Sleepy Students: How can we help?

Sleepy Students: How can we help?

1. Identify keys factors which contribute to late bedtimes and insufficient sleep among college students. 2. Discuss how sleep deprivation impairs academic performance, memory, mood, and driving. 3. Explain how to use specific questions about a student s sleep patterns to develop tailored sleep recommendations which help modify a student s bedtime, wake time, and winddown time. 4. Outline how to create a student-led public health campaign to promote healthy sleep using education of providers, health and wellness websites, and social media.

1. State of sleep among students 2. Why does sleep deprivation occur 3. Consequences of sleep deprivation 4. Potential interventions

In one of our first studies we evaluated the usefulness of the MSLT by comparing narcoleptics and normal sleepers. The results were fabulous. The MSLT distinguished patients and normals, however some of the normals were pathologically sleepy (1-5 minutes). This group tended to be college students. For a while we thought these younger normals

were in the early stage of the narcoleptic sleep disorder But it was hard to imagine why Stanford University would attract so many budding narcoleptics Nearly all the students appeared pathologically sleepy! I should have not been so surprised, because I have been watching students fall asleep in class forever WC. Dement The Promise of Sleep

80 70 60 50 40 30 20 10 0 8 hours of sleep Less than 8 hours Lund, H. G., B. D. Reider, et al. (2010). "Sleep patterns and predictors of disturbed sleep in a large population of college students." The Journal of Adolescent Health 46(2): 124-132.

Percent Students 50 40 30 20 10 Students 0 Average 3 allnighters a month 2-4 hours 5-6 hours 6-7 hours 7+ hours Bachman L, Bachman C. Student perceptions of academic workload in architectural education. J Archit Plan Res. Win 2006;23(4):271 304.

High School College High School College

50 82% report significant sleepiness at University of Michigan 40 Percent Students 30 20 10 Teens College Adults 0 Memory Sleepiness Concentration Oginska, H. Fatigue and Mood Correlates of Sleep length in three Age- Social Groups: School Children, Students, and Employees. Chronobiology International 2006 1317-1328

The story of Hector 15

Red Bull (8.2 oz) 80.0 Jolt 71.2 Pepsi One55.5 Mountain Dew 55.0 Mountain Dew Code Diet Coke 45.6

Sleep is required for memory consolidation

Dependence on REM sleep of overnight improvement of a perceptual skill. Karni A et al. Science. Jul 29 1994;265(5172):679-682. Normal sleep or SWS deprived REM sleep deprived

Improvement in visual discrimination Testing at 5 pm on day of learning task: comparing no nap, +SWS/-REM, +SWS/+ REM sleep Mednick, S. Sleep Dependent learning: a nap is as good as a night. Nature Neuroscience Vol 6, July 2003.

Arithmetic task Michael W.L. Chee Functional imaging of working memory following normal sleep and after 24 and 35 h of sleep deprivation: Correlations of fronto-parietal activation with performance NeuroImage, Volume 31, Issue 1, 15 May 2006, Pages 419-428

Short sleepers < 6 hours found to have lower GPAs (2.74) Long sleepers > 9 hours higher GPAs (3.24) Kelly WE, Kelley, Kathryn E., Clanton, Robert C. The relationship between sleep length and grade point average among college students. College Student Journal. 2001;35(1).

Trockel, MS. Health-related variables and Academic Performance among First-Year College Students: Implications for Sleep and Other Behaviors. J of Amer Coll Health 2004 Weekday 1 Hour later wake time.132 GPA r=-.350 Weekend 1 hour later wake time.115 GPA r=-.321 the relationship between sleep habits and higher GPA provides strong support for the hypothesis that sleep habits account for some of the variance in first-year students GPA.

The all-nighter: dumb and doesn t know it. I rocked that test! Perceived better Performance and Effort All-nighter Normal Sleep Pilchner, JJ. How Sleep Deprivation Affects Psychological Variables Related to College Students Cognitive Performance. J Amer Coll Health. Nov 1997

Anger Confusion Fatigue Depression Increased stress Students more likely to use prescribed and OTC stimulants, ETOH Lund, H. G., B. D. Reider, et al. (2010). "Sleep patterns and predictors of disturbed sleep in a large population of college students." The Journal of Adolescent Health 46(2): 124-132.

PTSD Depression Anxiety Nightmare Insomnia Nadorff, M. R., S. Nazem, et al. (2011). "Insomnia symptoms, nightmares, and suicidal ideation in a college student sample." Sleep 34(1): 93-98. Nightmares

Electronic CBT Breathe (stress reduction, coping skills) Refresh (sleep, sleep hygiene) Refresh associated with improved sleep and decreased depressive symptoms Trockel, M., R. Manber, et al. (2011). "An E-mail delivered CBT for sleephealth program for college students: Effects on sleep quality and depression symptoms." Journal of Clinical Sleep Medicine 7(3): 273-278.

PVT and 4h, 6h, 8h sleep restriction SD-64-88 hrs Subjects perception of sleepiness was not progressive (Stanford Sleepiness Scale) Van Dongen, HPA. The cumulative Cost of Additional Wakefulness: Dose- Response Effects on Neurobehavioral Functions and Sleep Physiology from Chronic Sleep Restriction and Total Sleep Deprivation. Sleep. 2003

35 30 25 20 15 10 5 0 GPA<2 GPA>2 Gaultney JF. The prevalence of sleep disorders in college students: Impact on academic performance. J Am Coll Health. Sep-Oct 2010;59(2):91-97.

Snoring Apneas Overweight Sleepiness

Inadequate sleep Perceived effort Erratic sleep schedule Academics Sleep Disorders

Short sleep duration and obesity Average BMI by Sleep Duration BMI 30 29 28 27 26 25 4 and under 5 6 7 8 hours of sleep Sleep duration and risk of obesity 4 hours OR 2.35 5 hours OR 1.60 Gangwisch, JE. Inadequate Sleep as a Risk Factor for Obesity: Analysis of the NHANES1 Sleep 2005 1289-1296 6 hours OR1.27

% of drivers Howard, ME.et al., The interactive effects of extended wakefulness and low dose alcohol on simulated driving and vigilance. Sleep 2007.

Wake up at the same time each day. Stop drinking coffee by noon. Turn off the dang laptop and get off your phone. Go to BED!

Education School Policies Sleep Individual Students Naps

Age Number of studies Number of students Junior High 9.5-12.5 3 108 (26, 27,55) High School 14-18 4 College 19.5 3 1332 (25, 1200, 22, 58) 1030 (19, 122, 889) Secondary (International schools) 14-16 4 638 (28, 81, 104, 425) Blunden, S. L., J. Chapman, et al. (2012). "Are sleep education programs successful? The case for improved and consistent research efforts." Sleep Medicine Reviews 16(4): 355-370. Trockel, M., R. Manber, et al. (2011). "An E-mail delivered CBT for sleep-health program for college students: Effects on sleep quality and depression symptoms." Journal of Clinical Sleep M di i 7(3) 273 278

Classroom lectures, power point presentations, surveys, hand-on activities, sleep pamphlets, group discussions, Sessions: 30 minutes 60 minutes 3 forty-five minute sessions 4, 5, 7, 8, and 12 fifty minute sessions

Knowledge- tested in 6 programs Increase in sleep knowledge Behavior -tested in 6 programs Variable questions

30 25 20 15 10 * Complete modules Partial Modules Standard Instruction 5 0 Pre Test First Test Sleep Test Post Test Quan, SF. Use of Supplementary Internet Based Education Programs Improves Sleep Literacy in College Psychology Students, J Clin Sleep Med 2013:9(2):155-160

60 50 40 30 20 Sleep Module Standard Instruction 10 0 Sleep Hygiene More Consitent Wake Time More Sleep Quan, SF. Use of Supplementary Internet Based Education Programs Improves Sleep Literacy in College Psychology Students, J Clin Sleep Med 2013:9(2):155-160

Good Sleep Knowledge Good Sleep Behavior Good Sleep Behavior Good Sleep Quality Brown FC, et al. Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behavior Med 2002:2833-8

Yes No Decrease in Sleep Latency 2 4 Naps 2 Less Irregular Sleep Schedule Less Sleepiness Increased Sleep Duration 3 1 1 (weekends only) 2 (marginal) 1

For nearly four decades, researchers have found that knowledge is generally unrelated to health behavior and that simple information transmission fails to change health-related behaviors. Yet the concept of the pamphlet rack outside of the doctor s office, even in electronic form, endures. Strecher, V. Internet Methods for Delivering Behavioral and Health- Related Interventions (ehealth), Annu Rev Clinical Psychol 200753-76

Time Personnel Effectiveness Cost Motivation for behavioral change

Behavior Control or Selfefficacy Knowledge Chang e Attitude Intention The Norm Importance Parks et al. The stages of physical activity and exercise behavior: an integrated approach to the theory of planned behavior. Asia Pac J Public Health 2009

Everybody is doing it. Personalization

Addressing the individual student Key sleep behaviors: 1. Sleep schedule 2. Bedtime behaviors 3. Level of sleepiness

Average sleep amount per night: 4.5 to 8 hours How long does it take you to fall asleep? 15 to 60 min

Bedtime behaviors

Broad categories: Further evaluation or Sleep Clinic Referral

Establish a dialog about increasing sleep which might encourage behavior change. Discussing grades and sleep, health, and mood might have an impact

Focus on wake time! If possible a consistent wake time is best, but most students won t/can t do this. So find a compromise wake time. On school days wake time: Latest should be 11 AM Avoid naps Earliest Class Time Compromise wake time Later Class Time Compromise wake time 8 AM 7:30 AM 9 AM 8:30 AM 9 AM 8:30 AM 10 AM 9:00 AM 10 AM 9:30 AM 11 AM 9:30 AM 11 AM 11 AM 12 PM or later 10:30 to 11 AM 12 PM or later 11 AM

Wake at 1 pm, may not be sleepy until 7 am Wake at 11 am, may not be sleepy until 4 am

Bedtime Routine: Off electronics for a minimum of 30 minutes Stop caffeine 8 hours before bed Read (a book no electronics) until drowsy No time cues (phone, alarm clock, etc)

At the brightest setting measured from the same distance from a user's face, the iphone 4 measured 275 lux, the ipad 1 measured 124 lux, and the ipad 3 measured 248 lux all far above the melatonin-disrupting limit. When held 14 inches away at the brightest setting, the iphone 4 measured 8 lux and the ipad 1 measured 21 lux. The ipad 3, however, measured 32 lux just above the threshold.

Helpful: Small and realistic changes Discuss the why Focus on academics catch-up sleep on the weekends Ask what keeps you from trying this? If appropriate (sleepy or won t sleep group) discuss naps Not so Helpful The term sleep hygiene Same weekend schedule Not acknowledging students challenging schedule

N=63 Yes No Did SASS help you understand the student s sleep issues? 72% 28% Was the student receptive to the sleep recommendations? 69% 31% Would you use SASS regularly to address sleep issues? 76% 24%

most of the time when people talk about sleep, they talk about getting 8 hours of sleep- there is no way that I can do that. I didn t know small changes could make a difference School s should teach more about sleep I thought watching videos would relax me, I didn t realize that (it) made it harder to fall asleep

Naps Public Health Campaign Education of counselors and providers School start time Orientation

Electronic CBT Breathe (stress reduction, coping skills) Refresh (sleep, sleep hygiene) Refresh associated with improved sleep and decreased depressive symptoms Trockel, M., R. Manber, et al. (2011). "An E-mail delivered CBT for sleep-health program for college students: Effects on sleep quality and depression symptoms." Journal of Clinical Sleep Medicine 7(3): 273-278.

% 60 50 40 52 30 20 10 28 GPA >3.5 GPA<2.7 0 GPA >3.5 GPA<2.7 Eliasson et al. Early to bed, early to rise! Sleep habits and academic performance in college students Sleep and Breathing. 2010

26 university students with no daytime sleepiness. Lahl, et al. An ultra short episode of sleep is sufficient to promote declarative memory performance, Journal of Sleep Research, 2008 Eliasson, et al. Early to bed, early to rise! Sleep Habits and Academic Performance in College Students. Sleep Breath 2010

100 90 80 70 60 50 40 30 20 10 0 Sleepiness hurts academics Naps would help Yes No Not sure Would you take more naps

Concern for belongings concern for safety No place on campus Home is too far away No time No need 0 20 40 60 80

Students are not so picky: Comfortable couch Place to lock belongings Women also want: Privacy screen Close to classes Not worried about: A separate room, identified as a nap location, an alarm, close to studying.

70 60 50 40 30 20 Undergraduate Graduate 10 0 No Time No Space Concern belongings

Small, but measurable change in sleep behavior 9% reported: 1. earlier bedtime, 2. shorter sleep latency 3. longer sleep duration 4. improved sleep quality Orzech KM. The state of sleep among college students at a large public university. J Am Coll Health. 2011;59(7):612-619.

100 80 60 40 20 Before After 0 Sleepiness Sleepiness in Class Falling Asleep in Class Owens JA. Impact of delaying school start time on adolescent sleep, mood, and behavior. Archives of pediatrics & adolescent medicine. 2010;164(7):608-614

100 80 60 40 20 Earlier start Later start 0 Somewhat depressed Irritated or annoyed Owens JA. Impact of delaying school start time on adolescent sleep, mood, and behavior. Archives of pediatrics & adolescent medicine. 2010;164(7):608-614

300 250 200 150 100 Before Change After Change 50 0 State County Danner, F., & Phillips, B. (2008). Adolescent sleep, school start times, and teen motor vehicle crashes. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 4(6), 533 535

1. Reasonable deadline for assignments 2. Stop 8 AM classes 3. Improve sleep environments in the dorms Dim the lights Enforce quiet hours 4. Educate professors, advisors, counselors on the impact of sleep Change the norm.

A sleepy night owl (MEQ 16-30) Morning rock, but you re still sleepy (MEQ 59-69) You like days and nights (MEQ 42-58) A night owl (MEQ 31-41) Morning rock! (MEQ 70-86

Technology and Sleep GPA Don t Sleep, Don t Drive: Nap On!

Sleep deprivation Impaired learning, memory, grades, drowsy driving Does education change behavior? Behavior change Tailored feedback, address barriers to change Other interventions-nap locations, sleep information available to students, Future Directions- Sleep friendly school policies