AAMC Reporter: July 2006

Waking Up to Sleep Disorders

New study addresses the problems and solutions of sleep disorders

Want to get over a sleep problem? Drink a glass of warm milk, a friend might say. Or count sheep. Try reading a boring book.

It's possible that these and other well-worn folk remedies comprise a large part of the general public's arsenal in combating sleep disorders. Information in a new study from the Institute of Medicine (IOM) confirms that, both in the public and the medical community, not enough is known, or done, about sleep disorders and the ripple effect they have on general health. But the authors of this recent study are hopeful that will soon change.

The IOM report, "Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem," advocates for significant advances in the way health care professionals approach sleep from workforce, research, and academic perspectives. It also aims to change the public perception that sleep is something to be taken for granted. The study is the work of a 14-member committee representing a wide swath of medical fields including pulmonology, cardiology, neurology, pediatrics, psychiatry, public health, and health sciences research.

Institute of Medicine Sleep Disorders Report: Key Recommendations The National Center on Sleep Disorders Research and its advisory board should play a more proactive role in stimulating and coordinating the field. The National Institutes of Health and private foundations must increase investment in interdisciplinary somnology and sleep medicine research training and mentoring activities. Academic health centers should integrate the teaching of somnology and sleep medicine into baccalaureate and doctoral health sciences programs, as well as residency and fellowship training and continuing professional development programs. The National Institutes of Health and the Agency for Healthcare Research and Quality should support the validation and development of existing and new diagnostic and therapeutic technologies. Sleep laboratories should be part of accredited sleep centers, which include long-term strategies for patient care and chronic disease management. Source: Institute of Medicine

"The magnitude of the problem of sleep loss and sleep disorders is rather enormous," said study chair Harvey R. Colten, M.D., vice president and senior associate dean for translational research at faculties of health sciences and medicine at Columbia University College of Physicians and Surgeons. "There are economic, social, and medical consequences that are unappreciated by the medical community and by the public at large."

According to the committee, those consequences are staggering. The study estimates that 50 million to 70 million Americans suffer from a chronic disorder of sleep and wakefulness, including sleep apnea, chronic insomnia, restless legs syndrome, and periodic limb movement disorder.

While the committee said there is little hard evidence of the direct and derivative impacts of sleep disorders, they estimated that, "at a minimum," hundreds of billions of dollars are spent each year on direct medical costs associated with doctor visits, hospital services, and prescription and over-the-counter medications. Sleepiness also causes almost 20 percent of all serious car-crash injuries (independent of alcohol effects), not to mention work-related injuries and lost productivity.

The problematic effects of sleep problems bleed into many facets of health, the committee noted. Sleep disorders can contribute or lead to problems such as obesity, diabetes, stroke, hypertension, and depression.

"However, given this burden, awareness among the general public and health care professionals is low," the report stated.

"In addition, the current clinical and scientific workforce is not sufficient to diagnose and treat individuals with sleep disorders."

In this vein, one of the report's major recommendations is educating doctors today so that sleep becomes a larger factor in tomorrow's practices. Specifically, the report suggested that "academic health centers should integrate the teaching of somnology and sleep medicine into baccalaureate and doctoral health sciences programs, as well as residency and fellowship training and continuing professional development programs."

"If the medical profession is not aware of the major problems of sleep disorders, then one of the natural starting places is to make sure students and residents are fully exposed to and aware of the issue," said committee member Thomas F. Boat, M.D., physician- in-chief of Cincinnati Children's Hospital Medical Center (CCHMC) and professor and chairman of the University of Cincinnati College of Medicine's Department of Pediatrics.

Boat said CCHMC features the nation's only pediatric sleep training program and that similar "sleep centers" that integrate care and training across specialty disciplines are an integral part of helping students and physicians learn about and treat sleep problems.

"Increased education is not going to happen without some kind of sleep center at every school," Boat said.

The growing trend throughout the medical community of taking this multi-disciplinary approach to care is ideally suited for sleep disorders, Colten noted.

"Academic health centers have used a variety of mechanisms to organize fields that cross-cut traditional specialty lines," he said. "Different trans-disciplinary institutions or centers have been effective, and sleep medicine is clearly right for that. It includes people from pulmonology, nursing, neurology. Optimum education and clinical care require the capacity to call on these disciplines as needed."

Another top recommendation in the report is expanding accreditation of sleep centers to include sleep laboratories and emphasize "long-term strategies of patient care and chronic disease management."

"There are thousands of sleep laboratories out there, and the supervision and accreditation of these labs has to be viewed seriously," said committee member François M. Abboud, M.D., professor of medicine, and of physiology and biophysics, associate vice pres- ident for research, and director of the cardiovascular research center at the University of Iowa Carver College of Medicine. "Sometimes, these labs can be left open to exploitation by commercial interests. Overall, they need more monitoring and surveillance. As part of this, when we can, we should affiliate sleep laboratories with academic medical centers."

Another major recommendation in the study is that all new and existing sleep programs in academic health centers should conform to one of three basic program types — a Type I clinical interdisciplinary sleep program; a Type II clinical, research, and training interdisciplinary sleep program; or a Type III regional comprehensive sleep program.

"We offered a template for the increasing complexity of these units," Colten said.

Aside from ways to strengthen the infrastructure of sleep education and research models, the study emphasized more tangible goals, such as developing and improving new and existing technologies for treating and diagnosing sleep disorders. For instance, Abboud pointed to continuous positive airway pressure (C-PAP), a common treatment for sleep apnea by which a machine forces air into a person's nose to keep the airway open and unobstructed.

"Some people love C-PAP, and others can't tolerate it and think it's hellish," Abboud said. "That's primitive. So technology development is going to be an important part of all this. New equipment and therapeutic treatments are important, and diagnostic equipment will also be important."

The study committee made several other recommendations in a variety of related areas. It called on the National Institutes of Health (NIH) and other public and private foundations and organizations to increase investment in somnology and sleep medicine research training and mentoring, launch multimedia campaigns to inform public opinion on the subject, and establish a National Somnology and Sleep Medicine Research Network through the NIH.

"The focus of all of these recommendations is on how to build the field," said Bruce M. Altevogt, Ph.D., study director and senior program officer with IOM's Board on Health Sciences Policy. "We want to find the best academic structures and to find how it will continue to fit in with academia as it evolves."

Altevogt said the report is already bearing fruit. The National Sleep Foundation and the Centers for Disease Control and Prevention are using the study to guide public awareness campaigns on sleep, and two medical schools — the University of Pittsburgh School of Medicine and the University of Wisconsin School of Medicine and Public Health — are using the report to assess their own sleep programs. Committee members are in ongoing discussions with various other sleep-related organizations.

"The report already has had a positive impact," Altevogt said. "People have really taken a grasp of the report and are letting it shape their campaigns.... In the long term, I do feel the committee's vision will really make a difference."

The study was supported by the National Academy of Sciences, the American Academy of Sleep Medicine, the Department of Health and Human Services, the National Sleep Foundation, and the Sleep Research Society.

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