k productivity, about $150 billion, a lost supported by businesses.

The National Sleep Foundation (NSF) reports over 70 million American Adults (33% to 40% reported in 1999) with a hazardous level of sleepiness.  Dr Martin Thory emphasized that this population contributes to more than 100,000 police reported crashes, causing 1,500 death (40,000 are reported by Gofrey) and 71,000 injuries (250,000 by Gofrey) each year in the USA alone.  More than half of those car crashes involved drivers between the ages of 15 and 24, who were estimated to sleep an average of 6 hours (instead of 9 hours, which is usually recommended for this segment of the population.)

     NHTSA estimated the crashes monetary losses alone to be $12.5 billion ($43.15 billon and $56.02 billon from other sources) every year.

    The implication of sleepiness in traffic accidents has been studied extensively: according to a 1999 survey conducted by NSF, 62% of adults declared that they have driven while drowsy with a 27% admittance to falling asleep behind the wheel – so about 100 million people have driven drowsy and 14 million fell asleep driving.  The work related accidents caused by sleepiness are estimated to produce 945,000 disabling injuries with 5,565 fatalities, and a cost between $43.15 and $ 56.02 billion every year, and a direct cost of $24.7 billion (National Capital Center for cranial pain.)  It appears that staying awake between 17 and19 hours decreases the reaction time up to 50% - even slower than after drinking 50 mg/dl of alcohol (research done in occupational and environmental medicine, which proves that cumulative effects of moderate sleep deprivation can produce cognitive and motor impairments similar to legal levels of alcohol intoxication.)

Working over 60 hours increased the odds of accidents by 40%, and working night shift increased the odds by 6 times (AAAFTS).

              According to NSF, 60% of children are complaining of feeling tired during the day with 15% of them admitting they fall asleep in school.  The cost and consequences of this problem are not yet evaluated but the burden in health and education is obvious.

Television and videos and electronic games are “blamed” for many children sleep and psychological problems, affecting children as young as 1 to 3 years of age.  It is estimated that the average American child spends 4 hours per day in front of a television screen, which causes major changes in the total sleep time, dream content, sleep fragmentation, and biologic rhythms.  Sleeping late and superficial becomes a habit children carry throughout their life.

 Although the cost of sleep disorders has not yet been sufficiently studied, the direct cost of sleep apnea in USA in 1990 was $ 275 million, based on 70 sleep laboratories with a capacity of 5 to 6 patients per night.  But sleep apnea alone, is considered to be associated with a 23 - fold increase in the risk of a heart attack, 2.7 fold increased in vascular death, 27-47.8% in high blood pressure, and up to 9 times increased in motor vehicle accidents.  Mortality rates for mild to severe untreated sleep apneics are 2.1% (for mild) and 10.6% (for severe), but the treatment fully reverses the disease with 0% mortality in treated patients. 

The direct cost of insomnia in 1990 was $15.4 billion, which was spent primary on physician visits and prescription medication.  It does not include over the counter pills, herbal treatments, “miracle mattresses” and all the other “commercial remedies.”              Narcolepsy was reported as being responsible for 18.9% of industrial injuries, due to failure to recognize and properly treat it.

Today the costs have increased significantly, but the treatments for sleep diseases is usually very efficient, so early recognition and treatment of these diseases can be highly efficient in terms of years of lost life and economical costs.  The consequences of not detecting sleep diseases have been well documented.  They include impairment in performance, irritability, memory loss, mood swings, too often treated as psychiatric diseases, errors which result in additional unevaluated cost for society.

Night shift workers schedules are associated with additional problems: ulcers, gastrointestinal disorders, increased respiratory infections risk, attacks in asthmatic patients, headaches, low back pain, susceptibilities to stress which potentially increases smoking and the alcohol use, emotional and marital difficulties, memory lapses, and an overall decline in general health and well-being of the worker. This increases the medical cost, which the employer and society health expenditures must cover.

Industrial accidents due to fatigability can be devastating, taking just these few examples: Three Mile Island, Chernobyl, Challenger, Bhopal, or Exxon Valdez, which were proved to be the result of sleepiness among workers.  Marked increase in job related errors due to tiredness were cited as factors in California Rancho Seco nuclear reactor automatic tripping and the failure to regain control of the plant.  The skipper of the World Prodigy, responsible for the 300,000 barrels of oil dumped into Narragansett Bay, had not slept for 36 hours when the accident occurred.  Similarly, the accidental drainage of

18,000 lbs of oxygen from Columbia space shuttle in 1986 escaped detection because the operator was extremely fatigue.  Sleepy employees, with potentially dangerous degree of impairment, comparable to substance abusers are a worldwide reality.  Many other errors related to sleepiness are documented in gas work employees, truck drivers, train and pilots engineers, etc.  An estimated 80% of policemen admitted they have fallen asleep at least once a week when working night shifts.  Overall, out of all nightshift workers, 50% fall asleep weekly, 75% fight with sleepiness every night shift, and 20% fall asleep at any given night on the job.

Additional information about sleep in adults between 55 to 84 years of age were published on April 1, 2003 by National Sleep Foundation (http://www.sleepfoundation.org ) and represent the results of a national survey, among a random sample of 1,506 American residents. 

        In conclusion, it is helpful to review the Findings National Commission on Sleep Disorder Research from 1992: “millions of Americans are affected by sleep disorders, sleep disorders affect all age groups; minorities and the poor have extremely limited access to sleep medicine, …, America is seriously sleep –deprived with disastrous consequences, …,the cost in dollars ,lives and human suffering is very high ,… ,pervasive failure of knowledge transfer (exist) … they are many serious gaps in research,…, and alarmingly few young investigators (are) in pipeline.”



            The Public Health Service, National Institute of Health designed a complex National Sleep Disorders Research Plan since January 1996 and acknowledged the need of a coordinated Public Health Intervention since 1998 with the establishment of a National Commission on Sleep Disorder Research Plan, multidisciplinary in nature.

 The vision was “to improve the health, safety and productivity of Americans.”

The recommendations for Public Health as well as for patient-oriented research were focused on epidemiological techniques, behavioral science and clinical outcome research with experimental therapeutics. These include screening methods for sleepiness and sleep disorders in high-risk population; programs to combat sleepiness, with the goal of improving safety and productivity in healthy workers as well in population with sleep disorders.  Development of technologies for sleepiness detection and monitoring was also proposed, as well as an evaluation of the utility of interventions that ultimately try to counteract sleepiness in certain situations (eg. in military).

            Extended research for the screening of sleepiness and sleep disorders are currently being tested; yet a definite method has not been determined.  Multiple studies were performed to assess the screening value of the following detection and prevention of sleep disorders: home monitoring systems, actigraphy, oximetry, electrocardiogram (EKG), questionnaires, sleep diaries, and artificial neural networks (ANNS).  These tests provided mixed results; therefore a screening method generally agreed upon has not been determined. Encouraging results appear to be linked with oximetry and electrocardiogram analysis.

Research on the shift work has focused on new schedules, daytime light simulation (bright lights), and melatonin administration to the night workers.

The Industrial Sleep Management program was developed because the workplace can be extremely complex and safety requires attention, decision – making capacity, memory, and the ability to perform complex sequences at any given time.

The need for legal rest requirements is obvious for driving or operating “a tractor, a convertible, a truck, a plane, a train, a space shuttle, or a space shuttle with nuclear cargo.”  They are extremely varied: up to 100 hours/month for the commercial airline pilot, up to 260 hours/month for the truck driver and over 360 hours/month for the shipboard personnel.  The absence of legal requirements for accommodations and insufficient education regard sleep, requests an initiative and future interventions.

The Job Accommodation Network (JAN) provides ideas of intervention for workers with sleep disorders (http://www.jan.wvu.edu/media/Sleep.html.)  Reports show that 50% of all these measures cost less than $500, yet employers report to have benefits exceeding $5,000; a worthwhile investment.

Shift workers as well as the general population need to have increased awareness of the short and long term effects of improper sleep, with a priority on the education of children and adolescents.  Current nationwide efforts to increases sleep awareness are concentrated during the National Sleep Awareness Week (March 31 –April 5) when the mass media is stimulated to participate in the public education of sleep problems.  The intervention includes: lectures, conferences, and workshops for the general public.  Brochures on healthy sleep habits, SIDS prevention, snoring, insomnia, and other sleep disorders are provided. 

One of the most successful and renowned programs is represented by the NHLBI Launches Sleep and Children Education Program, with Garfield the cat as “spokescat.”  The goal of the campaign is to encourage children to get at least nine hours of sleep each night, and the theme is “Sleep Well. Do Well.”  One-way used to increase awareness in children is through the website http://www.nhlbi.nih.gov/health/public/sleep/starslp/ where children can play the “Garfield Sheep Shot Game” which promotes sleep education through entertainment.

Although this attempt is well intended and formulated in such a way as to promote children to follow better sleeping patterns, it fails to be widely advertised which defeats the purpose of reaching a widespread audience.

Researchers have demonstrated that performance in elementary school is greatly improved by starting the school day later in the morning, which allows school children to gain additional hours of sleep.  Unfortunately no national steps have been taken by the department of education to generalize the practice of starting the school day at a later hour.

Health information dissemination regarding all of these major sleep related problems; if coordinated by National Institute of Health, Federal agencies and public entities, and nonprofit organizations; could have a huge impact and potential success in increasing the general health of our population.  The result of the smoking campaign in the USA is an example of how behavior changes can be stimulated by education, persistence, and a collective effort.  In addition it should be far easier to persuade the population to respect their internal biological clocks rather than to give up a highly addictive substance such as nicotine contained in cigarettes.  Mass media cooperation towards the spread of informative public messages in regards to sleep deprivation must be encouraged.  Pools should be conducted, prior to the release of widespread public broadcasting, on the impact of advertising slogans such as  “Sleep deprivation can kill.”

Sleep education among all physicians, targeted on Medical Schools programs, postgraduate trainings and continuing medical education levels appears to be a high necessity, knowing that the co morbidity between sleep disorder and other diseases often bring the typical sleep apneic patient first to the cardiologist or the nutritionist.  

Extended efforts of public health interventions performed lately were focused on parents’ education regarding baby sleep hygiene and the promotion of back sleeping for all infants.  Educational efforts and public interventions have greatly reduced the prevalence of SIDS, which out of all sleep diseases has been most drastically addressed.  This demonstrates that widespread public heath interventions can effectively reduce morbidity and mortality in the general population, which encourages future efforts in this field.   





§         Sleep at nighttime; choose your bedtime at least 1-2 hours before 12 pm.

§         Try to avoid napping too much (if any) during the daytime-this might be a reason for being less sleepy and eventually sleep will be fragmented at night.

§         Follow the same regular schedule, with approximate same hour of bedtime and waking time.

§         The natural light during the daytime hours especially in the afternoon promotes a good sleep.

§         Physical exercise during the day, light exercise in the afternoon, at regular time contributes to better sleep.

§         Avoid copious late dinners-eat dinner around 6pm and if necessary eat something light like a cup of warm milk, some cereals or crackers etc. before bedtime.

§         Avoid Caffeine late in the day-most tea and pop beverages contain caffeine!!!

§         Do not smoke before bedtime –nicotine is a stimulant too!

§         Alcohol may enhance early sleep but the sleep is highly fragmented and sleep maintenance is poor with early awaking in the morning-so alcohol at dinner does not necessarily relax!!!!

§         Keep the bedroom for sleep –avoid TV in the bedroom and falling asleep with the TV on -it is an unhealthy behavior more and more spread in general population, which fragments the sleep and possible doesn’t allow the body to relax and go to deeper stages of sleep.

§         Bedroom should be used just for sleeping –a period of 15-20 min should be enough to fall asleep –if not is highly recommended to leave the bedroom and come back when sleepy; worrying about sleep is not good either-mental games (counting, positive thinking etc) usually help to eliminate or reduce the tension.

§         Persistent problems (the primary care physician and sleep disorder specialist should assess over 2 - 3 weeks).





Different questionnaires are available free on Internet sides. Some examples are

 Screening for Sleep Apnea at

§        A.P.N.E.A. NET found on http://www.apneanet.org/question.htm.

§        Quiz from Phantom of the Night at http://www.healthyresources.com/sleep/apnea/question/quiz.html

Screening for Parasomnias at

§        http://www.postgradmed.com/issues/2000/03_00/schneck.htm  

Sleep self-evaluation form for Parkinson patients:

·        http://www.parkinson.org/qsleep.htm




·        NASA/AMES Fatigue Countermeasures Program-for studies correlated with fatigue. *


·        National Center for Sleep Disorders Research *

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For Sleep Apnea

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    1., 5 Kryger Meir, Roth Thomas, Dement William PRINCIPLE AND PRACTICE OF SLEEP MEDICINE, 1989 W.B.SAUNDERS COMPANY, chapters 4: Mammalian sleep, page 39-41. ; 5-section 4, Chronobiology

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 * HTTP://www.stanford.edu/-dement /fed.html Federal Organization, Federal Transportation and Industry related Organizations updated october1, 1998

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 24. George T. O’Connor, MD, MS; Bonnie K. Lind, MS; Elisa T. Lee, PhD; F. Javier Nieto, MD, PhD; Susan Redline, MD, MPH; Jonathan M. Samet, MD, MS; Lori L. Boland, MPH; Joyce A. Walsleben, PhD; Gregory L. Foster, MA for the Sleep Heart Health Study (SHHS) Investigators.  Variation in Symptoms of Sleep-Disordered Breathing with Race and Ethnicity: The Sleep Heart Health Study.  Sleep.

  25. Shahar E, Redline S, Young T, Boland LL, Baldwin CM, Nieto FJ, O'Connor GT, Rapoport DM, Robbins JA.  Hormone-Replacement Therapy and Sleep-Disordered Breathing.  Am J Respir Crit Care Med. 2003 Jan 16

.  26. Resnick HE, Redline S, Shahar E, Gilpin A, Newman A, Walter R, Ewy GA, Howard BV, Punjabi NM.  Diabetes and Sleep Disturbances: Findings from the Sleep Heart Health Study.  Diabetes Care. 2003 Mar;26(3):702-709.