PARTICIPANT WORKBOOK

Presented by the Pinellas County

Employee Wellness Program
 Session 1: Sleep Basics
National Sleep Statistics
Let’s take a look at some statistics first.
Depending on where we live in the country, one-third to one-half of Americans report
they sleep 6 hours or less.
Almost 40% of Floridians report 6 hours or less sleep per night.
Adults Getting More Than 6 Hours of Sleep per Night

Data Source: National Health Interview Survey (NHIS); Centers for Disease Control and Prevention,
National Center for Health Statistics (CDC/NCHS)

Page 1
Rally Health Survey Overview
The 2018 employee health survey shows that we are fairly close to the state and
national averages.
1,039 employees answered the sleep question in the survey.
 65% of those employees (in the yellow and green areas of the donut)
responded that they get 7 or 8 hours of sleep
 35% of this group gets 6 hours or less
Here’s what this means in terms of claims cost to employees and the County (bar
graph):

 The left bar on the graph shows that employees who get 7 or more hours of
sleep a night cost the County roughly $4,500 a year in medical
reimbursement. This number represents the amount UnitedHealthcare pays
after discounts but does not include the member responsibility (the amount
you pay).
 These averages exclude catastrophic cost (specific high-risk conditions such
as cancer, unforeseen traumas such as car accidents and other severe
injuries).
 The middle bar shows that employees who get about 6 hours of sleep per
night cost about $4,650 per year.
 Employees who get less than 6 hours cost $5,000, or about $500 dollars
more.
As you can imagine, high claims cost paid also means a higher member responsibility
(the part that you pay).
Lack of sleep not only affects our health, it also affects our personal finances.

Page 2
What is Sleep and Why Do We Do It?
The definition of sleep from Merriam-Webster:
“The natural periodic suspension of consciousness during which the
powers of the body are restored.”
Why humans sleep has eluded doctors and scientists for millennia. It’s one of the
biggest biological mysteries.
Sleep is one of the four basic drives in life, along with:
 To eat
 To drink
 To reproduce
 To sleep
BUT sleep is:
 More than just a basic life drive
 More than just a lack of consciousness
 Complex
 Biologically active
If we look at it from an evolutionary standpoint, sleep actually seems
like a waste of time. When we’re asleep, we cannot gather food or drink, we cannot be
social or find a mate. Sleep leaves us vulnerable to predators. Asking why we sleep,
however, is too simple of a question, because it implies there’s only one function. We
tend to think of sleep merely as a state of unconsciousness, when in fact it is complex
and an extremely biologically active endeavor, providing vital restoration and health for
both brain and body.

Sleep Facts
All living beings sleep –
even flies!

Page 3
Why Sleep Matters

There are four pillars of health that work together to create wellbeing: physical, social,
emotional and financial. Optimal health requires that we achieve balance between all
four pillars. None, however, can be achieved without proper sleep.
Every major organ (including the brain) and tissue suffers if you are sleep deprived.
Countless large scale studies across industrialized countries that have included people
of all gender, race, ethnicity and age have irrefutably come to the same conclusion: the
shorter the sleep, the shorter the lifespan.

Sleep Facts
We lose about 1 liter of water
through our breathing each night.
When you wake up each day,
drink 12-16 oz. of water first thing
in the a.m. (room temperature).
This helps to replace water loss.

Page 4
Emotional & Mental Health Benefits
Areas of the Brain
Different parts of the brain take part in regulating our mental health. If you took the
Stress-Proof Brain Wellness Series, you may remember the parts of the brain that affect
stress:
 Amygdala - fight or flight response, exaggerated emotion
 Prefrontal cortex (hypothalamus) - the brain’s CEO, reasoning and logical
thinking
 Hippocampus - the brain’s biographer, memory
Together, these brain area connections work to regulate emotions as well. We’ll explore
these more in a later class.

Nature’s Best Medicine

The power of a good night’s rest is astounding. It is nature’s best medicine, a free, daily
prescription that helps us feel better.
 Recalibrates brain circuits
 Improves navigation of social and stressful situations
 Controls rational thinking
 Re-sets the brain to create new memories and imprint older ones
 Manage depression, anxiety and other mental health disorders

Sleep Facts
Wait 90 minutes for your
first cup of caffeine. It’s a
diuretic and will cause
additional water loss.
Have a second cup of
water and then reach for
coffee.

Page 5
Sleep Deprivation & Social Connection
If you are sleep deprived, you may have trouble with:
 Interpreting your environment
 Processing emotions
 Working well in a team
 Decision-making, problem solving
 Personal relationships
 Emotional control
 Reasoning
 Empathy
Sleep also impacts not only our desire for social connections, but our ability to navigate
them effectively diminishes when we’re tired.
A sleep-deprived brain has trouble reading facial expressions and is more likely to
interpret faces as threatening. As such, they are less likely to engage in conversations
with others and may be very irritable.
Sleeplessness also affects the ability to process emotions - meaning sleep-deprived
individuals often gauge the feelings of other people inaccurately, which reduces their
ability to empathize.
Both personal and work relationships suffer.
Lack of these crucial abilities negatively affects communication, teamwork, trust, and
cooperation. Teams with sleep-deprived members could potentially experience a lack of
trust, teamwork and effective problem solving.
Brain Re-boot
You need sleep so your brain can re-boot and so
you can:
 Effectively manage stress
 Improve memory
 Have more energy
 Increase attention span and
ability to concentrate
 Strengthen relationships

Page 6
Body Health Benefits
Sleep:
 Reduces blood pressure and keeps the heart healthy
 Regulates hunger hormones
 Controls blood sugar
 Helps fight off infection and improves healing
These processes:
 Prevent and help manage health conditions such as
 Heart disease
 Diabetes
 Cancer
 Obesity
 Assist with weight control
 Boost immunity

How Much Do I Really Need?

It is mind-boggling how sleep affects so many processes in our bodies. You’ve probably
heard that doctors and scientists say we need about
8 hours of sleep. In this case, scientists
define “need” by whether the amount of
sleep obtained is adequate to complete all
of the processes it’s designed for. When
we say, “I only need 6 hours of sleep,” we
tend to use a different definition of need:
The number of hours I get/or need to get
through the day. However, with chronic
sleep deprivation, our bodies will
acclimate and learn to function on
less sleep, giving us a false sense
that we are giving our bodies
enough time to re-set.
Exact sleep requirements can
vary from person to person. You
may need slightly less or slightly
more than 8 hours, but the fact
remains that if you’re getting less than
7, you’re not getting enough to reap the benefits, and in fact, are
doing your health a huge disservice.
The amount of sleep needed depends on a variety of factors such as age, physical
exertion, health (are you fighting the flu?), pregnancy, etc.

Page 7
How Much?
Sleep Opportunity
The recommendation includes time
for sleep opportunity, not just the
hours actually asleep.
Sleep opportunity is the time we
physically get into and out of bed.
When we get into bed at 10 p.m.
and wake up at 6 a.m., we give
ourselves 8 hours of sleep
opportunity, giving ourselves time
to fall asleep, reach deep sleep and
wake up naturally. The time spent
asleep is usually about an hour less.
Although sleep time is less than 8 hours, this additional time we allow ourselves to
move through stages of the sleep cycle is just as important.
Thus, if you get into bed at midnight and wake up at 6 a.m., the sleep opportunity is 6
hours, but actual sleep time is roughly only 5 hours, falling far short of the
recommendation for good health.

Are you sleeping?

Universal indicators of sleep:
 Usually horizontal position
 Lowered muscle tone and relaxation of postural muscles
 No signs of communication or responsivity
 Easily reversible (unlike coma, anesthesia, or death)

Was I asleep?
When we wake up, we automatically know we’ve been sleeping, and we can also gauge
whether we slept well or not.
We experience:
 Loss of awareness of the outside world
 Time distortion – don’t know how long or what time it is when we wake up

Page 8
Sleep By YOUR Numbers
Assessing our own sleep habits can be extremely helpful in
bringing awareness to ways in which we can improve it. We
are going to do so in two ways.
 A quick sleep assessment
 Track our sleep and keep a sleep diary for the
next 4 weeks

Sleep Assessment

Total your score and take a look at the point ranges. The lower the score, the lower the
sleep health.
Now ask yourself - Do you feel tired during the day? Or do you drink so much caffeine
to numb your tiredness that you can’t fall asleep when you finally have the chance? In
order to decide how much sleep you need, it’s important to note how your body
functions and feels throughout the day.

Page 9
Sleep Tracking

It should take 20-30 minutes after you get into bed to fall asleep. Any sooner than that,
and you’re probably too tired. Any longer than that, you may be getting too much sleep.
In the morning, you should wake up ready to take on your day. You may or may not
wake up a little bit before your alarm, but if you do, you’re more than likely getting
enough rest.
To determine how much sleep you need, let’s start by noting how much you’re getting
now, how you feel, and your lifestyle behaviors. There are many variables that could
make finding sleep hard.
You’ll find a sleep diary in the Resources section in the back of this workbook. It may
seem like a lot of effort, but if you’re serious about feeling better and becoming
healthier, it’s worth it.
In the morning, assess your sleep the night before. In the evening, take note of how you
felt during the day, and the things you drank, ate and did.
Notice the first morning box asks what time you went to bed and woke up, and the time
you slept. This measures your sleep opportunity as well as actual sleep duration.
Page 10
Work through the boxes and take additional notes if you need to.
In the evening, assess your caffeine and alcoholic beverage intake, energy and activity
levels. Were you excessively hungry/craved carbs? Had trouble concentrating? Felt
irritable? Too tired to exercise? These can all affect your sleep quality and duration.
At the end of the day, compare your morning notes with your evening notes. Do you see
any connection?

Sleep Trackers
A note about trackers…If you’re using a Fitbit
or other wearable device, you can pull the
information from the app; however, use the
diary as well to observe additional information
that will help identify your daily habits. Don’t
worry if you don’t have a sleep tracker; it is not
needed to use the diary.
If you’re interested in trying a sleep tracker
app, there are free and subscription-based
apps both for Android and iPhone.
Keep in mind that the only accurate way to measure sleep is a sleep study done at a
sleep clinic. Both wearable devices and sleep tracker apps have limitations as to their
accuracy. They’ll provide a general idea of sleep quality and duration but should not be
used to self-diagnose any type of sleep condition.

Page 11
Adjusting Sleep
Once you’ve spent a week getting an idea of your sleep and lifestyle patterns and
making necessary adjustments, continue to keep a sleep diary and follow these steps:

Go to sleep 15 minutes earlier every 2-3 nights, until you’re getting at least 7 hours of
sleep every single night.
Use a sleep calculator tool to figure out what time you need to go to bed to achieve the
hours of sleep you’d like (don’t forget to factor in sleep opportunity). See the Bedtime
Calculator on the National Sleep Foundation’s website.
If you’re still tired during the day or you’re not ready to wake up when your alarm goes
off, move your bedtime 15 minutes earlier.
Continue this process until you are getting enough sleep every night. You’ll probably
end up somewhere between 7 and 9 hours, but listen to your body and follow its needs.
Keep in mind that this only determines how much sleep you need right now. If
something changes in your life, your sleep needs could change, too. Or, as you become
more and more rested, you may find that you need less sleep.

Page 12
 Session 2: Engineering Sleep
Review
Sleep is universal to all living things.
Sleep is the foundation for all the pillars of wellness:
 Physical
 Social
 Emotional
 Financial
Sleep is very complex and biologically active.

Engineering Sleep
Watch the video.

Page 13
Sleep Signals

The Sensory Gatekeeper:

The Thalamus
When we’re awake, we’re aware of all of
our senses. We can smell, see, hear,
taste and touch. These signals all
converge in one central area of the brain.
As we fall into slumber, they continue to
come together in the zone; however, the
thalamus, which acts as the sensory
gatekeeper, blocks these signals from
reaching the cortex of the brain. The
cortex allows us to consciously perceive
the senses.
While the organs continue to receive the
signals when we are asleep, the
thalamus induces a state where we lose
consciousness with the outside world.

Brainwaves
When we are awake, our electrical brain signals (brainwaves) are very frenetic and
incoherent because we’re constantly processing and responding to the real world
environment. When we move into the sleep stages, brainwaves become longer and
slower the deeper we sleep.
A good analogy for brain cell activity in wakefulness is to think of them as people seated
in different parts of a large stadium. If you placed a microphone in the middle of the
stadium, you’d hear a cacophony of noises from all areas, as the people are all having
their own conversations. In Non-rapid Eye Movement (NREM) sleep, these
conversations all become synchronized, increasing at the
same time with an accompanying silent pause that directly
follows it. Sleep Facts
Interestingly, occasionally a sleep spindle, a burst of Marine animals have
brainwave activity, appears at the end of a slow wave. almost no REM sleep
Sleep spindles have multiple purposes, but one of them is because the muscles
to shield sleep by blocking out external noises. are turned off and they
must retain muscle
movement to stay aware
of their environment.

Page 14
Sleep Rhythms
What time is it?
Our bodies know when to wake up and go to bed based on signals from our Circadian
Rhythms. Along with sleep pressure and melatonin, they drive the various stages of the
sleep/wakefulness cycle.

Circadian Rhythms

Circadian rhythms are biochemical, physiological, and behavioral cycles in all living
things. In humans, they rise and fall in 24-hour cycles.
Numerous clocks throughout the human body drive circadian rhythms. Think of them as
pacemakers.
Circadian rhythms are important because they:
 Prepare the body for expected environment
Sleep Facts
changes (like exercise, sleep and meal Dolphins use both sides
times) of the brain to stay
vigilant. NREM
o Set the sleep and wakefulness cycles
alternates between the
o Promote sleepiness at usual bedtime
two sides which allows
o Initiate sleep
for one side of the brain
o Promote wakefulness before usual
to be alert at all times.
wake-up time

Page 15
  Set the timing for other circadian rhythms that regulate physiology and
behaviors
o Hormones
o Body temperature rhythm (higher in late afternoon and lower when we
sleep)
o Eating and digesting food
The pacemaker has an internally driven 24-hour rhythm that urges the body to wake up
at the beginning of the day and go to sleep at night.
The day/night rhythms remain unchanged, preferring sleep at nighttime and
wakefulness in the daytime.
External cues also impact the cycle.

Light and the Brain

Light and dark are the strongest cues for
circadian rhythms. Exercise and melatonin
also appear to influence the timing of the
pacemaker, but not as much as light. Normally,
light enters the eye (even through closed
eyelids during sleep) and signals the
pacemaker to wake up, perform certain
activities, and go to sleep.

Page 16
Individual Rhythms
 Rhythms vary from person to person Sleep Facts
 Early birds and night owls Some seals, who spend
 Partially genetically determined both time on land and
 Impact work productivity time in the water, have
Not all humans have precisely the same circadian rhythm. REM sleep on land
You probably already know whether you’re an early bird (when no aquatic
or a night owl. movement needed), and
enter only NREM sleep
This is determined partially by genetics.
under water.
Our own rhythms can work with or against our work
schedules. If you’re a night owl and naturally prefer to go
to bed late, it can be difficult to work an 8 a.m. - 5 p.m. schedule. The later sleep cycle
and earlier wake time can make it challenging to concentrate, have positive work
relationships and complete work duties.
Sleep Pressure
Another part of the sleep cycle is something called sleep pressure, caused by a steady
increase of the chemical adenosine in the brain, which builds up in the body during
waking hours and causes an increasing urge to sleep.
For most, this usually happens after
12 to 16 hours of wakefulness. The
pressure gets stronger the longer we
stay awake and decreases during
sleep, reaching a low after a full night
of good quality sleep. The cycle
repeats when we wake up.
The dashes in the graph show that
sleep pressure continues to increase if
we do not sleep, and resets when we
go to sleep.
Our body produces a higher need for
sleep under some circumstances, where sleep could be longer and/or deeper. Sleep
pressure increases:
 During illness/infection
 Learning/brain stimulation
 Intense physical demand
 Pregnancy

Page 17
Melatonin
The brain communicates day and night signals to the body by the way of a messenger
called melatonin. It is released into the bloodstream at dusk to send a message that it’s
dark. Melatonin concentrations slowly decrease throughout the night.
Example: When it gets dark earlier and nights are longer, have you ever felt like it was
time to go to bed earlier?

Although it is an extremely popular sleep aid, melatonin does not have anything to do
with the generation of sleep. Think of it as the timing official at a race. It signals the start
of the race but does not participate in it.
It can be helpful for jet lagged individuals whose nights and days
have been altered but it’s not a very effective sleep aid for those
on a regular night/day cycle. However, there is a significant sleep
placebo effect which should not be underestimated.

Caffeine
As adenosine builds up through the day, working with circadian rhythm and melatonin,
its signal to go to bed gets louder and louder.
Caffeine, which is the most widely used psychoactive stimulant in the world, fights the
sleep pressure chemical for the receptor sites on the brain that welcome adenosine.
Once caffeine occupies the landing sites, it masks the sleep signal, tricking the brain
into thinking it’s wide awake.
It takes about 30 minutes for the effects of caffeine to peak. It also has a half-life of 5 to
7 hours. Half-life means the time it takes the body to remove 50% of the concentration.
If you drink a cup of coffee with dinner at 7 p.m., your body would rid 50% of it at 1 a.m.,
Page 18
so about half the caffeine continues to circulate throughout the body. For this reason,
limiting caffeine intake to earlier in the day can be very helpful in improving sleep.
Synchronized Rhythms
The red line represents when we’re awake and the blue line represents sleep pressure.
Our feeling of being awake rises until it begins to diminish in the evening. At the same
time, the moment we wake from sleep, sleep pressure starts to build up again. Once we
fall asleep, the pressure clears out by morning.
If you have a normal
day/night wake/sleep
schedule, sleep pressure and
circadian rhythms are
synchronized. It would seem
logical to think that the
circadian cycle would
communicate with adenosine,
but in fact they do not.
Although they are
coordinated to work toward a
common goal, they do not
talk to one another.

De-synchronized Rhythms
Circadian rhythms, melatonin
and sleep pressure all march
along on the 24-hour cycle that
induces sleep at night and being
awake during the day. If we do
the opposite and stay awake at
night, all of these processes
continue to release signals and
chemicals signaling the body to
sleep at night. This
desynchronization causes
extreme fatigue and body
disruptions.

Page 19
Sleep Debt
When we don’t get enough sleep, we go into "sleep debt,” which builds over time. We
must catch up on sleep to "pay down" this debt. For example, a person needing 8 hours
of sleep but getting only 6 hours would accumulate a sleep debt of 2 hours that day. If
they continue for 5 days, they’ll have 10 hours of sleep
debt at the end of the week.
To keep sleep debt down, get the length of sleep you Sleep Facts
need in order to feel rested when you wake up. Allow Bird flocks line up in a
extra time to sleep if you were not able to get enough row to sleep. The two
sleep the previous night. A person does not necessarily end birds act as
need to pay back hour for hour of lost sleep since the sentinels, keeping the
body sometimes sleeps more soundly to pay down the outside eye open and
debt. that part of the brain
However, it is a bad idea to build up sleep debt regularly watchful for predators.
and try to pay it off later by catching up on sleep. Although Halfway through the
your level of sleepiness may return to normal after a day sleep cycle, they both
or two of recovery sleep, your brain and body functions turn 180 degrees, open
continue to be somewhat compromised when compared to the other eye and
your well-rested norm. It is extremely important to get activate the other side of
enough sleep on a regular basis rather than sporadically the brain.
on a continuous basis.

Sleep Cycles

Page 20
Humans don’t just sleep, they cycle through two completely different types of sleep in 5
cycles that repeat but are not symmetrical.
There is more deep NREM sleep earlier in the night, whereas REM sleep predominates
in the second half of the cycle.

Sleep Facts
People who are
sleep deprived do
not have the ability
to gauge how tired
they are.

Page 21
Sleep Cycle Video
Watch the video.

Non-Rapid Eye Movement (NREM)

Physical and electrical characteristics:
 Inactive muscles
 No eye movement
 Slower brainwaves

Hippocampus
Throughout the day, our brains absorb an incredible amount of information, which is
stored in the hippocampus. If you took the Stress-Proof Brain Wellness Series, you’ll
recall that the hippocampus is the biographer of the brain
– it writes down the stories of the day. However, it is only
temporary storage as it has limited space. NREM sleep
identifies which of these stories are important enough to
store permanently and with every slow brainwave,
transfers them into permanent storage in the cortex.
If we do not get enough sleep, NREM does not effectively
“clean house” in the hippocampus. As a result, we have
trouble absorbing and temporarily storing information the
next day. When sleep deprivation is chronic, it poses
continued memory problems.

Page 22
Also, when we absorb information the day prior, it can sometimes be difficult to recall
just before sleep. NREM refreshes the brain and allows for recall the next morning. After
a night of adequate NREM, we’ve all experienced a moment where we say, “Oh! I
remember now…”

NREM for Skill Memory

When we learn new skills that require movement, like riding a bike, typing
on a keyboard or playing the piano, we cannot learn them by simply
reading a book. They require repetitive and coordinated muscle
movement. We often refer to this type of learning as muscle memory,
when in fact, muscles do not have memory. The memories exist in the
brain, and with repetition, practice and time, the brain creates increasingly
strong neural pathways (information superhighways) to the muscle, giving
it instruction to perform the skill.
Research has found that increasing speed and accuracy resides in stage
2 NREM sleep, especially the last two hours of an 8 hour night. Skill
memory is linked to a high number of sleep spindles occurring at that
time.

Rapid Eye Movement (REM)

During rapid eye movement sleep, brainwaves are fast and remarkably similar to those
of wakefulness. If hooked up to a sleep tracking machine, the only distinguishing factor
would be that of a lack of muscle activity during REM. There is no muscle tone at all.
REM sleep has other unique characteristics. In deep Non-Rapid Eye Movement
(NREM) sleep, the floodgates from the thalamus to the cortex close, effectively blocking
external “noise.” During REM sleep, the gates open, but not in the same way as
wakefulness. Memories, emotions, motivations and many other signals reach the cortex
and are played out in different areas of the cortex that control hearing, vision and
movement.
REM sleep also produces dreams.
Key functions
Unlike NREM, which stores factual memories, REM processes these signals and refines
our understanding of the real world, including insight, problem solving and
communication. It also induces a therapeutic effect in ridding our brains of trauma and
negative emotional experiences, helping to maintain emotional health.
As highly evolved animals, REM plays a role in cognitive intelligence and our
understanding of the complexity of society and culture.

Page 23
Sleep Across the Lifespan
As we age, both circadian rhythms and NREM sleep change. They interconnect with the
brain in ways that both support early brain development, or, are affected by brain
degeneration later in life.

In Vitro and Infants

The brain develops at an intense and extremely directed way during this time. REM
sleep acts as a fertilizer for growing brain cells, which increases electrical activity,
creating and increasing millions of neural pathways and synapses between different
areas of the brain.
REM sleep is vital in building the brain mainframe. The objective is quantity because the
brain creates as many connections as possible to
provide for multiple ways of absorbing information
and learning. However, this creates redundancy,
which is addressed later in childhood. Also, baby’s
circadian rhythms don’t develop until after the first
few months of life where they finally start to show
signs of sleep rhythms. This explains the erratic
sleep of a newborn.
In the womb, a fetus spends the majority in REM
sleep and babies split their time 50/50 between
REM and NREM. Sleep disruption during this time is extremely serious as vital brain
development halts if REM sleep is interrupted. Over time, it never fully catches up.
A good analogy for early developmental brain growth is that of an internet service
provider laying fiber-optic cables in a new neighborhood. They lay the same type of
cable to all homes, providing the same bandwidth.

Page 24
Childhood
In mid to late childhood, the brain builds and learns from millions of experiences and
shifts focus to create efficiency and effectiveness. Here, the original brain architecture
begins to refine all of those connections, recognizing and choosing networks that are
quicker, more useful and efficient. NREM/REM ratio shifts dramatically to a 70/30
dominance of deep NREM sleep, which prunes the brain’s connections. It is also critical
in retaining new facts and cementing memories.
Continuing the internet analogy, we can liken this to the internet provider researching
which households need more data and which don’t use much, and programming the
cables to deliver stronger signals to the areas that need it most, and dial down signals in
lower-use households.
As children mature into adolescence, a markedly higher percentage of deep NREM
sleep develops cognitive reasoning and critical thinking.

Adolescence
Adolescents and young adults continue to broaden their cognitive capacity, building the
brain that will eventually develop into an adult brain capable of making complex
decisions, rational thinking, peer-group relationships and communication.
They face two challenges during this stage: a later circadian rhythm and early school
start times.
As any parent of a teenager knows, it can be frustrating to find their child awake late
into the night and unable to wake up in the morning. It turns out this is developmentally
normal in sleep cycles and brain development. Having to wake up early for an early
morning school start time poses a challenge for brain development and academic
performance.
If you have or will have a teenager in your home, it’s important to support their sleep
rather than label it as laziness. Go easy on your teenager; their brains are hard at work
and need the sleep!

Early Development & Mental Health

Both sleep types (NREM and REM) are critical for brain development. Insufficient
NREM in teenagers is linked to psychiatric disorders. Common disorders that appear in
childhood and adolescence:
 Bipolar disorder
 Schizophrenia
 Major depression
 ADHD
Altered or insufficient sleep during these critical stages early in life can have profoundly
negative effects on healthy cognitive function. NREM sleep in teenagers provides some
understanding of sleep’s connection to mental health.
Page 25
Adulthood and Aging
It is a myth that adults and older adults need less sleep. In fact, they need just as much
sleep as younger counterparts, and studies show they try to get enough, but aspects of
aging can make it difficult to fall or stay asleep.
As we age, we experience reduced quantity and quality of sleep, reduced sleep
efficiency and disrupted timing. REM sleep remains fairly constant throughout the
lifespan, but NREM sleep begins to degenerate in both quantity and quality in the late
twenties to early thirties. By our forties, our time spent in NREM sleep diminishes.
These restorative brainwaves decline in both number and power. By the late forties, we
experience 60-70% less NREM than teenagers, and 80-90% by the time we’re seventy.
This decline in NREM is directly related to degeneration of certain parts of the brain
associated with aging. The middle-frontal region generates NREM sleep, and
unfortunately is the first to decline. The more severe the deterioration of this region, the
more dramatic the loss of NREM.
Let’s recall how important NREM is in childhood and adolescence in cementing
memories and learning. Understanding that NREM suffers as we age, it’s not difficult to
draw a strong connection between sleep, forgetfulness and reduced cognitive function.

NREM Decline and Health

The decline in all aspects of sleep has a strong causal link to health, energy, memory
and mental health. Older adults often seek help for medical conditions but do not seek
guidance for sleep improvement from a sleep medicine professional. Not all health
conditions can be attributed to poor sleep quality and quantity; however, much research
points to a significant decline in quality of life as NREM sleep declines.
The further along in the lifespan, the more fragmented our sleep becomes. Medications,
a weak bladder and changing circadian rhythms disrupt sleep efficiency. Even if sleep
opportunity is 8 hours, frequent wake-ups during the night result in less time asleep.
This puts adults at a higher risk of disease, depression, memory loss and falling.
Scientists are researching how to address NREM decline in older adulthood in hopes of
improving quality of life.

Page 26
 Session 3:
The Good, the Bad and the Deadly
Review

The body generates sleep:

 Circadian rhythms
 Sleep pressure
 Melatonin
Two types of sleep:
 NREM
 REM
Sleep changes as we age.
Sleep impacts mental, physical and emotional health.

Sleep Tips
 Avoid exercise 2-3 hours before bed.
 Avoid nicotine. It’s a stimulant and causes light sleep.
 Avoid large meals and beverages at night.
 Naps are great earlier in the day.
 When possible, delay medications that keep you awake.
Check with your doctor.
 Wind down and relax before bed.
 Take a hot bath; it’ll drop your body temperature and make you sleepy.
 Check the environment. In addition to light and temperature, humidity affects
sleep.

Effects of Sleep Deprivation

There are so many benefits from a good night’s rest. What happens when we don’t get
enough? Watch the video.
 Acclimation to a state of deprivation
 Lack of concentration can be deadly
 Poor sleep and mortality exponential
 Fatigue and forgetfulness

Page 27
Deprivation Acclimation
 Our bodies get used to how we feel when sleep Sleep Facts
deprived Drowsy driving
 Function at a lower mental capacity causes more
 Feel tired and more irritable or depressed accidents than
 Reduced physical performance alcohol and drugs
 Unaware that this happened combined.
Over months and years of low level deprivation, we acclimate to
reduced energy levels and lower level functioning. We’re unaware of the mental and
physical performance degeneration, as well as the disastrous health effects that
accumulate over time.
Some people maintain that they do just fine on 5 to 6 hours of sleep. If assessed in a
sleep lab; however, the evidence would show to the contrary. Only an infinitesimally
small percentage of people successfully function on so few hours of sleep. If you
believe you’re one of them, it is extremely unlikely. To quote Dr. Thomas Roth (Henry
Ford Hospital), “The number of people who can survive on five hours of sleep or less
without impairment, expressed as a percent of the population, and rounded to a whole
number, is zero.”

Lack of Concentration
 Declines even with minimal sleep loss
 Slowed response time Sleep Facts
 Shortened focus duration
 Microsleep - loss of consciousness More than 250,000
people fall asleep at
o Eyes partially open or closed the wheel every
o No visual or motor perception day.
 Extremely dangerous while driving
 2 seconds can be fatal

Of all the dire consequences sleep deprivation inflicts, none suffers more quickly than
concentration. Even the smallest loss of sleep reduces the ability to focus. When behind
the wheel of a car, drowsy driving is as dangerous as driving under the influence of
drugs or alcohol.
Drivers very rarely fall completely asleep at the wheel; instead, they suffer from a
momentary lapse of consciousness called a microsleep. During microsleep, eyes can
be partially or completely closed. The brain loses sense not only of the outside world,
but its own perceptions, including visual and motor actions. Behind the wheel of a car,
two seconds is enough to kill.
In a study on the effect of sleep on concentration, one scientist took a group of
individuals into his laboratory for 14 days straight. They had 8 hours of sleep, measured
by the lab, every night, and were put through a concentration test. The experiment
Page 28
consisted of the participant pushing a button when a light appeared on a screen. Both
the responses and time to respond were recorded. After 14 days, researchers divided
the subjects into 4 groups that were given different “doses” of sleep deprivation for
another 2 weeks. The first group was kept awake for 72 hours straight, the second was
allowed 4 hours per night, the third 6 hours per night, and the last group remained the
control, continuing to get a full 8 hours rest.
Scientists observed striking results. It’s pretty obvious that those who lacked sufficient
sleep had slower reaction times and shortened concentration, but in addition, at
times, participants would stop responding altogether. The slower response speed
was not the most disturbing, but rather, a lack of response altogether. These
microsleeps were a complete loss of consciousness. Translated into a real world
scenario, this is all of the time it takes to strike a child who runs out into the street to get
a ball.
It’s not surprising that the control group maintained a Sleep Facts
steady and consistent response rate during the second 2
weeks, nor that the group that stayed up for 72 hours A car accident caused
increased the rate of missed responses by 400%. What by sleepiness occurs
was surprising, however, were the results from the groups every 30 seconds in the
who received 4 and 6 hours of sleep. After six consecutive U.S.
days of 4 hours of sleep, that group’s response rate MYTH: If driving while
decrease by 400% as well. By day 11, it was even worse. sleepy, rolling the
After ten days, the 6 hour sleep group’s results were akin window down, playing
to staying awake for a full 24 hours. This is extremely eye the radio loudly or talking
opening, given how common 6 hours of sleep is for many on the phone do not
adults. help drivers stay awake.

Drowsy vs. Drunk Driving

Later studies compared drowsy and drunk
driving impairment. After 19 hours of being
awake (ex: 6 a.m. - 1 a.m.), participants
were just as impaired as someone who
was legally drunk (0.08 blood alcohol).
Now consider what the response times
would be if an individual were both tired
and intoxicated.
It would stand to reason that the impact
doubles, but in fact, it multiplies.

Page 29
In a study using a driving simulator, four groups of various sleep deprivation doses and
inebriation doses were tested. Scientists predicted that those under the influence of
both, based on the results of the other groups, would deviate from the simulated road
12 times more often than a well-rested individual. What they found was they deviated 30
times more.
If you’re still not convinced drowsy driving is an epidemic in the Sleep Facts
developing world, make sure to read the Sleep Facts scattered
throughout this section. Drowsy driving is
responsible for
1,550 fatalities and
40,000 nonfatal
Brain Anatomy and Feelings injuries annually in
Two different areas of the brain light up in different ways where the United States.
emotion is concerned. The amygdala is the first responder to
external stimulus. It triggers an alarm when it thinks danger,
stress or conflict are present. Its job is to protect us by triggering a “fight or flight”
response, which releases a whole cascade of hormones such as cortisol and
adrenaline. These and other hormones increase heart rate and breathing and engage
muscles to leave the scene.
While serving an important purpose, if the “fight or flight” becomes chronic, the body
remains in a high sense of alert, stress and emotional stimulation (not the good kind!).
The amygdala is not capable of classifying the external stimulus as good or bad. It is
therefore important that its connection to the prefrontal cortex is a superhighway, and
not a small path.
The prefrontal cortex is the brain’s CEO. It processes information on a higher level,
assessing in a critical, logical and organized way, allowing the brain to identify what type
of response or emotion is appropriate to the situation. Quality sleep helps to strengthen
and speed up the neural connections between the amygdala and the prefrontal cortex,
allowing us to regulate emotions.
Studies also show that in sleep deprivation, not only is the connection weakened,
amygdala activity increases, which means we’re much more prone to moodiness,
anger, and a diminished ability to read others’ emotions.
It bears noting that stress management also reigns in an overactive amygdala and
promotes its communication with the prefrontal cortex. And since sleep impacts our
stress levels, all roads lead back to the importance of a good night’s rest!
Emotional Consequences
 Irrational anger
 Irritability
 Mood swings (including positive)
 Aggression
 Bullying
 Violence
 Cravings and addictions
Page 30
Emotional brain consequences are many fold.
Think about the implications this has both in our personal lives and in the workplace.
We can all think of a time when we were tired that we flew off the handle and
overreacted.
We’re much better equipped to handle peer and family relationships and
communication, and are much more likely to seek out social connections, when we’re
able to successfully control stress and emotion.

Psychiatric Disorders
All major conditions exhibit abnormal sleep:
 Depression
 Anxiety
 PTSD
There is not one psychiatric disorder that exhibits normal sleep.
Mental health clinicians have always assumed that sleep disturbance is the result of the
disorder, suggesting a one way relationship between the two.

New Research
 Brain regions impacted by mood disorders are the same as sleep regulation
and loss
 Abnormal genes in some psychiatric disorders are the same as circadian
rhythm control
Certain disorders possess the very same brain region abnormalities as those
associated with sleep regulation and sleep loss. What’s more, genetic research has
found that genetic abnormalities evident in some disorders are the very same that are
responsible for circadian rhythm control. This is not to suggest that sleep loss causes or
can cure mental health disorders, only that there is more of a two-way relationship than
once believed.

Alzheimer’s Disease
A public health challenge.
 Over 40 million people suffer from Alzheimer’s (Walker, 2017)
 1 in 10 over the age of 65 have it (Walker, 2017)
 Longer lifespan and decreased sleep time will increase this number
in the future
 Sleep is key lifestyle factor
 No treatment or cure
 Exaggerated sleep disturbance

Page 31
 o Early warning sign?
o Contributes to disease?
o Sleep and disease in negative spiral
 NREM
 Beta-amyloid and glymphatic system
Alzheimer’s is a brain disease that continues to be misunderstood, with no prevention or
treatment available. In years of research, scientists have discovered that there’s a build-
up of a toxic protein called beta-amyloid. It collects in sticky clumps in the brain and kills
off brain cells in some (but not all) areas of the brain.
Sleep and the disease are intertwined in a negative spiral which worsens the condition.
Looking at an Alzheimer’s sufferer’s sleep, we would see that it is much more disrupted
than the normal NREM decline associated with aging. Exaggerated sleep disturbances
begin occurring several years prior to the onset of Alzheimer’s, meaning it could be
either contributing to it or an early warning sign. The degree of sleep disruption mirrors
that of the severity of the disease - the more jarring the sleep, the worse the disease.
Scientists discovered brain “power cleaners” called glial cells. They form the glympathic
system, which acts much like the lymphatic system in the body, a sewage system that
cleans out unwanted waste. Among this metabolic waste is the sticky amyloid and
other proteins that may be linked to Alzheimer’s. Clean-up occurs during NREM. This
finding adds yet one more compelling reason to give ourselves the opportunity for both
types of sleep throughout life.

Sleep and the Body

In addition to brain benefits, sleep keeps our bodies healthy:
 Heart health
 Immunity
 Cancer
 Weight gain/obesity
 Diabetes

Page 32
Heart Health
Sleep is blood pressure medication.
Quality sleep provides a healthy dose of
(free) blood pressure medication. With as
little as 1-2 hours of sleep deprivation, our
bodies begin to decline. Our heart rate
accelerates and our blood pressure goes up.
In essence, we’re triggering a “fight or flight”
response. With a release of stress
hormones cortisol and adrenaline, we’re
primed and pumped.
As we discussed earlier, living in a chronic
state of stress damages the body. Blood vessels deteriorate and no longer function
properly; They’re prone to plaque buildup and hardening of the coronary arteries.
What’s worse, the healing benefits of growth hormone is altered during stress/sleep
deprivation, so we lose our ability to repair the damage.
During NREM sleep, the brain sends calming signals to the sympathetic nervous
system to provide much needed relaxation and repair.
The chronically sleep deprived are at an extremely high risk for cardiovascular
disease, heart attack and stroke.
Immunity
Sleep and immunity go together:
 Disease-fighting superpowers diminish
 When we’re ill, we need more sleep
Good sleep:
 Fosters stronger immunity
 Produces protective antibodies

The connection between illness and sleep is two

way. When we lack sleep, disease-fighting
superpowers diminish. When we’re ill, our need for sleep increases in order to combat
the illness. Together with a healthy diet and regular exercise, sleep is the foundation for
a strong immune system. We are born with an army of disease-fighting defenders,
natural killer cells that mobilize and attack foreign bacteria, viruses and cells. With even
a small sleep deficiency, killer cells are less effective.
One researcher at the University of California San Francisco performed an interesting
study on 150 participants willing to subject themselves to a flu virus. First, he measured
their sleep using a wearable device for one week. Second, he quarantined them in a lab
and injected them with a flu virus. Samples of blood, saliva and mucus were collected to
track the immune response. Based on antibody levels in the blood and saliva, he
Page 33
determined who caught the flu. The scientist then separated them into 4 groups based
on the number of hours of sleep obtained the week prior. The infection rate for those
that slept an average 5 hours was 50%, whereas the rate was only 18% for those that
slept 7 or more hours. (Walker, 2017)
Sleep also affects our ability to build antibodies. When scientists administered the flu
vaccine to 2 groups of adults with different sleep amounts, they found something
surprising. Those that slept 4 hours for 6 nights produced only half the flu-fighting
antibodies that their counterparts who got a full night’s rest did. Studies on Hepatitis A
and B vaccines produced similar results.

Cancer
The science showing the link between lack of sleep and cancer is so strong, that the
World Health Organization has classified nighttime shiftwork as a “probable
carcinogen.”
We now know that people who work nights are at an astronomically higher risk of
developing disease, including cancer. Chronic inadequate and low quality sleep
compromises the immune system and every organ and tissue in the body. Our army of
natural killer cells, when robust and fortified by sleep, are capable of destroying
malignant tumor cells. A disrupted circadian rhythm renders killer cells less effective.
There’s evidence that getting half the recommended hours of sleep (4 hours), reduces
killer cell circulation in the immune system
by 70%. (Walker, 2017)
Individuals with less than 6 hours of sleep have a 40% higher risk of developing cancer
than those who get between 7 and 8 hours. In addition to being higher risk, if cancer is
present, it spreads much more quickly.

Page 34
Metabolism: Weight Gain & Obesity
 Hunger hormones disrupted
 “I’m full” signal turned off (leptin)
 “I’m hungry” signal amped up (ghrelin)
 Consume additional 300 calories per day
 10-15 pounds weight gain per year
 Pre-frontal cortex turns off when food is
present
Watch the short clip.

It referred to the skewed interplay of hunger hormones leptin and ghrelin when we’re
tired. Not only is our “I’m full” signal turned off, but our “I’m hungry, feed me please,”
dials up. We crave quick energy sources - carbs and sugar. The more tired we are, the
more we eat, and the more weight we gain. Couple fatigue and the lack of desire for
physical activity, and we have a recipe for obesity.
Studies show we eat up to an additional 300 calories per day when we’re sleepy. Add
that up across a year, and the scale creeps up 10-15 pounds!
Researchers also studied brain activity patterns of sleep deprived individuals about to
partake in a meal. Remember the pre-frontal cortex, the brain’s CEO in charge of self-
control, reasoning and logical thinking? We remember from earlier that communication
and signals decrease when we’re tired. When shown images of food, participants’
prefrontal cortex remained quiet, while the areas of the brain associated with pleasure
and desire lit up.

Diabetes
A serious health condition where the body is unable to control
blood sugar levels.
Individuals with diabetes are at a high risk for:
 Blindness
 High blood pressure and heart disease
 Kidney failure
 Nerve problems and limb amputations
Both fatigue and a poor diet lead us on a path to diabetes. In healthy individuals, the
release of insulin successfully maintains glucose levels. Over the years, unmanaged
diabetes damages the body and shortens life span. Their life expectancy is 10 years
shorter than that of a healthy individual.
 Sleep loss - major contributor to type 2 diabetes
 Link between sleep and blood sugar
 Cells become less responsive to insulin
 Financial impact
o About $85,000 treatment costs annually
Page 35
Research has shown a connection between sleep loss and abnormal blood sugar
levels. In one early study on diabetes, a group of otherwise healthy adults were allowed
only 4 hours of sleep in a lab for 6 nights. In only 6 days, researchers found that their
ability to absorb glucose by releasing insulin had reduced by 40%! We now know that
the cells themselves become far less responsive to insulin, resisting insulin’s message
for cells to open their receptors and absorb it.
The disease also impacts financial health. The average treatment cost for a diabetic is
$85,000 per year. Evidence has shown that chronic sleep deprivation is a major
contributor to type 2 diabetes, and is a completely preventable contribution. (Walker,
2017)

Mindfulness Based on Science

Mindfulness and sleep share similar benefits, PLUS minfulness helps you fall asleep.
 Affects at least 8 parts of brain
 Self-regulation
 Memory
 Focus
 Motivation
 Compassion
 Resilience

Mindfulness
 A state of attention and focus on the present
 Active skill, not zoning out
Types:
 Breathing exercises
 Mindfulness of the senses (touch, sound, taste,
smell)
 Meditation
 Yoga

Page 36
Breathing Exercises
 Calms the amygdala and sympathetic nervous system (like
REM)
 Blood pressure and heart rate return to normal levels
Breathing exercises are the most common form of mindfulness.
When you get stressed, your breathing becomes faster and
shallower as your sympathetic nervous system prepares you for
fight or flight. When the stressful situation is over, your
parasympathetic nervous system kicks in and slows down your
breathing. With mindfulness, you purposely slow your breathing
down and this slows down your heart rate. The parts of your brain
responsible for sensing movement and breathing send signals to
your amygdala that the threat is over and the whole system begins
to calm down.
We’re going to try a short breathing exercise now. Remember as you go through this
that there is no wrong or right way to do this. Do not change anything, simply notice
where you are and do not judge or worry if you’re doing it right. Most importantly, be
open to the experience!
Watch the video.

Page 37
 Session 4:
Awake at Night – the Downside of the
Modern Age
Sleep Disorders
There are over 100 classified sleep disorders. We’re going to cover only the most
common; however, there are more resources in the Appendix. If you feel you may have
a sleep disorder, start with your primary care physician, who will make an initial
assessment and provide next steps as necessary.

Insomnia
 Most common sleep disorder
 NOT sleep deprivation (able to sleep but inadequate sleep opportunity)
 Insomniacs have adequate sleep opportunity but are unable to sleep
Two types
 Sleep onset
 Sleep maintenance
 Can have one or the other or both
Diagnostic Criteria
 Unsatisfied with length or quality of sleep
o Falling asleep
o Staying asleep
o Waking early
 Significant impairment during the day
 At least 3x/week for more than 3 months
 No existing mental or medical conditions
that can masquerade as insomnia
Insomnia Triggers
 Emotional concerns and worry Sleep Facts
 Emotional distress and anxiety 10 million Americans
 Psychological (mental health disorders) take a sleeping aid
 Medical every month.
 Physical
o Aging, caffeine and alcohol consumption, physical activity

Page 38
Prevalence / Risk Factors
 Extremely prevalent
 40 million people (1 in 9 Americans)
 If guidelines were 1x/week, 2/3 of population would be insomniac
 Twice as common in women
 African and Hispanic American - increased risk
A note about African Americans and Hispanic Americans. Both of these groups have a
higher prevalence of cardiovascular disease, diabetes and obesity, so it’s not surprising
that we also see a higher likelihood of insomnia.

Page 39
Physical Effects
As with other conditions, an insomniac has the inability to
wind down and shut active areas of the brain down. Their
sympathetic nervous system remains activated, remaining
in the “fight or flight” state resulting in elevated heart rate
and blood pressure, metabolic rate and release of stress
hormones.
Those suffering from insomnia also have a higher core
temperature (remember, our body temperature drops for
sufficient sleep). When sufferers remain in the “fight or
flight” mode, they are in “alertness” mode and release
cortisol, adrenaline and noradrenaline into the blood
stream. When we look at the brainwaves of someone who has chronic trouble finding
sleep, the activity pattern is different than that of normal sleep. The emotion-centered
amygdala, and the memory-linked brain keeps the brain in a constant memory of
reliving past experiences and worrying about the future. Insomniac brains, once asleep,
achieve more shallow NREM and fragmented REM.

Old School vs. New School: Sleep in the Modern Age

Our ancestors followed the most innate circadian rhythms.
Sleep Facts With no electricity or temperature control, they rose with the
sun and went to bed when it got dark. Even after the discovery
The use of an iPad of fire and later gas lamps, nighttime activities such as
reduces melatonin storytelling and singing or playing an instrument were
release by 50% at subdued, and bedtime continued to be much earlier.
night.
Electricity and the invention of the lightbulb changed
everything. Humans could extend the daylight hours and
maintain warmer temperatures inside. Televisions and
eventually computers came to every household.
In 1997, Japanese engineers invented the LED (light
emitting diode). Unlike other
forms of light, LED emits
Sleep blue light. The human eye is
Facts particularly sensitive to blue
in the color spectrum which
90% of Americans suppresses the nighttime
use some form of release of melatonin by 50%
LED electronic when compared to a warm light incandescent bulb.
device less than
60 minutes before
bed.

Page 40
Sleep Apnea
A condition where the upper area of the breathing airways closes up and cuts
off/interrupt breathing until you wake up again.
 Affects 18 million Americans
 Frequent awakenings prevent sufficient restorative deep sleep
Higher risk for:
 Behavior and mood problems
 Tripled risk of car accidents
 Increased headaches
 Trouble concentrating, thinking clearly, learning, remembering
Because people who have sleep apnea frequently go from deeper sleep to lighter sleep
during the night, they rarely spend enough time in deep, restorative stages of sleep.
They are therefore often excessively sleepy during the day. Such sleepiness is thought
to lead to mood and behavior problems, including depression, and it more than triples
the risk of being in a traffic or work-related accident.

The many brief drops in blood-oxygen levels that occur during the night can result in
morning headaches and trouble concentrating, thinking clearly, learning, and
remembering. Additionally, the intermittent oxygen drops and reduced sleep quality
together trigger the release of stress hormones. These hormones raise your blood
pressure and heart rate and boost the risk of heart attack, stroke, irregular heartbeats,
and congestive heart failure.

Page 41
Signs of Apnea
Common signs of apnea:
 Loud, consistent snoring
o Wake up gasping for air
o Stop breathing momentarily
o Making choking sounds
 Waking up tired
 Sleeping with mouth open
 Waking up due to breathing difficulty
If you know or have been told by your partner that you snore, stop breathing or gasp for
air, the best place to start is with your primary care physician (PCP). Your PCP can
exclude other issues, determine if a sleep study might be warranted, and refer you to a
sleep specialist.

Sleep Facts
What is a Sleep Study? The optimal sleep
temperature is
Watch the video. about 65 degrees
Fahrenheit.
UnitedHealthcare (UHC) Cost Estimator
Find sleep specialists on www.myuhc.com. You’ll also want to use the cost calculator to
get an estimate of the cost of a sleep study. Providers negotiate different contracts with
insurance companies, so some are much more affordable to you than others (usually
depending on the location of the study).
Log into www.myUHC.com:
 Find Care and Costs
 Cost Estimates
 Office Visit
 Specialist Visit
Keep in mind that at-home sleep studies are much less
expensive. There is specific medical criteria and physician
documentation that is required in order for insurance to
cover part of the cost.

Page 42
Somnoambulism
Somno = sleep | Ambulism = movement
 Sleep walking
 Sleep eating
 Sleep talking
 Sleep texting
 Sleep homicide (very rare)
Scientists aren’t sure why this moving during sleep happens, but one guess is that there
is a spike in the nervous system which jolts the brain from NREM to consciousness but
gets stuck in the middle. It is somewhat common, especially in children, and unless it
poses a safety or health risk, is not dangerous.
 Not REM dream sleep (remember muscles are completely turned off!)
 In NREM sleep

Take a Chill Pill (or Not)

Natural sleep is far different than the “sleep” that comes out
of a prescription bottle, which actually increases health
risks. Sleeping pills are sedative hypnotics, so rather than
helping us to sleep, they sedate us. When compared,
sedative brainwaves lack the largest and deepest
brainwaves natural sleep entails. Additionally, side effects
include inability to cement memories, grogginess and slowed reaction times. This may
induce a vicious cycle where we consume more caffeine to stay awake, only to have
trouble falling asleep the following night, thereby perpetuating the insomnia.
Sleeping pills also induce an insomnia rebound effect. We build up a tolerance to the
drug and when the drug is stopped, our brains go through a withdrawal process. This
usually entails far worse sleep than prior to taking the pills.
When a committee of researchers reviewed published studies on newer sleep
sedatives, they found that although individuals reported that they fell asleep faster, slept
more soundly and woke up less often. When subjected to a sleep test that looked at
brainwaves, that was not in fact the case. The amount of time it took individuals to fall
asleep on the placebo versus the medication was roughly the same, so there was no
benefit to the medication beyond what the placebo effect accomplished.*
*Source: T.B. Huedo-Medina, I. Kirsch, J. Middlemass, et al. “Effectiveness of non-benzodiazepine
hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug
Administration,” BMJ 345 (2012): e8343

Page 43
Pill Pitfalls
 May weaken brain connections associated with learning and memory
 Higher likelihood of developing cancer
 Higher risk of fatality
o Could be due to lowered immunity
o Higher risk of fatal drowsy driving
o Incurred health risk due to poor sleep prior to meds
In animal studies, the use of Ambien to induce sleep showed that the drug actually
weakened the neural connections that form during learning and cementing memories.
Doctors are now prescribing sleeping sedatives to younger and younger populations,
which is concerning since the brain is in full development and increasing and refining
these connections.*
Another concerning effect of sleep aids such as Ambien is that individuals who use the
drug are much more likely to develop cancer than those who did not.^ In 2012, over
10,000 individuals taking Ambien or Restoril were followed across two-and-a half years.
They were compared against a group of 20,000 that were not. After controlling for many
factors, including BMI, smoking, exercise history and drinking, those that took sleeping
pills were 4.6 times more likely to die over this two year period. The more frequent use,
the higher the likelihood of death compared to those not using sleep aids. Fifteen other
studies to date have shown similar findings.
The reason for higher mortality rates is hard to answer from available data. One
frequent cause of death is the risk of infection. Remember that natural sleep provides
strong immunity. Sleeping pills that sedate users do not offer these health benefits.
Another potential cause of death is a higher rate of fatal car accidents. Upon waking
after a night of sedation, users are more groggy and drowsy, putting them at a higher
risk.
To be clear, these findings do not prove that sleep sedatives cause cancer. Other
factors could play a role, especially that of the individual’s poor sleep prior to taking the
medication (which would put them at a higher risk of disease and deadly drowsy driving
as well). More research needs to be done.
If you currently use Ambien or another sedative, we are NOT prescribing that you cease
taking them, but it’s important to be aware of risks in order to make a well-informed
decision about using the medication.
*Source: Hypnotics in insomnia: the experience of zolpidem,” Clinical Therapeutics 36, no.11 (2014):
1676-1701.
^Source: D.F. Kripke, R.D. Langer and L.E. Kline, “Hypnotics’ association with mortality or cancer: a
matched cohort study,” BMJ Open 2 no.1 (2012): e000850

Page 44
Other Sleep Therapy Options
Other methods in early stages of research:
 Electrical
 Magnetic
 Auditory (sounds)
Alternative methods of sleep therapy that include electrical, magnetic and auditory
stimulation are under research; however, these are in the early stages.
The most effective method to improve insomnia is cognitive behavioral therapy for
insomnia (CBT-I). This treatment involves working with a therapist for several weeks
who instructs the patient on techniques to improve bad sleep habits and decrease
anxiety. Some include the tips for better sleep reviewed earlier in the class; however,
some are actually counterintuitive, such as initially reducing time in bed to six hours or
less. Over time, the patient’s confidence to generate good sleep increases.

Sleep in the Workplace

Societal change in industrialized countries:
 Must start work at a certain time
 Culture shift that values less sleep
o Example: CEO’s/supervisors send emails late into night
There is an organizational disconnect between sleep and productivity. There are
existing policies on:
 Employee health
 Safety
 Conduct
 Smoking
 Ethical behavior
 Substance abuse
But no sleep policy.
The High Cost of Sleep Deprivation
 Estimated $2,000 cost per employee in lost productivity per year
 $411 BILLION lost productivity in the U.S.*
o Unproductive employees (“presenteeism”)
o Less accurate solutions
o Less motivated, less creative
o Ethics negatively affected

*Source: RAND Corporation, Lack of Sleep Costing UK Economy Up to 4o Billion pounds per year.
Accessed at http://www.rand.org/news/press/2016/11/30index1.html.
Page 45
Leaders and Supervisors
 Reduced ability to lead effectively
 Poor self-control
 Employees less engaged
Sleep deprivation in leaders and supervisors results in a reduction of effective
leadership, self-control and employee engagement.

Leadership Support
When leadership supports work-life programs:
 74% employees exceed performance expectations
 75% more satisfied with job
 48% increase in morale
 53% improved health
 44% manage stress better
 Only half of employees felt they had supervisor support in work/life program
use
A 2018 Federal Government study of government employees* found that those who
engaged in work/life and health and wellness programs were 74% more likely to exceed
expectations on performance reviews, were 75% more satisfied with their job, and were
66% more likely to want to remain with their employer. There is a 48% increase in
morale, 53% improved health, and 44% were able to better manage stress.
Eighty two percent of employees perceive supervisor support of employee needs (time
off, personal and family responsibility, etc.), but only about half feel that supervisors
support the use of work/life programs. This is an important consideration for
supervisors, who have an opportunity to improve their department culture, employee
happiness and ultimately production.
*United States Office of Personnel Management, “Federal Work-Life Survey Government wide Report”,
March 2018

In Conclusion …
There are a vast range of sleep deprivation consequences from poor brain development
and crankiness to fatality.
To foster change:
 Individual internal motivation to improve sleep
 Societal/workplace support of wellness, work/life balance, and adequate rest

Page 46
 APPENDIX
This class was inspired by the work of Dr. Matthew Walker, Ph.D.
Why We Sleep: Unlocking the Power of Sleep and Dreams, Matthew Walker, Ph.D.,
2017

CLASS VIDEOS
Session 2:
 Sleep Cycles www.youtube.com/watch?v=GMV6Cd0jVzc
 Five Tips for Falling Asleep Quicker
www.youtube.com/watch?v=ZKNQ6gsW45M
Session 3:
 Effects of Sleep Deprivation www.youtube.com/watch?v=0HxvEcvfbho
 Breathing Exercise www.youtube.com/watch?v=SEfs5TJZ6Nk
Session 4:
 Sleep Study www.youtube.com/watch?v=GMV6Cd0jVzc

ASSESSMENTS
SATED Sleep Assessment - Sleep Apnea www.reading.guru/how-to-measure-your-
sleep-health-sated-questionnaire/

RESOURCES / INFORMATION
 Bedtime Calculator www.sleepfoundation.org/articles/bedtime-calculatortm
 Diary, Sleep www.pinellascounty.org/hr/health_wellness/pdf/sleep-diary.pdf
 Dreams - How Lucid Dreaming Works www.youtube.com/watch?v=qH-MGqokk_Y
 Drowsy Driving www.sleepfoundation.org/professionals/drowsy-driving
 The Effects of Alcohol on Quality of Sleep
www.ncbi.nlm.nih.gov/pmc/articles/PMC4666864/
 Guide to Healthy Sleep (National Institute of Health: National Heart, Lung, and
Blood Institute) www.nhlbi.nih.gov/files/docs/public/sleep/healthy_sleep.pdf
 Healthy People 2020 Objectives (Office of Disease Prevention and Health
Promotion) www.healthypeople.gov/2020/topics-objectives/topic/sleep-health
 National Center for Sleep Disorder Research
www.nhlbi.nih.gov/about/divisions/division-lung-diseases/national-center-sleep-
disorders-research
Page 47
  National Sleep Foundation www.sleep.org/
 Pain www.sleepfoundation.org/articles/pain-and-sleep
 Pillows www.sleepfoundation.org/articles/how-pick-right-pillow-you
 Restless Leg Syndrome www.rls.org/

Shiftwork
 Nightshift Worker Training (Centers for Disease Control and Prevention: National
Institute for Occupational Safety and Health) www.cdc.gov/niosh/docs/2015-115/
 www.sleepfoundation.org/articles/shift-work-and-sleep

Statistics
 www.sleepassociation.org/about-sleep/sleep-statistics/
 www.healthypeople.gov/2020/data/map/5261?year=2013

Teens and Sleep www.sleepfoundation.org/sleep-topics/teens-and-sleep

UnitedHealthcare Resources
 13 min video on Sleep Health
www.brainshark.com/uhcna/vu?pi=zI4z2dQjvzORnTz0&nodesktopflash=1
 Find a sleep doctor or sleep clinic www.myuhc.com

Page 48
Sleep Diary
Name: Beginning date:

Day of the week: EXAMPLE Sun. Mon. Tue. Wed. Thu. Fri. Sat.

Time I went to bed last night: 11 p.m.

Section 1: Complete in the MORNING

Time I woke up this morning: 7 a.m.

Number of hours slept last night: 8

Number of awakenings and total time 5 times
awake last night: 2 hours
How long it took to fall asleep: 30 minutes

Medications taken last night: None

How awake did I feel when I got up this
morning?
1 – wide awake 2
2 – awake but a little tired
3 - sleepy
Number of caffeinated drinks (coffee, tea, 1drink
Section 2: Complete in the EVENING

soda) and time when I had them: 8 p.m.

Number of alcoholic drinks (beer, wine, 2 drinks
liquor) and time when I had them: 9 p.m.
3:30 p.m.,
Naptimes and lengths today:
45 minutes
Exercise times and lengths: None
How sleepy did I feel during the day?
1 – So sleepy had to struggle to stay
awake during much of the day
1
2 – Somewhat tired
3 – Fairly alert
4 – Wide awake

Source: National Heart, Lung, and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services.
Health & Wellness Program
(727) 464-4049
wellness@pinellascounty.org
Visit the Wellness website at www.pinellascounty.org/hr/wellness