Sleep-Health

= = =Sleep Health =



**FACILITATORS: Whitney Potharla, Jennifer Simonson, H****annah Belknap**


 * **Contents** * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

Learner Objectives »

 * ====Examine how adequate sleep relates to Healthy People 2020 goals for adults and adolescents.====
 * ====Understand how sleep problems are experienced by people of varying ages and ethnicities.====
 * ====Discuss the adverse effects of insufficient sleep and who is most at risk.====
 * ====Identify and use assessment and screening tools for sleep disorders, insomnia, obstructive sleep apnea, and children's sleep.====
 * ====Understand the behavioral interventions based on the guidelines and apply them to the discussion board prompt .====

 Required readings and Websites »

 * Mc Daniel et. al., (2005) Chap. 6. Building Partnership: Promoting working alliances and motivation for change. (p. 72-89)
 * [|WEBSITE: CDC-Key Sleep Disorders]
 * [|WEBSITE: Healthy People 2020 Sleep Health]
 * [|WEBSITE: USPSTF website use to identify appropriate prevention interventions]
 * [|VIDEO: The need for sleep to stay healthy]
 * [|INTERACTIVE SLEEP QUIZ: Test your sleep knowledge!]
 * ARTICLE: The Better Weight-Better Sleep Sleep Study[[file:Better weight better sleep.pdf]]
 * [|ARTICLE: CDC: Unhealthy Sleep-Related Behaviors]


 * **RECOMMENDED READING/SOURCES**
 * ARTICLE: Relationships between hours of sleep and health-risk behaviors in US adolescent students[[file:Adolescent sleep article.pdf]]
 * [|CDC: Wisconsin Insufficient Sleep Fact Sheet 2011]
 * [|VIDEO: National Sleep Foundation: Heads Up at the Wheel-Drowsy Driving Prevention]
 * ARTICLE: The link between short sleep duration and obesity: We should recommend more sleep to prevent obesity [[file:The link between short sleep duration and obesity.pdf]]
 * ARTICLE: Use of the 'BEARS' sleep screening tool in a pediatric residents' continuity clinic: A pilot study [[file:BEARS tool.pdf]]
 * ARTICLE: Ostfeld, B.M., Esposito, L., Perl, H., & Hegyi, T. (2010). Concurrent risks in sudden infant death syndrome. //Pediatrics//, //125//, 447-453.
 * ARTICLE: Waterfield, J. (2010). Hypnotics: prescribing issues and mechanisms of action. //Nurse// //Prescribing, 8,// 279-283. [[file:Waterfield, 2010[1].pdf]]

Required Video: CBS-The need for sleep to stay healthy
media type="custom" key="13989762"

National Sleep Foundation-Heads Up at the Wheel-Drowsy Driving Prevention
==media type="youtube" key="ZkVzvboYXAQ" height="219" width="294" == ==

==

Healthy People 2020 Objectives »
SH-1 Increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation.

<span style="font-family: Arial,Helvetica,sans-serif;">SH-2 Reduce the rate of vehicular crashes per 100 million miles traveled that are due to drowsy driving.

<span style="font-family: Arial,Helvetica,sans-serif;">SH-3 Increase the proportion of students in grades 9-12 who get sufficient sleep.

<span style="font-family: Arial,Helvetica,sans-serif;">SH-4 Increase the proportion of adults who get sufficient sleep.

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Related Epidemiological Data »
Insufficient sleep has been linked to a growing number of health problems including cardiovascular disease, diabetes, obesity, and depression. Additionally, lack of sleep has an adverse effect on the treatment of disease. As many as 25% of Americans report having a lack of sleep at least some of the time and 10% of Americans suffer from chronic insomnia (CDC, 2012). Insufficient sleep is a public health risk. Motor vehicle crashes, work-related injuries, and medical errors are all adversely affected by lack of sleep (CDC, 2011 a). In 2009, the Center for Disease Control (CDC) found that, of the 74,571 adults surveyed: (CDC, 2011 c) =**Impact on adolecents**= Insufficient sleep and poor sleep habits affect children and teens as well. A staggering 70% of high school-aged children do not get the recommended 8 hours of sleep on school nights (McKnight-Eily et al., 2011). Teens who sleep less than 7 hrs were found to have higher incidences of the following risky behaviors as compared with teens who sleep more than 8 hours: Interestingly, the results from this study did not differ by sex or race. =Sleep Variations by Ethnicity= The National Sleep Foundation (2010) conducted the 2010 Sleep in America Poll, which highlighted several sleep variations between Whites, Blacks, Hispanics and Asians. You can access the entire report [|here]
 * 37% slept less than 7 hours per night
 * 48% snored
 * 37.9% nodded off unintentionally during the day
 * 4.7% fell asleep while driving in the past 30 days
 * People ages 25-55 reported sleeping less than 7 hours most often with an average of 39%
 * Women and men report sleeping <7 hrs and nodding off during the day at about the same rate
 * More men (56.5%) than women (39.6%) snore
 * More men (5.8%) than women (3.5%) report nodding off while diving
 * Blacks (48%) sleep the least, followed by Whites (35%) and Hispanics (33%)
 * Sexual activity
 * Alcohol and drug use
 * Smoking
 * Feeling sad
 * Getting into physical fights

The following results highlight the sleep differences between the ethnicities: Sleep needs: Seeking help: Sleep disorders:
 * All groups report not feeling that their work schedules allow for enough sleep
 * Blacks sleep the least amount of hours (6hr 14min)
 * Asians and Hispanics report needing the most sleep (7 ½ hr)
 * Asians are the least likely to talk to a health professional about sleep problems
 * Whites (30%) and Hispanics (26%) take sleep aids most frequently
 * A significant number of adults use alcohol, beer or wine (10% Whites, 9% Blacks/ African-Americans and 8% Hispanics) as “sleep aids” at least a few nights a week, with Asians being the least likely to use any form or alcohol (3%).
 * Blacks (14%) are diagnosed most often with sleep apnea, followed by Whites (6%) and Asians (4%)
 * Whites (10%) are more often diagnosed with insomnia than blacks (3%) or Asians (4%)
 * Whites (6%) are diagnosed more often than blacks (1%) with restless leg syndrome, which can significantly affect sleep

=Wisconsin Data (CDC, 2011 b)=

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Potential Impact of Poor Sleep
<span style="font-family: "Times New Roman","serif"; font-size: 16px;"> Despite a vast improvement in education efforts, many children under the age of one are at an increased risk for sudden infant death syndrome (SIDS). Almost all cases of SIDS occur in the presence of one or more risk factors. Risks for SIDS include non-supine or prone positioning, co-sleeping (bed sharing), and maternal/paternal smoking in the home (Ostfeld, Esposito, & Hegyi, 2010). All parents, grandparents, and caregivers should be educated about the ABC's of infant sleep:
 * Infants:**


 * A- Alone** in the crib without toys, blankets, bumpers or other objects
 * B- Back-** babies should always be placed on their backs to sleep
 * C-Crib-** babies should only be placed in a crib or pack-n-play when sleeping

Please click on this link to hear one nurse's story: []

Sleep disorders and chronic short sleep contribute to morbidity and mortality. Listed below are just some of the consequences of poor sleep:
 * Adults**
 * Lack of sufficient sleep is associated with fair/poor general health, mental and physical distress, anxiety, pain, and depressive symptoms (CDC, 2011 c, p. 233)
 * Sleep disorders are associated with up to twice increased risk of **obesity, hypertension, diabetes, stroke, CVA, substance abuse, and all cause mortality** (National Institutes of Health, National Center On Sleep Disorder Research, 2011, p. 7)
 * **Driving:**
 * 1/3 of Americans report falling asleep behind the wheel 1-2 times a month and 26% report driving while drowsy during the day (National Institutes of Health, National Center On Sleep Disorder Research, 2011, p. 7)
 * Sleep deprivation may play a role in approximately 20% of all serious motor vehicle accidents (National Institutes of Health, National Center On Sleep Disorder Research, 2011, p. 7)
 * **Workplace accidents:** Accidents in the work place caused by sleep deprived workers cost employers billions each year. Major catastrophes, including the Three Mile Island and Chernobyl nuclear power plant disasters, the Exxon Valdez oil spill, and the Space Shuttle Challenger disaster have been credited to poor judgment by sleep deprived employees (Pressman, 2011).
 * **Immune function:** Inadequate sleep weakens the immune system and is correlated with increased plasma levels of soluble tumor necrosis fator (TNF)-alfa and interleukin (IL)-6 ((Pressman, 2011).
 * **Type 2 diabetes:** Sleep deprivation increases the risk for type 2 diabetes. Sleep quality and duration have been linked to hemoglobin A1C values, suggesting that enhancing sleep quality and duration is important to improve blood sugar control among patients with type 2 diabetes (CDC, 2011 d).
 * **Cardiovascular disease:** Obstructive sleep apnea is associated with increased proinflammatory and prothrombotic factors that play a role in the development of atherosclerosis (Kasasbeh, Chi, & Krishnaswamy, 2006). Individuals with obstructive sleep apnea have higher rates of hypertension, stroke, coronary artery disease, and cardiac arrhythmias than individuals without sleep disturbances (CDC, 2011 d).
 * **Obesity:** Short sleep duration has been associated with excess body weight for all age groups. This relationship is especially noted in children and adolescents, among whom there is a linear dose-response relationship between shorter sleep and excess body weight. Insufficient sleep in children is thought to negatively impact the hypothalamus, which is responsible for appetite regulation energy expenditure. Among adults, insufficient sleep is associated with metabolic changes that contribute for obesity. For instance, sleep deprivation has been associated with low leptin levels and high ghrelin levels, both of which increase appetite (Taheri, 2006).
 * **Depression:** Sleep disturbances are both a symptom and instigator of depression. Depression may improve once sleep apnea is treated and sufficient sleep is restored (CDC, 2011 d).
 * **Adolescents and children:** Inadequate sleep in adolescents and children is associated with poor academic performance and behavioral problems (National Institutes of Health, National Center On Sleep Disorder Research, 2011)

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<span style="color: #000099; font-family: Verdana,Geneva,sans-serif; font-size: 1.3em;">Risk factors for poor sleep (National Sleep Foundation, 2011):

 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Attention-deficit hyperactivity disorder** (ADHD)
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">One recent study found that children with ADHD had higher rates of daytime sleepiness than children without ADHD. Another study found that 50% of children with ADHD had signs of sleep disordered breathing, compared to only 22% of children without ADHD. Research also suggests that restless legs syndrome and periodic leg movement syndrome are also common in children with ADHD.


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Aging**
 * Changes to sleep patterns are part of the normal aging process. As people age they tend to have a harder time falling asleep andmore trouble staying asleep than when they were younger.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Alzheimer's disease** and **senile dementia**
 * Alzheimer’s and dementia are characterized by frequent sleep disturbance, both for those diagnosed and their caregivers. In fact, many caregivers cite sleep disturbances, including night wandering and confusion, as the reason for institutionalizing the elderly. Once institutionalized, these elderly residents' sleep disturbances don't cease, and tranquilizing medications may increase the risk of falls and further confusion.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Asthma**
 * People with asthma often suffer from nighttime coughing, wheezing and breathlessness that disturb their sleep. It is not clear whether there is a circadian rhythm factor responsible for these nighttime disturbances or whether sleep in some way contributes to them, but studies designed to uncover the exact influence of sleep or circadian rhythms on asthma have been largely inconclusive.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Caffeine consumption**
 * While caffeine does not replace sleep, it can temporarily cause alertness by blocking the sleep-inducing chemicals in the brain and increasing adrenaline production.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Depression**
 * Sleep problems and depression may share risk factors and biological features, and both conditions may respond to some of the same treatment strategies. Sleep problems are also associated with more severe depressive illness. Insomnia is associated with depressed patients, occurring 10 times more than in those who sleep well. Research suggests that the risk of developing depression is highest among people with both sleep onset and sleep maintenance insomnia.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Restless leg syndrome** (RLS)
 * Restless legs syndrome (RLS), a neurological condition that causes discomfort in the legs and sleep problems, is also associated with depression. According to the Restless Legs Syndrome Foundation, approximately 40% of people with RLS complain of symptoms that would indicate depression if assessed without consideration of a sleep disorder.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Obesity** and **sleep apnea**
 * An estimated 18 million Americans have sleep apnea, a sleep-related breathing disorder that leads individuals to repeatedly stop breathing during sleep. Not only does sleep apnea seriously affect one’s quality of sleep, but it can also lead to health risks such as stroke, heart attack, congestive heart failure and excessive daytime sleepiness.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Gastroesophageal reflux disorder** (GERD)
 * According to the 2001 NSF //Sleep in America// poll, adults in America who experience nighttime heartburn are more likely to report having symptoms of sleep problems/disorders such as insomnia, sleep apnea, daytime sleepiness and restless legs syndrome than those who don’t have nighttime heartburn.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Menopause**
 * From peri-menopause to post-menopause, women report the most sleeping problems, including hot flashes, mood disorders, insomnia and sleep-disordered breathing. Sleep problems are often accompanied by depression and anxiety.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">**Multiple sclerosis** (MS)
 * According to a study led by W. Elon Fleming, MD, at the Sleep Disorders Center at Island Hospital in Anacortes, Washington, the most common sleep disorders in MS patients are insomnia, nocturnal leg spasms, narcolepsy, REM sleep behavior disorder, and sleep disordered breathing. Restless legs syndrome (RLS) is also highly prevalent among MS patients.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Pregnancy**
 * According to the National Sleep Foundation's 1998 //Women and Sleep// poll, 78% of women report more disturbed sleep during pregnancy than at other times.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Shift-work**
 * Some of the most serious and persistent problems shift workers face are frequent sleep disturbance and associated excessive sleepiness. Sleepiness/fatigue in the work place can lead to poor concentration, absenteeism, accidents, errors, injuries, and fatalities. The issue becomes more alarming when you consider that shift workers are often employed in the most dangerous of jobs, such as firefighting, emergency medical services, law enforcement and security
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**Traumatic event**
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">When the body is overstimulated, the brain is flooded with neurochemicals that keep us awake, such as epinephrine and adrenaline, making it difficult to wind down at the end of the day. The neurochemicals remain present in the brain and can interrupt the normal sleep cycle, resulting in insomnia, bad dreams, and daytime fatigue caused by sleep disturbance.

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Screening Guidelines and Assessment Parameters »
If patients present with one or more of these complaints, initial screening and assessment for sleep disorders should be preformed (Bonnett & Arand, 2011).
 * Adults: **The U.S. Preventative Services Task force (USPSTF) does not have a single set of recommendations regarding screening for sleep disorders in adults or children. However, according to the //UptoDate// guideline recommendations (Pressman, 2011), patients who complain of difficulty sleeping (including difficulty mainting sleep, waking up too early, or poor quality sleep) should be screened for insomnia and other sleep disorders. Patients may also complain of difficulty functioning during the day time, including:
 * 1) Fatigue or malaise
 * 2) Poor attention or concentration
 * 3) Social or occupational dysfunction
 * 4) Mood disturbance
 * 5) Daytime sleepiness
 * 6) Reduced motivation or energy
 * 7) Increased errors or accidents
 * 8) Tension, headache, or GI symptoms
 * 9) Continual worry about sleep

**Screening tools**
There several reliable and valid sleep disorder screening tools in practice, including: Click [|here] to link to the Johns Hopkins Medicne Sleep University CME to see a description of each of the screening tools and related articles.
 * Epworth Sleepiness Scale (ESS)
 * Stanford Sleepiness Scale (SSS),
 * Pittsburgh Sleep Quality Index (PSQI)
 * STOP Questionnaire, Berlin Questionnaire
 * Apnea Risk Evaluation System Questionnaire (ARES Q).

//Epworth Sleepness Scale (ESS)//
The Epworth Sleepiness Scale (ESS) has proven to be a valid and reliable screening tool for sleep disorders and is widely used in practice. Scores on the ESS have been shown to distinguish patients with a variety of sleep disorders, including obstructive sleep apnea, narcolepsy, and idiopathic hypersomnia. ESS scores have also been shown o be significantly correlated with multiple sleep latency tests and overnight polysomnography (Johns, 1991, p. 140).

The ESS asks patients to rate the chance they will doze off or fall asleep in a variety of daily situations on a scale from 0-3. The numbers are then added together and patients are given a score between 0-24 (Johns, 1991, p. 140). The higher the score, the higher the amount of daytime sleepiness. A “normal” score for patients who do not have a chronic sleep disorder (including snoring), is 4.6 with a standard deviation of +/- 2.8. Thus, if patients score higher than ~7.4 on the ESS, additional assessment and evaluation should be preformed. The tool is shown below: (Johns, 1997)

**Insomnia: Recommendations by the American Academy of Sleep Medicine**
The American Academy of Sleep Medicine has a number of screening recommendations for screening, assessment, and diagnosis of sleep disorders. Recommendations are classified by level of evidence and labeled as //standard// (level 1 evidence), //guideline// (level 2 evidence), //consensus// (level 3 evidence), and //option (//inconclusive or conflicting evidence). An explanation of the levels of evidence and recommendations is listed after the recommendations.

Insomnia is defined as "the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment" (Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008). Insomnia screening and assessment recommendations include the following:
 * **Thorough sleep history:**Helps determine type and evolution of insomnia, perpetuating factors, and identify comorbid medical, substance, and/or psychiatric complaints.
 * History should include: Specific insomnia complaints (i.e. at what point during sleep insomnia occurs, etc), pre-sleep conditions and bedtime routines, sleep-wake patterns, other-sleep related symptoms, and daytime consequences //(Consensus)//
 * **Use of instruments:**Helpful instruments to evaluate insomnia include self-administered questionnaires, at-home sleep logs, symptoms checklists, psychological screening tests, and bed partner interviews //(Guideline)//
 * At a minimum, the patient should complete:
 * General medical/psychiatric questionnaire
 * Epworth Sleepiness Scale or other sleepiness assessment
 * A two week sleep log to identify general patterns of sleep-wake times and day-to-day variability //(Consensus)//
 * **Sleep diary**: data should be collected prior to and during the course of active treatment, if symptoms recur, and for long term evaluation //(Consensus)//
 * **Additional assessment instruments**: Evaluation of measures such as subjective sleep quality, quality of life, dysfunctional believes and attitudes may be helpful in follow up with patients with chronic insomnia //(Consensus)//
 * **Physical and mental status examination:** Provides important information regarding co-morbidities and differential diagnosis //(Standard)//
 * **Polysomnography and daytime multiple sleep latency testing:** Not indicated for routine insominia. Polysomnography is indicated if: reasonable suspicion of breathing (sleep apnea) or movement disorders, initial diagnosis is uncertain, behavioral or pharmacologic treatment fails, abrupt arousals occur with behavior that is violent or causes injury //(Guideline)//
 * **Actigraphy:** Indicated to characterize circadian rhythm patterns or sleep disturbances in individuals with insomnia, including insomnia associated with depression //(Option)//
 * **Other laboratory testing:** Not indicated in routine evaluation of insomnia, unless there is suspicion for comorbid disorders //(Consensus)//

//Levels of Evidence// <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**__ Level 1 __** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Risk/Assessment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Validating1 cohort with well-validated reference standards2 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Treatment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: High quality randomized controlled trial (RCT) on well-characterized subjects or patients <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**__ Level 2 __** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Risk/Assessment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Smaller or "exploratory" cohort study or one that has incompletely validated reference standards2 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Treatment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Cohort study or flawed clinical trial (e.g., small N, blinding not specified, possible assignment to treatment, incompletely validated reference standards2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**__ Level 3 __** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Risk/Assessment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Case control or cross sectional study <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Treatment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Case control study <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**__ Level 4 __** <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Risk/Assessment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Case series (and poor quality cohort and case control studies) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Treatment ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: Case series (and poor quality cohort and case control studies) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**__ Notes __** //<span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Levels of Recommendation // <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Standard ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: This is a generally accepted patient-care strategy that reflects a high degree of clinical certainty. The term standard generally implies the use of Level I Evidence, which directly addresses the clinical issue, or overwhelming Level II Evidence. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Guideline ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: This is a patient-care strategy that reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II Evidence or a consensus of Level III Evidence. <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">** Option ** <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">: This is a patient-care strategy that reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.
 * 1) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">1. Validating studies test the quality of a specific diagnostic test, based on prior evidence.
 * 2) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">2. Reference standards: polysomnography (PSG), sleep logs, actigraphy, phase markers, validated self-reports.

(Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008)

Sleep Apnea: Recommendations by the American Academy of Sleep Medicine
Obstructive sleep apnea involves repetitive collapse of the upper airway during sleep (Epstein et al., 2009). Airway collapse results in sleep fragmentation, hypoxia, hypercapnea, variations in intrathroacic pressure, and increased sympathetic nervous system activity. (Epstein et al., 2009). The following flow charts depicts recommendations for and evaluation of patients who are suspected to have obstructive sleep apnea:





[[image:nursing6244/Chart-jpeg.jpg width="593" height="755"]]
(Epstien et al., 2009)

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">**Circadian Rhythm Sleep Disorders: Recommendations by the American Academy of Sleep Medicine (2007)** Circadain rhythm sleep disorders involve problems with the timing of when an individual is asleep and awake (American Academy of Sleep Medicine, 2007). Listed below are recommendations for screening and assessment of circadian rhythm sleep disorders.
 * 1) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Use of a sleep log or diary is indicated in the assessment of patients with a suspected CRSD. **(Guideline)**
 * 2) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Actigraphy is indicated to assist in evaluation of patients suspected of CRSDs, including irregular sleep-wake disorder (ISWR), free-running disorder (FRD) (with or without blindness)**(Option)**, and in advanced sleep phase disorder (ASPD), delayed sleep phase disorder (DSPD), and shift work disorder (SWD). **(Guideline)**
 * 3) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Actigraphy is useful as an outcome measure in evaluating the response to treatment for CRSDs. **(Guideline)**
 * 4) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">There is insufficient evidence to recommend the routine use of the Morningness-Eveningness Questionnaire (MEQ) for the clinical evaluation of CRSDs. **(Option)**
 * 5) <span style="color: #333333; font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Circadian phase markers are useful to determine circadian phase and confirm the diagnosis of FRD in sighted and unsighted patients but there is insufficient evidence to recommend their routine use in the diagnosis of SWD, jet lag disorder (JLD), ASPD, DSPD, or ISWR. **(Option)**
 * 6) Polysomnography (PSG) is indicated to rule out another primary sleep disorder in patients with symptoms suggestive of both a CRSD and another primary sleep disorder, but is not routinely indicated for the diagnosis of CRSDs. **(Standard)**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">(American Academy of Sleep Medicine, 2007)

**Screening for sleep disorders in children**
The **BEARS sleep screen** is a 5-item sleep questionnaire that has shown to be effective to alert primary care providers to sleep problems among children ages 2-18 in primary care settings. Use of the BEARS screen allows primary care providers to identify potential sleep, conduct more in-depth assessment when warranted, and intervene when appropriate (Owens & Dalzell, 2004). The “trigger question” on the BEARS screen are asked to either the parent or the child and tailored to the child’s age and addresses the follow topics:


 * B=Bedtime issues**
 * Preschool (2-5 years):
 * Parent: Does your child have any problems going to bed? Falling asleep?
 * School aged (6-12 years):
 * Parent: Does your child have any problems at bedtime?
 * Child: Do you have any problems going to bed?
 * Adolescents (13-18 years):
 * Child: Do you have any problems falling asleep at bedtime
 * E=Excessive Daytime Sleepiness,**
 * Preschool (2-5 years):
 * Parent: Does your child seem over tired or sleepy a lot during the day? Does she still take naps?
 * School aged (6-12 years):
 * Parent: Does your child have difficulty awaking in the morning, seem sleepy during the day or take naps?
 * Child: Do you feel tired a lot?
 * Adolescents (13-18 years):
 * Child: Do you feel sleepy a lot during the day? In school? While driving?
 * A=Night Awakenings**
 * Preschool (2-5 years): Does your child wake up a lot at night?
 * School aged (6-12 years):
 * Parent: Does your child seem to wake up a lot at night? Any sleepwaking or nightmares?
 * Child: Do you wake up a lot at night? Have trouble getting back to sleep?
 * Adolescents (13-18 years):
 * Child: Do you wake up a lot at night? Do you have trouble getting back to sleep?
 * R=Regularity and duration of sleep**
 * Preschool (2-5 years):
 * Parent: Does your child have a regular bed time and wake time? What are they?
 * School aged (6-12 years):
 * Parent: What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep?
 * Adolescents (13-18 years):
 * Child: What time do you usually go to bed on school nights? Weekends? How much sleep do you usually get?
 * S=Sleep disordered breathing**
 * Preschool (2-5 years):
 * Parent: Does your child snore a lot or have difficulty breathing at night?
 * School aged (6-12 years):
 * Parent: Does your child have loud or nightly snoring or any difficulties breathing at nights?
 * Adolescents (13-18 years):
 * Parent: Does your teenager snore loudly or nightly?

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Behavioral Intervention Recommendations »
<span style="display: block; font-family: arial,helvetica,sans-serif; line-height: normal; margin: 5pt 0in; text-align: left;"><span style="font-family: arial,helvetica,sans-serif; font-size: 11pt; line-height: normal; margin: 5pt 0in;">Recommendations for good sleep hygiene from the National Sleep Foundation ** NSF, 2011: ** <span style="display: block; font-family: arial,helvetica,sans-serif; line-height: normal; margin: 5pt 0in; text-align: left;"> <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 12pt; line-height: normal; margin: 5pt 0in; text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Ensure sleep environment is appropriate:
 * <span style="font-family: Arial,Helvetica,sans-serif;">Maintain a regular bed and wake time schedule including weekend
 * <span style="font-family: Arial,Helvetica,sans-serif;">Establish a regular, relaxing bedtime routine such as taking a bath or listening to music
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sleep-conducive environment that is dark, quiet, comfortable and cool
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sleep on a comfortable mattress and pillow
 * <span style="font-family: Arial,Helvetica,sans-serif;">Use the bedroom only for sleep and sex
 * <span style="font-family: Arial,Helvetica,sans-serif;">Finish eating at least 2-3 hours before bedtime
 * <span style="font-family: Arial,Helvetica,sans-serif;">Exercise regularly but avoid it a few hours before bedtime
 * <span style="font-family: Arial,Helvetica,sans-serif;">Avoid caffeine (e.g. coffee, tea, soft drinks, chocolate) close to bedtime
 * <span style="font-family: Arial,Helvetica,sans-serif;">Don't smoke -- not only is it a major health risk it can lead to poor sleep
 * <span style="font-family: Arial,Helvetica,sans-serif;">Avoid alcohol close to bedtime; it can lead to disrupted sleep later in the night
 * 1) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; line-height: normal; margin: 5pt 0in;">**Noise** including a faucet dropping or the absence of a familiar background sound, can impact sleep.Studies show that sounds you hear repeatedly, even sirens and traffic sounds, can become soothing apart of the ordinary background. To alleviate problems with noises, try to block out unwanted sounds with earplugs or use a white noise, such as a fan or air cleaner, to help you sleep. When you travel bring familiar sound, such as a ticking clock, along with you.
 * 2) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; line-height: normal; margin: 5pt 0in;">**Temperatures** too high or too low can interrupt sleep. Generally a slightly cool room helps because it mimics what occurs inside the body when your internal temperature drops during the night. Turn the thermostat down at night and using blankets, comforters, and electric blankets in cold weather help wit sleep. Sleeping in a hot environment has been found to cause more wake time and a light sleep at night. Air conditioners, fans, or humidifiers can help create the right temperature
 * 3) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; margin: 5pt 0in;">**Lighting** is another important factor for setting a comfortable sleep environment. Outdoor light is a powerful biological clock regulator, which influences feeling sleepy or awake. Exposure to bright light during the day followed by darkness in the night using curtains, shades, or blinds, can help create a good sleep environment. Avoid bright light in the middle of the night to use the bathroom by using a night light.
 * 4) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; margin: 5pt 0in;">Having enough **space** to sleep as well as a pillow and mattress that fits your needs will be the most comfortable for the whole night. The pillow should support your head and neck, and should be changed regularly.
 * 5) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; margin: 5pt 0in;">According to the National Sleep Foundation’s 2005 “Sleep in America” poll, 67% of people report their partner **snores**, 27% said their intimate relationship was affected by being too sleepy, and 38% report relationship problems due to a partner’s sleep disorder. Talk with your partner about the problem, and seek treatment from a doctor if necessary. Try using ear plugs or creating a comfortable sleeping arrangement that works for both individuals.
 * 6) <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 10pt; margin: 5pt 0in; text-align: left;">Sleep environment should be only for sleep and sex. Quality of sleep is negatively affected by doing work, watching TV, or using a computer around bedtime or in the bedroom.

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">**If sleep problems persist or interfere with daily function or activities**, the National Sleep Foundation (2011) recommends seeking evaluation and treatment by a physician, preferably one who is familiar with assessing and treating sleep disorders. The Centers for Disease Control and Prevention (2012) also recommends keeping a **sleep diary** of sleep habits for about 10 days, including when:
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">going to bed
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">going to sleep
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">waking up
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">getting out of bed
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">taking naps
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">exercising
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">consuming alcohol
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px; line-height: 17px;">consuming caffeinated beverages

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 90%;">Example of a [|sleep diary][|[PDF 579K]][] (CDC, 2012).

= **Treatment of Insomnia with Medications:** = **Medications may be taken when:** • The cause of insomnia has been identified and is best treated with medication. • Sleep difficulties cause problems in accomplishing daily activities. • Behavioral approaches have proven ineffective and the person is unwilling to try them. • A person is suffering insomnia-related distress and beginning behavioral therapy. • Insomnia is temporary or short-term. • Insomnia is expected or occurs in association with a known medical or biological condition (e.g. Premenstrual Syndrome) or an event such as giving a speech or traveling across time zones. **GUIDELINES:** Treatment with medications should: • begin with the lowest possible effective dose • be short-term, if used nightly • be intermittent, if used long-term • be used only in combination with good sleep practices and/or behavioral approaches Treatment for insomnia depends on the diagnosis, medical condition, use of alcohol and other drugs, age, and the need to function when awakened during the usual sleep period. Antidepressants are used if depression is causing a sleep problem, and anti-anxiety meds are used for insomnia related to anxiety (NSF, 2011). **Hypnotics**, prescription medications that promote sleep, are the most effective sleep aids currently available. One group of hypnotics, benzodiazepine agonists, are used to induce and maintain sleep effectively and safely by acting at the part of the brain believed to be involved with sleep promotion (NSF, 2011). Hypnotics differ by their chemical structure as well as half-life, affecting how long the drug is active in the body. Hypnotics have different recommended doses, which can be problematic when a higher dose is used, potentially causing rebound insomnia. Use of **hypnotics for short-term therapy** has been studied by comparing appropriate doses with placebo pills, and has been determined **effective and reliable for**: > **The length of treatment depends on various circumstances:**
 * shortening the time it takes to fall asleep
 * increasing total sleep time
 * decreasing the number of awakenings
 * improving sleep quality
 * Accepted insomnia guidelines call for short-term treatment, but long-term use of sleep aids is not uncommon.
 * 4 weeks is the recommended limit.
 * Not prescribing hypnotics may cause unnecessary patient distress, particularly when the person does well on the same dose and has no side effects.
 * Still, most sleep specialists share the belief that sleep aids shouldn't be a long-term answer to poor sleep for most people who have trouble sleeping.
 * More studies are needed on long-term effects of the use of sleep aids.

**Risks of Hypnotics:**
 * Falls
 * Sleepwalking
 * Driving accidents in older adults, particularly during 1st week of use
 * Stopping medication abruptly rather than tapering


 * People at risk while taking hypnotics include those who:**
 * drink alcohol
 * are elderly
 * operate machinery soon after awakening
 * have sleep apnea
 * take excessive doses or abuse other drugs/alcohol
 * use higher doses and hypnotics with longer half-lives

(National Sleep Foundation, 2011)

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Discussion of Intervention Efficacy »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 10pt;">The American Academy of Sleep Medicine provides definitions for the level of treatment and recommendations, as listed previously. The National Sleep Foundation (2011) provides recommendations for behavior modification as well as for seeking appropriate professional treatment. The United States Preventive Services Task Force (USPSTF) does not have recommendations specifically addressing sleep hygiene or sleeping disorders.

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">D2L Discussion Prompt »
<span style="display: block; height: 1px; left: 0px; overflow-x: hidden; overflow-y: hidden; position: absolute; top: 6452px; width: 1px;"> Recommendations for optimal sleep health from the National Sleep Foundation (NSF, 2011): - Maintain a regular bed and wake time schedule including weekends - Establish a regular, relaxing bedtime routine such as taking a bath or listening to music - Create a sleep-conducive environment that is dark, quiet, comfortable and cool - Sleep on a comfortable mattress and pillows - Use your bedroom only for sleep and sex - Finish eating at least 2-3 hours before your regular bedtime - Exercise regularly but avoid it a few hours before bedtime - Avoid caffeine (e.g. coffee, tea, soft drinks, chocolate) close to bedtime - Don't smoke -- not only is it a major health risk it can lead to poor sleep - Avoid alcohol close to bedtime; it can lead to disrupted sleep later in the night Ensure sleep environment is appropriate: - Noise, including a faucet dropping or the absence of a familiar background sound, can impact sleep. Studies show that sounds you hear repeatedly, even sirens and traffic sounds, can become soothing as part of the ordinary background. To alleviate problems with noises, try to block out unwanted sounds with earplugs or use a white noise, such as a fan or air cleaner, to help you sleep. When you travel bring a familiar sound, such as a ticking clock, along with you. - Temperatures too high or too low can interrupt sleep. Generally a slightly cool room helps because it mimics what occurs inside the body when your internal temperature drops during the night. Turn the thermostat down at night and using blankets, comforters, and electric blankets in cold weather help with sleep. Sleeping in a hot environment has been found to cause more wake time and a light sleep at night. Air conditioners, fans, or humidifiers can help create the right temperature. - Lighting is another important factor for setting a comfortable sleep environment. Outdoor light is a powerful biological clock regulator, which influences feeling sleepy or awake. Exposure to bright light during the day followed by darkness in the night using curtains, shades, or blinds, can help create a good sleep environment. Avoid bright light in the middle of the night to use the bathroom by using a night light. - Having enough space to sleep as well as a pillow and mattress that fits your needs will be the most comfortable for the whole night. The pillow should support your head and neck, and should be changed regularly. - According to the National Sleep Foundation’s 2005 “Sleep in America” poll, 67% of people report that their partner snores, 27% said their intimate relationship was affected by being too sleepy, and 38% report relationship problems due to a partner’s sleep disorder. Talk with your partner about the problem, and seek treatment from a doctor if necessary. Try using ear plugs or creating a comfortable sleeping arrangement that works for both individuals. - Sleep environment should be only for sleep and sex. Quality of sleep is negatively affected by doing work, watching TV, or using a computer around bedtime or in the bedroom.

**Risk factors for poor sleep:** - Attention-deficit hyperactivity disorder (ADHD) o ADHD is linked with a variety of sleep problems. For example, one recent study found that children with ADHD had higher rates of daytime sleepiness than children without ADHD. Another study found that 50% of children with ADHD had signs of sleep disordered breathing, compared to only 22% of children without ADHD. Research also suggests that restless legs syndrome and periodic leg movement syndrome are also common in children with ADHD. (NSF, 2011) - Aging o Changes to sleep patterns are part of the normal aging process. As people age they tend to have a harder time falling asleep and more trouble staying asleep than when they were younger. - Alzheimer's disease and senile dementia o Both Alzheimer’s and dementia are characterized by frequent sleep disturbance, both for those diagnosed and their caregivers. In fact, many caregivers cite sleep disturbances, including night wandering and confusion, as the reason for institutionalizing the elderly. Once institutionalized, these elderly residents' sleep disturbances don't cease, and tranquilizing medications may increase the risk of falls and further confusion. - Asthma o People with asthma often suffer from nighttime coughing, wheezing and breathlessness that disturb their sleep. It is not clear whether there is a circadian rhythm factor responsible for these nighttime disturbances or whether sleep in some way contributes to them, but studies designed to uncover the exact influence of sleep or circadian rhythms on asthma have been largely inconclusive. - Caffeine consumption o While caffeine does not replace sleep, it can temporarily cause alertness by blocking the sleep-inducing chemicals in the brain and increasing adrenaline production. - Depression o Sleep problems and depression may share risk factors and biological features, and both conditions may respond to some of the same treatment strategies. Sleep problems are also associated with more severe depressive illness. Insomnia is associated with depressed patients, occurring 10 times more than in those who sleep well. Research suggests that the risk of developing depression is highest among people with both sleep onset and sleep maintenance insomnia. - Restless leg syndrome (RLS) o Restless legs <span style="font-family: Arial,Helvetica,sans-serif; font-size: 17px;">Healthy People 2020 (2012). Improving the health of Americans. Retrieved from [|www.healthypeople.gov/2020] syndrome (RLS), a neurological condition that causes discomfort in the legs and sleep problems, is also associated with depression. According to the Restless Legs Syndrome Foundation, approximately 40% of people with RLS complain of symptoms that would indicate depression if assessed without consideration of a sleep disorder. - Obesity and sleep apnea o An estimated 18 million Americans have sleep apnea, a sleep-related breathing disorder that leads individuals to repeatedly stop breathing during sleep. Not only does sleep apnea seriously affect one’s quality of sleep, but it can also lead to health risks such as stroke, heart attack, congestive heart failure and excessive daytime sleepiness. - Gastroesophagel reflux disorder o According to the 2001 NSF //Sleep in America// poll, adults in America who experience nighttime heartburn are more likely to report having symptoms of sleep problems/disorders such as insomnia, sleep apnea, daytime sleepiness and restless legs syndrome than those who don’t have nighttime heartburn. - Menopause o From //peri-menopause// to post-menopause, women report the most sleeping problems, including hot flashes, mood disorders, insomnia and sleep-disordered breathing. Sleep problems are often accompanied by depression and anxiety. - Multiple sclerosis (MS) o According to a study led by W. Elon Fleming, MD, at the Sleep Disorders Center at Island Hospital in Anacortes, Washington, the most common sleep disorders in MS patients are insomnia, nocturnal leg spasms, narcolepsy, REM sleep behavior disorder, and sleep disordered breathing. Restless legs syndrome (RLS) is also highly prevalent among MS patients - Pregnancy o According to the National Sleep Foundation's 1998 //Women and Sleep// poll, 78% of women report more disturbed sleep during pregnancy than at other times. - Shift-working o Some of the most serious and persistent problems shift workers face are frequent sleep disturbance and associated excessive sleepiness. Sleepiness/fatigue in the work place can lead to poor concentration, absenteeism, accidents, errors, injuries, and fatalities. The issue becomes more alarming when you consider that shift workers are often employed in the most dangerous of jobs, such as firefighting, emergency medical services, law enforcement and security - Traumatic event o Stress from a traumatic event can often lead to a variety of sleep problems. When the body is overstimulated, the brain is flooded with neurochemicals that keep us awake, such as epinephrine and adrenaline, making it difficult to wind down at the end of the day. The neurochemicals remain present in the brain and can interrupt your normal sleep cycle. The result can be insomnia, bad dreams, and daytime fatigue caused by sleep disturbance. Hello, I am Larry, age 42, had an MI 4 weeks before. I started cardiac rehab with my wife, Shranda, age 38. We have 2 children, Issac 8 years old, and Precious 3 years old. We were referred to see you the APN, by cardiac rehabilitation program staff. We are married for almost 21 years. At the time of the MI, and we were taken by surprise, because I had shown no prior symptoms. Shranda was physically active in several sports, but I have a history of minimal exercise and being overweight. Shranda was more interested in health generally and had become a vegetarian 10 years ago, whereas I continued to eat “whatever I want.” We experienced a significant area of conflict in the marriage for some time especially about the health behaviors of the children who are above the 95% for weight. I am Shranda, have a range of emotions, including fear related to Larry’s brush with death, anger that he had failed to follow my health suggestions, and guilt over my anger. I have less tolerance for my children’s crying and tantrums than I used to. I am back, (Larry) I have strong feelings of guilt as well, in addition to anxiety and frustration because I believed that “now I will have to listen to her like she is my mother.” I have some anxiety and depressive symptoms, including sadness, lack of concentration, and a worry about the future (“I know I am going to die soon.”). Neither of us sleeps very well, due to my snoring and restless sleep. Can you order hypnotics for us? In one paragraph summarize, (a) Larry’s and Shranda’s risk factors for poor sleep, (b) Identify sleep hygiene strategies for Larry and Shranda. Review the family levels of care (e.g., minimal, information & collaboration, feeling & support, primary care family assessment & counseling, and medical family therapy) in Mc Daniel, et al. (2005) Chapter 1. (c) Select one of the family levels of care that you will use to guide your interventions with Larry and Shranda, (d) identify 2 corresponding interventions based on the level of care you selected. (e) Identify 2 other screening or clinical prevention strategies that are appropriate for Larry and Shranda today.
 * Discussion prompt**

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif; font-size: 1.3em;">References
Bonnet, M.H., Arand, D.L. (2011). Overview of insomnia. In B. Rose (Ed.), //UptoDate.// Retrieved from http://www.uptodate.com/contents/overview-of-insomnia?source=search_result&search=sleep&selectedTitle=8%7E150.

CDC (2011 a). Insufficient sleep is a public health epidemic. Retrieved from []

CDC (2011 b). Insufficient Sleep among WIsconsin adults. Retrieved from []

CDC (2011 c). Unhealthy sleep-related behaviors. //Morbidity and Mortality Weekly Report (60)//8, 234-242. Retrieved from []

CDC (2011 d). Sleep and chronic disease. Retrieved from http://www.cdc.gov/sleep/about_sleep/chronic_disease.htm.

CDC. (2012). Sleep and sleep disorders. Retrieved from []

Epstein, L.J., Kristo, D., Strollo, P.J., Friedman, N., Malhotra, A., Patel, S.P.,...Weinstein, M.D. (2009). Clinical guideline for the evaluation, management, and long-term care of obstructive sleep apnea in adults. //Journal of Clinical Sleep Medicine, 5(//3), 263-276. Retreived from http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf.

Healthy People 2020 (2012). Improving the health of Americans. Retrieved from [|www.healthypeople.gov/2020]

Johns Hopkins University School of Medicine. (2010). //Sleep university cme-screening tools for sleep disorders.// Retrieved from http://www.sleepuniversitycme.com/screening_tools.asp.

Johns, M.W. (1997). The epworth sleepiness scale 1997 version of ess. Retrieved from http://epworthsleepinessscale.com/1997-version-ess/

Johns, M.W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepiness scale. //Sleep, 14(//6), 540–545.

Kasasbeh, E., Chi, D.S., Krishnaswamy, G. (2006). Inflammatory aspects of sleep apnea and their cardiovascular consequences. //South Medicine Journal, 99//(1), 58-67.

Logue, E. E., Bourquet, C. C., Palmieri, P. A., Scott, E. D., Matthews, B. A., Dudley, P., & Chipman, K. J. (2012). The better weight-better sleep study: a pilot intervention in primary care. //American Journal of Health Behavior, 36// (3), 319-334. McKnightly-Eily, L.R., Eaton, D.K., Lowry, R., Croft, J.B., Presley-Cantrell, L., & Perry, G.S. (2011). Relationships between hours of sleep and health-risk behaviors in US adolescent students. //Preventive Medicine, 53//(4-5), 271-273. Retrieved from www. elsevier.com/locate/ypmed National Institutes of Health, National Center On Sleep Disorder Research. (2011). //National institutes of health sleep disorders research plan (//NIH Publication No. 11-7820). Retrieved from http://www.nhlbi.nih.gov/health/prof/sleep/201101011NationalSleepDisordersResearchPlanDHHSPublication11-7820.pdf.

National Sleep Foundation (2010). //2010 Sleep in America Poll.// Retrieved from [] National Sleep Foundation. (2011). Sleep topics. Retrieved from [|__http://www.sleepfoundation.org/site__]

Owens, J.A., Dalzell, V. (2005). Use of 'BEARS' sleep screening tool in a pediatric residents' continuity clinic: A pilot study. //Sleep Medicine, 6//(1), 63-69. doi:10.1016/j.sleep.2004.07.015

Pressman, M.R. (2011). Definition and consequences of sleep deprivation. In B. Rose (Ed.), //UptoDate.// Retrieved from http://www.uptodate.com/contents/definition-and-consequences-of-sleep-deprivation?source=search_result&search=sleep&selectedTitle=6%7E150.

Taheri, S. (2006). The link between short sleep duration and obesity: We should recommend more sleep to prevent obesity. //Archives of Disease in Childhood, 91//(1), 881-994. doi:10.1136/adc.2005.093013

Schutte-Rodin, S., Broch, L, Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. //Journal of Clinical Sleep Medicine, 4//(5), 487-504. Retrieved from []