1

Maurice M. Ohayon, MD, DSc, PhDStanford Sleep Epidemiology Research Center

School of Medicine, Stanford University

Epidemiology of Non-Restorative Sleep in the

General Population

2

What is non-restorative sleep?

For DSM-IV• It is one of the four insomnia symptoms

• It is described as a feeling the sleep is restless, light or of poor quality

For ICSD• Insomnia is described as a complaint of insufficient amount of sleep or not feeling rested after the habitual sleep period

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Non-restorative sleep

Sleep not enough Poor sleep

Prevalence: 20% to 41.7%

Prevalence: 10% to 18.1%

•Husby & Lingjaerde, 1992 Norway (Tromso)•Ohayon et al., 1997, UK•Ohayon et al., 1997,Ca (MTL)•Ohayon et al., 2001 (Europe)

•Lugaresi et al., 1983 San Marino , IT•Kageyama et al., 1997 JP•Asplund & Aberg,1998 SE (Jamtland county)•Vela-Bueno et al., 1999 ES, Madrid

Non-restorative sleep is poorly defined when using sleeping not enough or complaining of a poor sleep: the prevalence variation is too high

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Definition of NRS

NRS can be defined as : •a moderate to severe complaint of being unrefreshed upon awakening (even if the sleep duration is sufficient according to the subject) occurring at least 3 nights per week during a period of at least one month

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Sample

Targeted population:• Representative sample of the general population aged >=18 years of California, New York and Texas (66 millions inhabitants)

• Total sample: 8,937 non-institutionalized individuals

• Average participation rate: 85.3%Telephone interviews using the

Sleep-EVAL system

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Information collected by Sleep-EVAL

Socio-demographics Symptoms of sleep, psychiatric and organic

disorders Quality of life Daytime functioning

• Fatigue• Daytime sleepiness• Social functioning

Medical history• Consultations, hospitalizations, medications, diseases,

etc.

8Diagnoses collected by Sleep-EVAL

Sleep disorder diagnoses according to DSM-IV and ICSD*

Mental disorder diagnoses according to DSM-IV*

Organic diseases according to ICD-10Psychotropic consumption according to

the roster of pharmacological compounds

* Positive and differential diagnoses

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How frequent is NRS?

19%

22%21%

18%

15%

10%

15% 15%

13%

17%

11%

6%

17%

19%

17% 17%

13%

9%

0%

5%

10%

15%

20%

25%

< 25 25-34 35-44 45-54 55-64 >=65

Age groups

Female Male Total

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What is the duration of NRS?

0%

10%

20%

30%

40%

50%

60%

<= 5 months 6 to 11 months 1 to 5 years >= 5 years

Duration

Association between NRS and other insomnia symptoms

1.9%

0.5%

0.5%

DIS (11.3%)>= 3T/Wk>= 1 ms 0.1% 1.3%

2.5%

9.2%4.0%

0.4%

1.3%

4.7%

0.5%

13.1%

NRS (17%)>= 3T/Wk>= 1 ms

NA (35.5%)

>= 3T/Wk

1.6%

4.1%

No DIS, DMS, NRS and

NA (54.1%)

DMS (22%) >= 3T/Wk>= 1 ms

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57% No 43% Yes

1 or 2 awakeningsper night (78%)

>= 3 awakeningsper night (22%) Have difficulty

DIS?

NRS?

GSD?

10.1% (7.2%) 5.9% (15.2%) 50.4% (37.4%)

13.6% (14.7%) 7.3% (28.5%) 38.6% (43.9%)

9.5% (10.9%) 8.3% (31.9%) 45.6% (50.4%)

33.5% (5.9%)

40.6% (10.8%)

36.6% (9.8%)

35.5% Yes (n=3173)

64.5% No (n=5764)

Daytimeimpairment?

(48.3%) (65.1%)(36.9%) (77.5%)

Difficulty resuming sleep once awaken?

Nocturnal awakening events >= 3 nights per week?

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13What factors are associated with NRS?

Sleep/wake schedule?Mental disorders?Health factors?

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Sleep/wake schedule

Adjusted OR (95% C.I.)

Nighttime sleep duration < 5:00 0.66 (0.46-0.94) 5:00-5:59 0.72 (0.55-0.94) 6:00-6:59 1.03 (0.85-1.24) 7:00-7:59 0.95 (0.80-1.13) 8:00-8:59 1.00 >=9:00 1.47 (1.12-1.92)

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Sleep/wake schedule

Adjusted OR

(95% C.I.)

Sleep latency

<= 15 min. 1.00 16-30 min. 1.39 (1.23-1.57) 31-60 min. 3.04 (2.57-3.59) >60 min. 4.79 (3.84-5.98)

Extra sleep on weekend and days off

0 minute 1.00 <= 60 min. 0.76 (0.64-0.90) 61 min. to 2 hrs 0.90 (0.77-1.05) >2 hrs to 3 hrs 1.12 (0.91-1.38) > 3 hrs 1.45 (1.17-1.79)

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NRS: Association with mental disorders

Odds ratio (95% CI)*

DIS/DMS no NRS NRS

Major depressive disorder 1.9 (1.5-2.4) 4.3 (3.3-5.5)

Bipolar disorder 1.8 (1.2-2.8) 3.2 (2.0-5.1)

Anxiety disorder 1.4 (1.2-1.7) 2.1 (1.7-2.5)

*Reference: no insomnia subjectsAdjusted for age and gender

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Physical Diseases

Odds ratio (95% CI)*

DIS/DMS no NRS NRS

Hypertension 1.6 (1.5-1.8) 1.4 (1.2-1.6)

Diabetes 1.6 (1.3-2.1) 2.8 (1.9-3.9)

Upper airway disease 1.9 (1.5-2.4) 2.0 (1.6-2.8)

Heart disease 3.3 (2.8-4.0) 2.2 (1.8-2.8)

Chronic pain 3.2 (2.8-3.5) 4.0 (3.5-4.6)

Other disease 1.7 (1.4-1.9) 2.1 (1.7-2.5)

Any disease 2.6 (2.4-2.8) 2.8 (2.6-3.1)

*Reference: no insomnia subjectsAdjusted for age and gender

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Daytime consequences

CognitionMoodFatigueSleepinessMedical consultations for sleep

problemsUse of sleep medication

19Is NRS causing more cognitive difficulties?

45.0

20.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

NRS DIS or DMS (NO-NRS)

Pe

rce

nta

ge

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IS NRS causing more mood changes?

18.5

6.5

19.1

6.6

15.1

37.6

0

5

10

15

20

25

30

35

40

NRS DIS or DMS (NO-NRS)

Pe

rce

nta

ge

Anxious mood

Depressive mood

Irritable mood

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Is NRS causing more daytime sleepiness?

14.8%

4.6%

20.7%

12.3%

31.5% 30.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Moderate Severe

Daytime Sleepiness

No insomnia

DIS/DMS no NRS

NRS

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Negative impacts

13.3%

9.9%8.1%

37.4%

29.8%

33.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Family relationships Social relationships Work

DIS/DMS no NRS NRS

23Consultations & medication for sleep problems

15.4

8.0

14.0

10.9

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

NRS DIS or DMS (NO-NRS)

Pe

rce

nta

ge

Consultations for sleepproblemsUse of sleep medication

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Duration of sleep medication intake

0

5

10

15

20

25

30

35

40

45

50

NRS DIS or DMS (NO-NRS)

Pe

rce

nta

ge

<= 1 month 1 to 12 months 1 to 5 years >= 5 years

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Conclusions

NRS is a symptom that must be taken seriously for several reasons: • Excessive daytime sleepiness more frequent in NRS• Mood swings and cognitive impairments more frequent in NRS

• NRS more likely to seek help for their sleep problems • Therefore, the societal costs are important in terms of decreased productivity and diminished quality of life