.

ILLUSTRATION: ©monika melnychuk/i2iart.com

For a decade or more retired freelance writer Norma Ramage, 62, has struggled to get a good night’s sleep. It can take her hours to fall asleep at night, sometimes sleep doesn’t come; other times she wakes in the night and is unable to get back to sleep.

“It sometimes feels like your life is slipping away,” says Ramage, who lives near Black Diamond, Alta., in the Rocky Mountain foothills a half hour southwest of Calgary. “It’s a life thief. You lie there for hours at night and by the time you’re up and moving it’s noon and then, where did the day go?”

Her mother and brother had similar troubles. “Maybe it’s a genetic thing. Maybe some people just don’t sleep well.” Medications, changes in diet, giving up caffeine, being checked for a sleep disorder, trying to nap during the day, going on hormone replacement therapy and retirement—nothing has worked. “It goes on and on forever. It’s not life-destroying, but it is lifestyle-destroying. It sure makes you feel miserable—and older than you should feel.”

She’s in good company. Canada is a sleep-deprived nation. According to a 2010 survey, approximately 60 per cent of Canadian adults and youth feel tired most of the time. Some suffer from apnea, restless legs, insomnia, narcolepsy or 80-some other conditions that disturb shut-eye. Many others regularly burn the candle at both ends. A report to the World Association of Sleep Medicine in 2011 said Canadian adults average 6.9 hours of sleep a night, and 30 per cent get less than six.

The inability to fall asleep, problems staying asleep and disrupted sleep have built up a national sleep deficit that is both a public health issue and a personal health problem. And it’s getting worse, says Dr. Adam Moscovitch, director of sleep-fatigue services with the AIM Health Group in Toronto and an associate clinical professor at the University of Calgary. “Our lifestyle has changed dramatically over the last 100 years. We get 20 per cent less sleep than our grandparents.”

While individual sleep need may vary, the average is about eight hours a night for adults. Invention of the light bulb, cathode ray tube, shift work, long commutes and computer games did not change the human body’s need for sleep. It is vital for health. During sleep our minds and bodies are repaired.

Although a third of Canadians have a sleep disorder, most are undiagnosed. That includes the people who drive transport trucks, maintain and fly passenger planes, drive buses, perform surgeries and take care of us in hospital, as well military personnel and the first responders who help us in times of emergency.

.

ILLUSTRATION: ©monika melnychuk/i2iart.com

Fatigue is the likely cause of 31 per cent of motor transport crashes, according to Transport Canada, as well as a third of injuries in the marine and railroad industries and between 21 and 70 per cent of aviation industry accidents, depending on what’s counted. Drowsy drivers cause roughly 20 per cent of private vehicle crashes. In 2004, the Traffic Injury Research Foundation revealed four million Canadian drivers have nodded off at the wheel at some time. Drivers who’ve been up 18 to 19 hours are as impaired as those with a 0.05 per cent blood alcohol concentration; after 20 hours, that rises to the equivalent of 0.08 to 0.10—impaired in any province or territory.

In 2010 the Canadian Nurses Association reported fatigue is a problem for Canada’s quarter-million nurses, caused in part by 12-hour shifts, staff shortages, frequent shift changes and short turnaround times. Just over 55 per cent of nurses surveyed said they were almost always tired at work. Although three quarters said they’d considered resigning or retiring due to fatigue, 90 per cent of their workplaces had no policies to address fatigue.

Fatigue compromises patient safety. It’s a major factor in medication errors; medical complications nearly double when surgeons perform operations on less than six hours of sleep.  A 2010 article in the New England Journal of Medicine suggests hospitals should reschedule elective surgery for sleep-deprived doctors and that patients be informed if their surgeons haven’t had enough sleep.

In Quebec, which has just over 23 per cent of Canada’s population, the economic burden of insomnia was estimated in 2009 at $6.6 billion annually for health care appointments, prescriptions, alcohol used as a sleep aid, absenteeism and lower productivity. Canadians fill nearly seven million prescriptions a year for sleeping drugs, at a cost of more than $162 million.

As well, fatigue is a major factor in reduced productivity, says Moscovitch, and should be addressed through workplace health and safety policies and programs. Although attitudes are changing, we’re some way from nap rooms on job sites. Employers are beginning to include fatigue management programs in their workers’ health and safety programs and fatigue research is being reflected in more and more government regulations and policies.

But change has been slow. “What’s needed is a comprehensive approach,” Moscovitch says, starting with education about health and safety risks of fatigue, adequate access to diagnosis and treatment, screening of workers so sleep disorders can be treated before problems occur, tougher policies, guidelines and laws, more individual responsibility for personal sleep hygiene.

But there’s resistance to recognizing and dealing with sleep problems. For business, the solution often translates to hiring more employees—and that affects the bottom line, whether in a business operating in a competitive global environment or in overburdened public systems with strained budgets. On a personal level, people may be afraid to identify they have a sleep disorder for fear of losing their job or drivers’ licence.  There’s also a cultural mindset that downtime—even for sleep—is a bad thing.  “People are still bragging about how little sleep they get by on,” says Moscovitch.

Such a change in attitude may be hurried along by the current legal climate, he says. Courts are beginning to ascribe responsibility—and cost—to employers whose overtired workers are injured on the job or on their way home. In other countries, injured patients have sued drowsy doctors and Canadian medical journals warn of an increase in medical malpractice suits citing fatigue.

In 2010, Quebec medical residents grieved 24-hour on-call duty. The arbitration hearing was told doctors tired from such long shifts are more than twice likely to crash their cars, have twice as many “attentional failures” and make nearly six times more serious diagnostic errors than those on a 16-hour schedule. In July new scheduling provisions came into effect reducing some on-call shifts in Quebec to 16 hours from 24.

The transportation industry has already limited duty hours and stipulated rest periods for airline pilots and commercial truck drivers. However, there’s pressure for even more change.

.

ILLUSTRATION: ©monika melnychuk/i2iart.com

Canadian pilots are lobbying for recognition that disruptions of circadian rhythm, the body’s sleep/wake cycle, is a safety issue. “Flight and duty times should be based on the science of fatigue,” said Barry Wiszniowski, chair of the technical safety division of the Air Canada Pilots Association. Canada last updated its regulations regarding pilot duty and rest periods in 1996.

Soon Canadian truck drivers will be required to be screened for sleep disorders in order to qualify for a commercial licence to work across the United States border—and on the horizon are similar regulations for Canada. “This is a good thing,” says Steve Laskowski, senior vice-president of the Canadian Trucking Alliance. In the next three years the U.S. wants to begin mandatory screening of commercial drivers with a high body mass index, which is highly correlated to obstructive sleep apnea (OSA). Some U.S. companies are already screening drivers. A 2006 pilot project at Schneider National, which operates in 28 countries, including Canada, followed performance of 339 drivers a year before and a year after OSA treatment. Preventable crashes dropped 30 per cent, the cost of crashes dropped 48 per cent, driver retention improved by 60 per cent and they saved $539 in health care costs monthly per driver. When the program was widened, Schneider discovered 2,000 of its 14,000 U.S. drivers had OSA; treating them resulted in a $15.7 million annual benefit for the company, which now screens all new U.S. hires.

.

ILLUSTRATION: ©monika melnychuk/i2iart.com

The Canadian Trucking Alliance is about to start its own pilot program, says Laskowski. “Many of our members service the U.S. market and have to comply with U.S. regulations while south of the border,” and changes to Canadian regulations are on the horizon. The screening goal is to have a driver tested for OSA, diagnosed and outfitted with a CPAP (continuous positive air pressure) machine with 72 hours, so there is no disturbance to income or loss of driver’s licence.  Provincial health care plans cover most of the cost for drivers treated in Canadian-owned labs.

“Most commonly, those who have sleep apnea are sedentary folks who don’t have regular diets and who are heavier. Truck drivers often fall into that description,” says Tammy Draper, respiratory division vice-president of Motion Specialties. “Between 40 to 50 per cent of commercial truck drivers are estimated to have OSA.” Motion Specialties is now screening 5,000 drivers from three Ontario trucking companies.

CPAP machines are equipped with computer chips that record use, monitoring drivers for compliance, an important step considering a $3.25 million settlement in December 2011 by a trucking firm in the first U.S. lawsuit for death resulting from a driver with uncontrolled OSA.

But fatigue isn’t just a public health and safety issue. There’s also a personal price. A study at Laval University revealed 40 per cent of adult Canadians suffer from insomnia—taking more than 30 minutes to fall asleep, or waking up for at least 30 minutes during the night at least thrice weekly. Yet few seek medical help for insomnia, although U.S. studies show there’s an 11 per cent increase in health care use among the most sleep deprived, and that bumps to as much as 20 per cent for those with OSA.

Chronic lack of sleep disrupts production of hormones, impairs the immune system and prevents the body and brain from regenerating. Sleep deprivation is implicated in high blood pressure, especially drug resistant hypertension, heart disease, obesity, development of diabetes, inflammation, plaque associated with Alzheimer’s disease, not to mention increased injuries and deaths from accidents. One Canadian researcher noted a seven per cent increase in traffic accidents the Monday following the shift to daylight savings time in the spring, and U.S. researchers have noted a similar increase in accidental death in the workplace.

While we can make up for a night or two of lost sleep simply by going to bed a bit earlier for a couple of days, losing sleep night after night over a long time takes its toll. Ramage has experienced the ravages of sleep deprivation. Before retiring a year ago, it meant dragging herself through the day on a couple of hours sleep, struggling with lack of energy and feeling out of focus. “When I look back at stories I wrote when I hadn’t had a good night’s sleep and compared them to the ones I wrote when I was sleeping, there’s a difference in quality.”

Now that she’s retired, she often tries to sleep in to catch up on rest, but “it throws your whole day out of whack. It’s like you’re living outside of time.”

.

ILLUSTRATION: ©monika melnychuk/i2iart.com

It’s a myth that we sleep worse as we age. In fact, studies show healthy older adults enjoy the best sleep of us all. Aging itself does not cause sleep problems—but chronic illness or stress do. Then there’s menopause. Hot flashes and night sweats can disrupt a woman’s sleep—and that of her husband or partner—for years.

Many seniors who complain they can’t sleep at night are actually getting their full complement with daytime napping. Sleeping in shifts is a historic human sleep pattern, historian Roger Ekirch argues. People used to go to bed after dusk, sleep a few hours then get up for awhile and return to bed before dawn. Historical references to first and second sleep disappeared as upper classes began affording evening candlepower; this was shortly followed by the first complaints in diaries of unwanted waking in the middle of the night. Modern Western lifestyles are built around a single eight-hour block of sleep.

The human body has a natural 24-hour sleep/wake cycle called the circadian rhythm. Sleep is cued by changes in light level and the amount of time awake. Body temperature and blood pressure drop in the evening and production of melatonin, the sleep hormone, ramps up. This cycle can be disrupted if you don’t get enough daylight or are exposed to too much artificial light at night, as well as caffeine and nicotine, prescription medications and supplements, alcohol, a bedroom that’s too hot or too cold, jet lag, shift work, illness, pain or sleep disorders.

Sleep is a very busy time for the body. As we cycle through five stages of light through deep sleep, tissue is repaired and regenerated, bone and muscle built, the immune system strengthened.

Our need for sleep gradually diminishes from 16 hours a day in infancy, to 8.5 to 10 for teens, and finally settles at 7.5 to nine in adulthood. Age doesn’t change the amount of sleep we need, but does change how deeply we sleep. Older people don’t get as much deep sleep, so are more easily roused. And new research has linked a natural yellowing of the eye lens with age to sleep disorders among seniors.

Age does affect the time of day we want to go to bed. Changes in circadian rhythm throughout life explain why teens want to stay up half the night and sleep until noon, while their parents want to retire and rise early. A jest of God, or nature preparing everyone for the empty nest, explains why these two generations frequently find themselves trying to sleep under the same roof.

.

ILLUSTRATION: ©monika melnychuk/i2iart.com

1. Be consistent. Establish a bedtime routine, go to bed and rise the same time every day.  Schedule enough time for sleep.

2. Exercise. But not too close to bedtime.

3. Get comfortable. Dark, cool rooms are best. Wear a sleep mask and ear plugs if necessary. Banish pesky pets and snoring or thrashing partners.

4. Pay back your sleep debt immediately. Schedule a couple of hours of extra sleep nightly for a couple of days. The longer you put it off, the worse you’ll feel. On weekends and holidays, go to bed at a regular time and sleep until you wake up naturally.

5. Ignore the clock. Looking at the time turns your focus from sleeping to how little sleep time is left. Face the clock to the wall and rely on your alarm.

6. Follow the 30-minute rule. If you can’t get to sleep or get back to sleep in half an hour, get up and do some repetitive task until you get sleepy.

7. Watch your mouth. Avoid caffeine, chocolate and alcohol. A small snack of complex carbohydrates (like whole wheat toast) before bed will cause a release of insulin, which clears away amino acids that compete with production of the relaxing neurotransmitters serotonin and melatonin. Tart cherries are a natural source of melatonin. Bananas are natural muscle relaxants, thanks to high potassium and magnesium content. And warm milk, high in sleep-promoting calcium, contains an amino acid that helps serotonin production.

8. Control light exposure. Get sunlight in the morning, but avoid bright lights, including computer and television screens, near bedtime.

9. See your doc. If you snore or stop breathing when you sleep, become really drowsy during the day or nod off while driving, you may have a medical condition that’s preventing restful sleep.