Thread by @DrMikeFarquhar

It’s #WorldSleepDay

Sleep is absolutely essential to your physical and mental health.

Sleep’s rhythms underpin everything you do, ensuring your brain and body are working at their best.

But we’re often bad at recognising that, and prioritising sleep in our lives

If you’ve had the right amount of good quality sleep, you should be waking physically and mentally ready to tackle the day ahead

#WorldSleepDay

... many of us don’t feel that way though, especially on a weekday!

Most adults in the UK get about an hour’s less sleep than they need ... the equivalent of missing an entire night of sleep every week!

rsph.org.uk/about-us/news/…

#WorldSleepDay

We shrug it off, tell ourselves we feel fine. Many of us start our days with a caffeine kick to counter lack of sleep.

When we prioritise sleep though, we feel better, we work better ... we make ourselves healthier.

Over the course of #WorldSleepDay I’ll hopefully persuade you!

“Sleep that knits up the ravell’d sleave of care ... balm of hurt minds”

We’ve long understood the importance of sleep ... Shakespeare’s Macbeth is basically a play-length argument that we need sleep, and things rapidly go off the rails without it

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And every now and then, as this @bmj_latest editorial demonstrates, the idea of widespread sleeplessness, tied into the pressures of our busy modern lives, comes into focus

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... the problem though is that @bmj_latest editorial isn’t from 2018 ... it’s from 1895.

“Modern life” has felt pressured for a long time now, and its effect on sleep well-recognised

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We’ve got new 21st Century ways to combat sleep though.

In the 19th Century it might have been Dickens’ latest page-turner stealing your sleep time ... in 2018, @netflix says their biggest competitor is sleep!

#WorldSleepDay

The CEO of @netflix is very clear ... he is competing with your sleep for time. He needs you to sacrifice sleep so his company can make money.

Problem is that leaves you sleep-deprived!

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(The research that’s been done so far on @netflix style binge-watching bears out how much of a negative impact it can have on your sleep quality: psychologytoday.com/blog/sleep-new… )

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So ... why is sleep so important?

What is it about sleep that makes it so essential?

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One of the exciting things about being a sleep physician is that we still don’t know all the answers ... we’re constantly learning new things about sleep’s role in our lives

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What we ALL know though is how we feel when we’re sleep deprived.

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“For all beings endowed with the crowning mercy of consciousness, sleep is a pleasure!”

(I love old-school textbook writing style!)

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Increasingly, we know that sleep deprivation significantly increases risk of physical health problems, including obesity, type 2 diabetes and heart disease. It affects how we think, how we feel, and likely also increases risk of conditions like Alzheimer’s Disease

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Here’s a piece I wrote for @MetroUK for last year’s #WorldSleepDay

metro.co.uk/2017/03/16/wha…

Throughout #WorldSleepDay, key @nhs organisations will be talking about importance of thinking about sleep and fatigue in context of care our teams deliver

It’s essential we look after our staff to be able to deliver safe, efficient, effective care to our patients

#FightFatigue

Recommendations for hospitals and departments about how best to #FightFatigue in @nhs from @TheBMA are launched today #WorldSleepDay

bma.org.uk/connecting-doc…

As are similar recommendations from @AAGBI @RCoANews @FICMNews

#FightFatigue #WorldSleepDay

You can read my editorial in support of @AAGBI and @RCoANews #FightFatigue work here, in @Anaes_Journal

#WorldSleepDay

onlinelibrary.wiley.com/getIdentityKey…

And a 15 minute video on why it’s so important for @nhs to think about how best to #FightFatigue for @RCoANews is here:



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At @gsttnhs, the importance of looking after our staff to make sure we deliver care to the highest possible standards is reflected in our “HALT: Take A Break” campaign

guysandstthomas.nhs.uk/news-and-event…

#FightFatigue #WorldSleepDay

HALT emphasises the importance of getting good quality sleep for *everyone*

#FightFatigue #WorldSleepDay

HALT makes it clear that rest and breaks are essential for staff to be able to deliver care to the standards @GSTTnhs aspires to

#FightFatigue #WorldSleepDay

And also talks in particular about how to cope better with working at night ... when your brain’s natural rhythms mean you expect to be asleep, not delivering care in acute, pressured clinical areas!

#FightFatigue #WorldSleepDay

More detailed advice for @nhs workers about sleep and shiftwork is available from @ArchivesEandP here: ep.bmj.com/content/102/3/…

#FightFatigue #WorldSleepDay

Sound sleep, balanced diet and regular exercise are three simple pillars for good health for everyone

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In turn, good quality sleep has 3 key elements:

Duration: right amount for you
Continuity: no disruption
Depth: good quality

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Getting enough sleep is often the biggest challenge ... most UK adults probably get at least an hour’s less sleep most nights than they know they need

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Everyone’s “magic bullet” amount of sleep is different, and individual to you. Most adults need somewhere between 7-9 hours sleep most nights.

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If you *need* 7 hours of sleep, and you get 7 hours, you’ll likely feel fine.

If you get 7 hours and you *need* 9 hours though ... you’ll be 2 hours sleep deprived *every* night.

Understanding your own sleep need is essential!

#WorldSleepDay

A simple check is whether you sleep much later at the weekend when you can wake without an alarm.

If you do, this catch-up sleep is called social jet-lag ... and is a strong marker of sleep deprivation!

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If that’s you ... it’s worth being honest with yourself about how much sleep you REALLY need every night, and making sure you schedule enough sleep opportunity time to allow it

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There’s no universal magic solution to getting good quality sleep ... as with most things, it’s about committing to doing simple things well.

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The foundation of quality sleep is a commitment to a good core sleep routine, adopting positive sleep habits and cutting down on habits that are likely to make sleep worse

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Your bedroom should be adapted for good quality sleep ... and, pretty much, ONLY for sleeping in!

Bedrooms should be cool, dark, quiet and comfortable. It’s worth investing to get it right!

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A regular routine is important for sleep. Most nights, you should aim to go to sleep at roughly the same time, and wake at the same time each day ... and you need to schedule the *right* amount of sleep time for you!

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Get as much natural, bright daylight light exposure as you can ... it helps keep your body clock properly tuned up.

We’ll come back to light and the body clock later!

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Get plenty of daytime exercise ... it helps most people sleep better. Be careful though ... for some people doing exercise too close to bedtime can make it more difficult to get to sleep (some people like a late-night gym session though!)

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Be aware of how alcohol affects sleep ... a glass of wine or beer with a meal can help people relax and wind down in the evening ... but too much can negatively affect sleep #WorldSleepDay

And be careful about how you use stimulants like caffeine ...

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Caffeine temporarily blocks the effect of adenosine, one of the substances which contributes to making you feel sleepy - so it can give a boost of alertness. But it wears off...

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Although the alertfulness wears off, the side effects of caffeine - including making your sleep quality worse! - take much longer to wear off

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There’s also probably more caffeine lurking around than you realise ... did you know green tea can have just as much caffeine? Or that ‘decaffeinated’ drinks still have caffeine in them?

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Some people are more genetically susceptible to caffeine’s effects than others ... but overall caffeine can have a major effect on your sleep

(Espressos in the dark not a solution!)

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Genetically, I’m a fast metaboliser of caffeine but, even so, I try not to drink caffeine after mid-afternoon as I know it can affect my sleep quality that night

#WorldSleepDay

(I should perhaps have warned you all that I would be tweeting a LOT for #WorldSleepDay, but I’m guessing you’ve worked it out now.

Hi, my name’s Mike and I’m a sleep geek.

Oh, and a sleep doctor @EvelinaLondon )

Asked to contribute to @bmj_latest Head to Head debate on whether I thought junior doctors should work 24+hr shifts.

It won’t surprise you to find out I said “No” ... but outdated attitudes still widely persist!

#WorldSleepDay #FightFatigue @TheBMA

bmj.com/content/358/bm…

Let’s do some basic sleep physiology.

This is the hypnogram ... the diagrammatic representation of normal sleep. Understanding it is the key to unlocking many of sleep’s features (and mysteries!)

#WorldSleepDay

We cycle through different stages of sleep through the night:

Transitional/Light: nREM 1 and 2
Deep: nREM 3
“Dream”: Rapid Eye Movement (REM)

Healthy sleep splits roughly like this across the night: 50% in light sleep, 25% in deep sleep, and 25% in REM (dream) sleep

#WorldSleepDay

Much to parents’ frequent chagrin, we all get most of the deepest sleep we will get towards the beginning of the sleep period. After that sleep is more light sleep and REM

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Sleep stages have different functions.

Deep sleep supports physical growth and repair. REM sleep is important for learning and emotional regulation. Light sleep plays a key role in memory processing.

But sleep is complex - and we still don’t understand it all!

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The rhythms of wake and sleep are reflected in almost any physiological system you choose. Our brains and bodies depend on those rhythms to function properly

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Growth hormone secretion, for example, is tied to sleep, with the biggest pulse coming during deep sleep.

If sleep is disrupted, children can ‘fail to thrive’ ... not grow as well as they should

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Sleep quality can be affected by lots of things ... and when that happens the hypnogram, the representation of the architecture of sleep itself, becomes fragmented. That has consequences!

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Someone whose hypnogram looks like this may *think* they’ve been asleep but, because the quality is poor, will still be sleep deprived the next day

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In children, many common conditions can contribute to sleep disruption. Improving sleep quality can involve a bit of detective work!

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For children and adults alike, stress, worry and anxiety can be a really potent cause of sleep problems. Improving sleep often needs the source to be identified and treated!

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(Every now and then I get to prescribe “Monster Spray” in my clinic, and it’s really satisfying when it works 😁)

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(By the way, when I’m explaining the hypnogram in clinic to children and families, it tends to be a bit more dynamic and uses a LOT of Sharpies 😁)

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“Healthy sleep is a rhythmic act, and rhythmic sleep must be cultivated”

The most fundamental rhythm of sleep is our body clock, our circadian drive, which acts like a master control to keep us awake by day, asleep by night ... unless we choose to fight it!

#WorldSleepDay

Our circadian rhythm is one of two major processes that regulate our sleep and wake. The other - Process S - is our sleep drive. The longer we are awake, the more tired we feel

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The interactions between sleep and alert drivers are a bit more complex than that ... and that means most people feel a bit more naturally sleepy in the early afternoon

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... the post-lunch dip is driven by your body clock physiology. Some cultures encourage a siesta ... we’re more likely to go to the coffee shop...

(We see this reflected in accident incidence figures)

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When we go against our body clocks - for example if we travel long-distance and are jet-lagged - we feel the effects of our brains and bodies being out of sync with the world

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Our society depends on many people, working at night, fighting against their body clocks, for our safety and convenience.

We should think better about that, and support them more

#WorldSleepDay #FightFatigue @bmj_latest

blogs.bmj.com/bmj/2017/10/06…

Everyone’s body clocks are wired slightly differently ... many people will know if they are a morning “lark” or an evening “owl”

This body clock preference is partly genetic

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Most people’s body clocks don’t run to a 24 hour day ... ~75% have body clocks >24hrs, 25% <24hrs.

We constantly resynchronise our clocks every day. Light is crucial to that process.

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The 2017 Nobel Prize in Medicine was awarded for work better describing how our body clocks work. It’s going to be a major area of development in 21st Century healthcare

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Let there be light!

Light is the most powerful external influence on our body clocks. Regular exposure to light and dark entrains our sleep cycle.

We use “zeitgeber” - ‘time giver’ - to describe any factor which can do this

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When you travel far enough around the world to be jet lagged, the pattern of exposure to light and dark in your new time zone is what readjusts your body clock to synchronise with local time

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Historically, the only light sources were sun, moon and fire ... out body clocks evolved to match that.

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That changed, dramatically, with the advent of electric light.

Suddenly ANY time of day could be brightly lit

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This is the difference in light exposure between people living in a traditional hunter/gatherer society and a modern industrial society

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Light has a major effect on your body clock. When your brain is exposed to bright light when it doesn’t expect to be, it is the same as telling your body clock you’ve moved time zones

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If you, in the UK, kept yourself awake with bright lights until 2-3am for several nights in a row, this is the equivalent of telling your body clock you are now in New York.

When you then try to go to sleep at 10pm ... your brain thinks it’s 5pm - so, no sleep!

#WorldSleepDay

This is what you are doing to your brain and body clock when you do this ...

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Light in the evening also suppresses melatonin, the signal the brain sends to your body to encourage sleep

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And the brighter the device, the stronger the effect

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The screen device companies will try to persuade you that night modes are the answer ... but the evidence coming in suggest they don’t significantly reduce the impact of electronic light on sleep

journals.sagepub.com/doi/abs/10.117…

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There is also a psychological effect ... the Wikipedia or YouTube “black hole” that keeps you awake until the early hours ... or @netflix skilfully encouraging you to binge watch!

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For good sleep, get plenty of light in the daytime ...

#WorldSleepDay

... but at night, aim to dim light as much as possible and, for best chance of a good night’s sleep, have an electronic curfew 1 hour before bedtime and ban screens from the bedroom altogether.

Family docking stations are a good way to remind everyone!

#WorldSleepDay

Try not to make this how you approach electronic screen devices at bedtime!

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It also leads to one of my favourite sleep “cures” though ... go camping to reset your body clock! 😁

#WorldSleepDay @bbchealth

bbc.co.uk/news/health-38…

If you’re @EvelinaLondon @GSTTnhs St Thomas’ Hospital, come and meet the @EvelinaLondon Sleep Team for #WorldSleepDay - we’re in Birdsong Corridor for the evening hometime rush 💤

... and if you fill in a brief Morningness/Eveningness questionnaire we’ll even give you a free circadian rhythm cookie 😁

#worldsleepday cookie @EvelinaLondon @GSTTnhs 😁

Sleep changes across the lifetime, in duration, timing and proportions of different sleep stages.

Babies, for example, sleep longer overall, but in shorter bursts, and spend much more time in REM-like sleep - supporting the huge brain growth in first year

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Children develop the sleep pattern parents hope for at different times, just like children are dry by night at different ages

Honest truth is children have been disrupting parents’ sleep since the Stone Age. Often it’s normal variation, and not a medical problem

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A guide to common sleep difficulties in typically developing kids from @ArchivesEandP is here: ep.bmj.com/content/101/4/…

@EvelinaLondon @RCPCHtweets

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Our @EvelinaLondon sleep department also developed an app-based approach for parents that self-guides them through common sleep issues in younger children

kidssleepdr.com (free, but iOS only at the moment, sorry!)

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There are also @NHSChoices resources for common sleep problems, for children and adults here:

nhs.uk/LiveWell/sleep…

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Other good first-line resources if you’re a parent struggling with your child’s sleep:

babysleep.com

m.raisingchildren.net.au/sleep/toddlers… (great general resource for all ages!)

#WorldSleepDay

And, when all else fails, there’s something therapeutic about listening to Samuel L Jackson read this out loud:

(Warning: not for young ears!)



#WorldSleepDay

Sleep problems in children are common, and most can be dealt with by applying simple knowledge, experience and advice consistently.

More kids with sleep problems need super nanny rather than a sleep doctor.

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Paediatric sleep medicine is a relatively new specialty, with not many of us doing it!

Sleep medicine is a mix of common sense general paediatrics, neurology, respiratory, mental health, neurodisability and community paediatrics.

Sleep affects everything!

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Our specialty might be fairly new, but as long as doctors have been thinking about children’s health, they’ve been thinking about their sleep!

This, by Thomas Phayre, is from 16th Century Boke of Chyldren - the first English-language paeds textbook!

#WorldSleepDay @RCPCHtweets

When children don’t sleep, it can have a huge impact on their parents physical and mental health. Better advice about sleep earlier can help - the answer is very rarely fancy tests, or sleeping medicines

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Kids’ opinions about their need for sleep are often very much at odds with their parents’ ideas!

...the day I have a simple ‘cure’ for that, I’ll be a very rich man!

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Dr Doom is right though ... children benefit even more than adults from getting the right amount of good quality sleep most nights. That means sticking to a good general routine and sleep habits most nights

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Children’s sleep services like those @EvelinaLondon are here to help in the assessment and management of complex, rare and refractory sleep diseases and disorders. We do a lot of public outreach work to try to help as many people as we can

#WorldSleepDay

evelinalondon.nhs.uk/our-services/h…

Because being a children’s sleep doctor is a bit, well, weird, the @PaediatricFoam team came to ask me about how I ended up doing this:

#WorldSleepDay @begley_roisin @PriyenShah86 (thanks both!)

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While many sleep problems either relate to issues with sleep routine or habits, or to the effect on sleep of other medical problems, there are >100 disorders of sleep itself.

Most are treatable.

#WorldSleepDay

How we breathe at night can affect sleep quality - obstructive sleep apnoea is a common sleep disorder in both adults and children. The airway becomes briefly, temporarily blocked, partially or totally

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While obstructive sleep apnoea is very very rarely immediately life-threatening, it can affect sleep quality, and cause fragmentation of sleep architecture.

That leads to next-day symptoms.

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While the most common cause of obstructive sleep apnoea in children are enlarged adenoids and tonsils, some groups of kids are at higher risk

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For kids with some conditions, that risk rises significantly!

Kids with Down Syndrome <6yrs old, 73% incidence of OSA, 14% moderate or severe. Needs screened, and treated!

#WorldSleepDay @drcathyhill @DsmigUKIreland

secure.jbs.elsevierhealth.com/action/getShar…

For many kids with OSA, adenotonsillectomy will solve the problem.

Our @EvelinaLondon ENT surgeons are amazingly skilful at doing this even in children with complex conditions (though not *quite* as easy as with the Power Cosmic...)

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Many kids with obvious OSA don’t need any sleep studies at all.

We use simple oximetry (which measures oxygen level) to help our ENT team stratify severity pre-operatively

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When OSA shows up on oximetry it looks like this - regular clusters of desaturation (during REM sleep...more on that later)

Problem is it’s not v sensitive, so not good for diagnosis

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More detailed sleep studies, like this one, let us look at breathing in sleep in much more detail

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These studies used to need an overnight admission to hospital ... but increasingly, as technology gets better, we can do more of these studies in the patient’s own home - much better for them!

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On a detailed respiratory sleep study, OSA looks like this - lots of ups and downs and fragmented sleep

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This is the same 4 year old after having his adenoids and tonsils out ... hopefully you don’t need to be a sleep expert to see how much smoother and more regular all the traces are!

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The most detailed type of sleep study, polysomnography, lets us monitor the brain’s electrical activity so we can tell what type of sleep someone is in.

This is REM

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During dream sleep, your voluntary muscles are paralysed, to stop you acting out your dreams. You’re not usually aware of it - but sometimes you can wake and feel like you can’t move.

This is sleep paralysis

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It can be accompanied by very vivid dream-like images - hypnagogic/pompic hallucinations.

In older times, people thought they were being attacked by demons. These days people more likely to think it’s an alien abduction!

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... sleep paralysis and hypnagogic hallucinations are WHY I’m a sleep doctor - started happening to me in my teens.

Once I’d calmed down, it started a life long fascination with sleep (boosted hugely by @neilhimself)

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Sleep paralysis and hypnagogic hallucinations can be absolutely terrifying, but are most often benign in themselves.

They’re often telling you to need to improve your core sleep routine/habits!

Can run in families too.

Occasionally can point to other problems

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A lot of sleep problems are like that - terrifying and weird, but relatively harmless.

It takes a bold doctor to name a scary - but usually benign - sleep condition “Exploding Head Syndrome” 🤯

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In childhood, one of the commoner sleep problems, and one which often freaks parents out are sleep terrors. Kids seem to wake, utterly terrified, run around, scream, shout, hit ... then settle back to sleep

Parents often need a stiff drink!

This is a sleep terror #WorldSleepDay

Again, in older times, kids were as likely to be taken to the minister for exorcism than to the doctor!

#WorldSleepDay

More on partial arousal parasomnias, including a link to my colleague @guy_lesch excellent @BBCRadio4 series on sleep here:

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There are several sleep conditions which are relatively easy (often) to help people suffering from them, but they need to be recognised as a sleep disease first: Restless Legs Syndrome is a good example

twitter.com/i/moments/8481…

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Patients in hospitals across the UK will be trying to settle to sleep about now.

Some of them will find it difficult because of the reasons they are in hospital in the first place.

Many though will struggle because hospitals are bad for sleep

#WorldSleepDay

Sleep is essential for recovery from illness and injury. It allows growth and repair. It keeps your immune system functioning properly. It strengthens emotional resilience and patience.

Simple strategies can make big differences, like @GSTTnhs SSH campaign

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Eye masks and earplugs for patients can help improve sleep quality.

Staff being a bit more consciously quiet, thinking about light, minimising unnecessary interruptions can help hugely.

#WorldSleepDay

A great example of what can be done to improve how patients sleep in hospital comes from @drcathyhill and @Sotonchildhosp team.

Even small changes are a good start!

piernetwork.org/shh.html

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I’ve almost run out of #WorldSleepDay, so much about sleep I haven’t even touched on

Hopefully I’ve not filled up your timeline too much, and you’ve learnt something new or interesting or useful about sleep.

(This was me as a kid...I didn’t need an iPhone to stop me sleeping!)

If you struggle to get to sleep, or to stay asleep, I recommend looking at this book - a great guide to self-help strategies for insomnia.

If you think you need more help, discuss with your doctor. Drugs often not a good long-term solution.

#WorldSleepDay

For those of you just starting a night shift - thank you.

Have a read of this: blogs.bmj.com/bmj/2017/10/06…

and this: ep.bmj.com/content/102/3/… @ArchivesEandP

#WorldSleepDay

Sleep helps define who we are.

Sleep is still full of mystery and magic and wonder.

It’s where science meets story, where medicine meets myth.

It is both rhythmical and random, and I t’s a privilege to spend so much of my life delving into it.

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Thank you for reading and responding today.

I hope your dreams are pleasant

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And, sleep well! Tomorrow is another day.

#WorldSleepDay