological bases of the sleep–wake cycle and how sleepiness is building up and dissipating, how it is influenced by light and other Zeitgebers, review the medical conditions that cause or with which is associated sleepiness, and discuss healthy and less appropriate lifestyle and habits. He will also learn how these factors exert an impact on industrial activities, transport, communica- tionsandsocialwelfare,andmostimportantly,howsleepinessshouldbeassessed, predicted and managed in a large variety of conditions. I hope that this book will stimulatenovelandintegrativeresearchactionsaimedataddressingsleepinessand the assessment of its human impact. Philippe Peigneux Current President-Elect of the European Sleep Research Society Chair Clinical Neuropsychology and Francqui Research Professor Université Libre de Bruxelles (ULB) Belgium Preface The subject of sleeplessness is once more under public discussion. The hurry and excitementofmodernlifeisheldtoberesponsibleformuchoftheinsomniaofwhichwe hear;andmostofthearticlesandlettersarefullofgoodadvicetolivemorequietlyandof platitudes concerning the harmfulness of rush and worry. The pity of it is that so many peopleareunabletofollowthisgoodadviceandareobligedtoleadalifeofanxietyand hightension.(Editorial.BrMedJ,1894,Sept29p.279) Our life is based on the circadian rhythm of the sleep/wake cycle, with sleep occupying about one-third of it. The qualitative and quantitative alterations of sleep inevitably result in drowsiness,whichisoneofthemainfactorsaffectingourhealth,psycho-physical performance,tolerancetostressand,henceourpersonalwell-being,aswellasthat of the whole society. For this reason we wanted to analyse sleepiness for the first time within the scope of the new WHO concept of Human Impact Assessment (HuIA), which is alreadyroutinelyusedtoanalyseconceptssuchasclimateandenvironment.Sleep isconsideredhereasthemicro-environment/climatethatwemustliveineveryday and protect. We tried to describe an integrated process including both Health Impact Assessment (HIA) and Social Impact Assessment (SIA). It is an ex-ante perspective tool, used to anticipate the outcomes of a programme, a project or a decision on human health and welfare. Wethentriedtocombinethepointsofviewofthreecolleagues(aneurologist,a clinical neurophysiologist and an occupational health physician), who have been working together for many years on joint projects in the field of Neuroscience, withthesupportofresearchersandprestigiousexpertsinthisarea.Withwhomwe hadtheprivilegeofexchangingideasandexperience,andtothemgoourheartfelt thanks for sharing this innovative experience and providing an outstanding contribution. Sergio Garbarino Lino Nobili Giovanni Costa ix Contents 1 Health Impact Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Emanuele Scafato Part I Regulation of Sleep and Circadian Rhythms 2 Circadian and Light Effects on Human Sleepiness–Alertness . . . . 9 Christian Cajochen, Sarah L. Chellappa and Christina Schmidt 3 Neurophysiology of Sleep and Wakefulness. . . . . . . . . . . . . . . . . 23 Sarah L. Chellappa, Christina Schmidt and Christian Cajochen 4 Circadian and Homeostatic Regulation of Sleepiness, Cognition, and Their Neuronal Underpinnings . . . . . . . . . . . . . . 43 Christina Schmidt, Christian Cajochen and Sarah L. Chellappa Part II Sleep, Arousal and Performance 5 Using Mathematical Models to Predict Sleepiness . . . . . . . . . . . . 63 Torbjörn Åkerstedt Part III Sleepiness and HuIA 6 Health-Related Quality of Life and Sleep Disorders Among Special Populations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Carol M. Baldwin, Luxana Reynaga-Ornelas, Maureen S. Russell, Salma Batool-Anwar and Stuart F. Quan 7 Errors and Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Pierre Philip, Cyril Chaufton, Lino Nobili and Sergio Garbarino xi