sleep. - Manitoba Farm & Rural Support Servic

sleep. - Manitoba Farm & Rural Support Servic

Sleep and Why You Should Do ItWellDr. Carlyle SmithProfessor Emeritus of Psychology and Directorof Trent University Sleep Research LaboratoriesPeterborough, Ontario

Basic Sleep Facts• We all spend about 1/3 of our lives sleeping• If you live to be 75, you will have spent 20-25years sleeping (or trying to sleep).• How well you perform during the day dependson how well you slept last night.• One sleep problem is insomnia – the inabilityto fall asleep or stay asleep all night.• Over 40% of Canadians suffer some insomniaat some point in their lives.

Some Consequences of Poor Sleep• Increased accidents and injuries.• Increased susceptibility to heart attack, strokeand many other medical problems.• Increased likelihood of depression and othermental health issues.• Increased substance abuse.• Substantial memory loss.• Decreased productivity (costs 25 billion/year inCanada)

The Ideal Night of Sleep• Young adults often (not always) have verygood sleep patterns.• Many of us remember fondly how well weslept when we were younger (and want itback).• There are several kinds of sleep and theyseem to have different functions.

Basic Sleep Stages for Humans• Sleep is divided into two basic components.• 1) Non-rapid eye movement (NREM) sleepor Slow Wave Sleep (SWS).– Within NREM/SWS sleep there are 4 divisions,Stages 1, 2, 3 & 4.• 2) Rapid eye movement (REM) sleep.– Sometimes called “dreaming” sleep

EEG Hook - Up

Sleep Electrode PlacementEEGEOGEMG

Behaviour in Stages 1 and 2• Some awareness of the surroundingsremains, especially in Stage 1• Muscle tension remains reasonably high• Autonomic activities such as heart rate andrespiration are slow and regular• There are no eye movements

Behaviour in Stages 3 and 4• Oblivious to environment• No eye movements• Autonomic activities (heart rate, etc.) slowand regular• Some muscle tension in large musclegroups

Behaviour During REM Sleep• Oblivious to the environment.• Large muscles completely paralyzed. Only theeye muscles work.• Sporadic rapid eye movements (REM)• Fluctuating heart rate, blood pressure,breathing rate, etc. (autonomic variability).• Brain is active and dreams are reported.

Sleeping Dog

Sleep Across the Night• The sleep stages run through a cycle every 90minutes.• Then they repeat the cycle.• The 90 minute NREM/REM cycle is anultradian rhythm.• This rhythm, to a certain extent, persists overthe 24 hour period even when we are awake.

Circadian Rhythms• We all have internal biological clocks.• The human circadian (daily) rhythm is anapproximate 24 hour rhythm.• Another circadian rhythm in humans istemperature which moves through a 1.5 oCelsius (or 3 o F) variation in 24 hours.• For best sleep, these sleep and temperaturerhythms should be synchronized.

24 Hour Temperature Variation

Circadian Rhythm Disorders• Circadian rhythms can becomedesynchronized. An example is the sleep -wake and temperature rhythms.• When we travel long distances rapidly, thesleep-wake cycle is changed. Called jet lag.• On a trip from Toronto - Paris, the timechange is 5 hours.

Circadian con’t...• The traveller is asked to start his/her day 5hours earlier than normal and then to go tosleep 5 hours sooner.• So the sleep-wake cycle is now “de-coupled”from the temperature cycle.• This makes the quality of the sleep cycle verypoor.• Shift workers are familiar with this problemand suffer even more hours change.

Sleep and the Shift Worker• The natural biochemistry of the sleep system isout of synch with other biological clocks• Individual is trying to sleep when his bodytemperature is rising, rather than falling.• S/he is trying to sleep while the day is gettingbrighter and noisier, not darker.• Day sleep is often interrupted for many reasons.• It is never as long or satisfactory as night sleep.

Who Suffers Most?• Anyone over 50• Those with health problems, especially heartproblems.• Those with a second job -“moonlighters”• Those on strong medications• Natural early risers – “larks” (as opposed to“owls”).• Those requiring lots of sleep (8-9 hours)• Those with psychiatric problems

Coping Strategies That Help• On leaving the workplace, wear sunglasses toeliminate bright daylight.• Have a dark environment to sleep in (thedarker the better).• Have a quiet environment. No telephones,bells, etc.• Keep a rigidly regular sleep schedule. (It trainsyour brain as well as your family, friends, etc).

Continued..• Have a 20-30 minute nap in the eveningbefore work, if possible. (Helps improvealertness at work).• Try to avoid caffeine for 4 hours before sleep.(Results in early awakening after sleep onset).• Don’t use alcohol – it reduces sleep quality• Don’t use sleeping pills of any kind.• Have a nourishing breakfast before going tobed (so you won’t get hungry).

Circadian con’t...• Best sleep occurs when the temperature ofthe body is falling at sleep onset.• It is much more difficult to fall asleep whenthe temperature of the body is high or isrising.• Methods of moving the body clocks.– 1) Exposure to well timed bright light pulses.– 2) Ingestion of melatonin, a naturally occurringhormone.

Melatonin• Problem sometimes treated with strategicallytimed doses of melatonin.• Melatonin is a naturally occurring hormone.• The ingestion of 3 mg of melatonin, for theaverage person, will advance sleep onset byabout 5- 6 hours (for some people).• Thus on a trip to Paris (5 hr. difference), takingthe melatonin at 7 PM Toronto time will movethe sleep onset to about 7:30 , Toronto time.

Melatonin con’t...• The advanced sleep onset time of 7:30 PM inToronto coincides with 12:30 AM in Paris.• This is an (almost) normal time to go to bedfor Parisians.• Thus, by sleeping on the plane (howeverpoorly), your sleep-wake cycle has beenmoved to coincide with living in Paris• Melatonin can be used for shift work changes.

Light Pulsing• Light Pulsing is also used to change circadianrhythms.• The light pulse, presented just prior to sleeponset will actually delay the sleep onset.• The number of hours of delay will depend onhow bright the light is and how long it ispresented.• Normal room light is not enough to changethe cycle (about 70-150 lux)

Light Pulsing Con’t...• If the light is 10,000 lux - (e.g. - 6-8fluorescent bulbs) – and is presented forabout 30 minutes, the sleep onset can bedelayed 3-4 hours.• Blue light is the most potent, white lightOK• 20 minutes of sunlight (50,000 lux+) will setback the sleep onset part of the sleep-wakecycle by about 4 hours.

Shift Workers• Finishing a 12 Midnight to 8 AM shift at 8 AMmeans driving home in the daytime.• The sunshine naturally sets the best sleeponset time (9 -10 AM) back by at least 4-6hours.• The worker gets rest, but not deep qualitysleep as a result.• Dark glasses can help with this by blocking thesunlight. (Goggle type frames are best.)

The Power of the Nap• Humans may have been programmed to nap.• If a person is isolated so that they cannot tellthe time or date and cannot see outside –(many experiments have been done) – theychose their own day-night.• The choice is virtually always a 6 hour night ofsleep and a 1-2 hour “afternoon” nap.• Their day becomes 24.5 hours long.

Napping• Many cultures have included a split day forsleeping, with a longer night and a shortafternoon nap.• Many of these cultures are giving up thispractice, as the world gets more competitive.• Napping is good for you.• There are planned naps, emergency naps, andhabitual naps.

Napping Tips• The nap should be short (typically 20-30 min).This helps avoid the groggy feeling after thenap.• Make sure you have a quiet, dark place to napif possible. Napping is much better thanresting.• Nap right after lunch if possible. Napping laterin the day can interfere with night sleeponset.

Napping Benefits• Napping restores alertness by 100% andenhances task performance 30-40%.• Napping can extend your ability to worklonger into the afternoon.• An evening nap before a night shift canincrease alertness.• An emergency nap before driving can saveyour life.

How Much Sleep is Enough ?• Very individual. 6-9 hours is the general range.• Some people feel fine after about 6 hours,others like more.• 5 hours is generally not enough andindividuals are error and accident prone.• More than 10 hours does not seem to harmanyone, but doesn’t seem to provide anyadvantage.• Best advice – sleep until you are done.

How Much Sleep is Enough• The number of hours of sleep needed maypartially depend on how efficient is the sleeper.• Sleep must occur in solid, un-interrupted chunksto be restorative. Awakenings make the sleepmuch less satisfactory.• Sleep efficiency is measured by [TimeAsleep/Time in Bed] x 100.• Efficient sleepers get ~ 95%, inefficient sleepersget ~ 80%.

Sleep Deprivation• What happens when we are deprived ofsleep?• Historically, experimental subjects were thosethat agreed to stay up for many days.• One individuals stayed up for at least 200consecutive hours (over 8 days).• He tried to function normally during this time.

History• The most celebrated and most closelyexamined case of sleep deprivation was thedisk jockey, Peter Tripp from New York City.• He stayed awake voluntarily for 200 hourswhile being watched by a team ofresearchers.• He gave a 3 hour radio program from 5-8 PMeach day.

His symptoms of sleep loss• 1) Attention deficit - an inability to focus onboring, repetitive problems (adding sums,etc.)• 2) Visual hallucinations - these began to occurafter 60-100 hours of deprivation (eg. seeingcobwebs everywhere)• 3) Paranoid delusions - began at 110 - 120hours (A tweed suit appeared to have writhingworms, the nurse was Dracula)

Con’t ...• At 170 hours, he believed that there was aplot to operate on him surgically and takeout his insides. He was sure someone wastrying to poison him.• EEG sleep recording showed Peter awakeand talking at the same time as his brainshowed Stage 2 sleep

Con’t...• Loss of memory (failure to convert shortterm to long term memory) was anotherproblem which was ongoing• Lots of wild statements and profanities notin character for Peter• These “bad” times came in cycles of 90 -100 minutes.

Recovery Sleep• Peter slept for 13 hours on his firstrecovery “night” of sleep.• His second night of sleep was just slightlylonger than normal (approximately 9hours).• His third night was essentially of normallength for him.

Con’t...• His third night was essentially normal forhim. Thus in two days, he “recovered”from 8.3 days of total sleep deprivation.• Despite the fact that he slept more thannormal, he did not replace the sleep helost.• He felt quite normal after his recoverysleep.

Other Physiological Changes• A number of sleep deprivation studies havebeen done since Peter Tripp.• Hallucinations and delusions do occur after 60hours of sleep loss.• Heart rate, blood pressure, respiration andtemperature measures show little changeafter 160 hours (6.5 days).• Some limb tremor and reduced painthresholds do occur.

Sleep Restriction• Most people do not go for such longperiods of time without some sleep.• Yet they continually sleep less hours thanthey should over a period of days.• The ability to perform under these partialsleep loss conditions is similar to thoseunder complete sleep deprivation.

Sleep Restriction…con’t..• One of the greatest dangers is the belief ofthe individual that they have adjusted tothe short sleep regime and are OK.• The number of errors made on a jobincrease dramatically.• Airline pilots and surgeons have beenstudied extensively.

Sleep Restriction…con’t..• Despite insisting that they feel great, sleepdeprived individuals often make hugemistakes.• The number of errors made on a job increasedramatically.• Airline pilots have been known to forget toland at a designated airport and continue tofly for up to 30 minutes in the wrongdirection.

Sleep Restriction…con’t..• Surgeons make many more errors duringoperations on patients.• A surprising number of surgeons havefallen asleep while assisting on anoperation.• They also have often had serious caraccidents on the drive home after anextended work schedule.

Sleep Restriction…con’t..• Food is metabolized at a faster rate duringsleep than during waking• On top of this, sleep deprived individualsare likely to want to snack. They wind upeating more.• The preferred foods are carbohydrates.• Increased weight gain is one consequenceof sleep deprivation.

Sleep Restriction…con’t..• Sleep deprivation impairs the immune system ofthe body.• Even modest sleep reduction reduces thenumber of normal immune system cells,especially “natural killer” (NK) cells.• These cells are active in keeping the body healthyand attacking aberrant cell activity.• Thus, sleep deprivation may reduce the ability tofight abnormal cells such as cancer cells.

Aging Factors• The quality of the sleep goes down as we age.• NREM (SWS) deep sleep diminishes after age30, by age 50 most adults have very littleStage 3/4.• There are more awakenings in the night forvarious reasons.• Good news – older people need somewhatless sleep than young people.


Insomnia• Three kinds of insomnia.• Sleep onset insomnia.• Sleep maintenance. Can get to sleep butcannot stay asleep.• Early awakening. Can get to sleep and stayasleep for a few hours but then awaken tooearly and can’t get back to sleep.• These can be mild, moderate or severe.

Drug Treatments for Insomnia• There are a number of prescription drugs thatare used to treat insomnia.• These may be OK over the short term, but arebad for health over the long term.• Unfortunately, they also lose their potency soincreased dosages are required to keep up theeffect (addiction).• Eventually, you have to stop taking thesemedications.

Over the Counter Drugs• These have not proved to be of great potency,but there is a strong placebo effect.• Like the prescribed drugs, increased dosesprove necessary over the long haul and in theend – you must stop.• Herbal remedies are basically unproven aswell, although there is a placebo effect hereas well.

Alcohol• A large number of insomniac individuals (40%)treat their insomnia by drinking alcohol beforebed.• It tends to induce good sleep onset, but the sleepis not natural.• After about 4 hours – it results in nightawakening.• Alcohol is addictive and the dosage has to beincreased to keep up the initial effect.• In the end – you have to stop.

Relaxation Techniques• Many studies now show that relaxationsessions result in improved sleep (CognitiveBehavioural Therapy or CBT).• The techniques are superior to any drugtreatments known.• They combine sleep restriction with relaxationtechniques• CBT techniques are slower to show results,but do last over the long term.

Cognitive Behavioural Therapy forInsomnia• This is a non-drug method of restoring nightsleep.• Person keeps a sleep diary to understand theirsleep and waking patterns.• Then a time period at night is designated forsleep only in a dark quiet room.• Outside of this time, there must be noattempt to sleep.

CBT continued…• The person must not try to go to bed earlierthan normal or to have a daytime nap. (Theserules are Sleep Restriction Therapy).• As sleep during the designated nightimproves, the length of the night islengthened.• Another facet of this therapy is StimulusControl.

CBT Continued…• Stimulus control attempts to condition thesleeper to the special bedroom.• Example: No time is to be spent in the room ifsleep does not occur within 20 min. Leave theroom and do something else. When sleepseems possible, the person can try again.• Sleep Hygiene – a list of rules which can helpyou to sleep well.

Some Sleep Hygiene Rules• Keep bedtime and wake times constant.• Do not ingest excessive alcohol, tobacco,caffeine, etc. at bedtime.• Do not exercise just before bedtime.• Keep emotionally exciting/upsetting activitiesto a minimum before bedtime.• Keep the bedroom for sleeping. (Avoid T.V.,computers, studying, snacking, etc.)

Continued…• Have a comfortable bed, good quality mattress.• Reduce the room temperature by 3-4 0 C. (If bodytemp stays high, sleep will not happen).• Do NOT have a HOT bath just before bed - itraises body temperature. (Have the bath 2hrbefore bed).• Have as dark a bedroom as possible. Partial lightreduces sleep quality.• Reduce other interference – such as pets, noise,etc.

Dietary Considerations• Big meals before bed reduce sleep quality(indigestion, awakenings for bathroom, etc.)• Caffeine avoidance helps• Allergies to certain foods. These can be foodsensitivities that develop as you age (theymay be unknown).• They can prevent sleep onset and/or sleepcontinuity.

Sleep Biochemistry• One of the most important amino acids (forprotein) is L-tryptophan.• It results in increased serotonin, melatonin.• It is found in high protein foods.• Calcium is also important as a neuraltransmitter.• The brain must have lots of these at bedtimefor good sleep to happen.

How to Get These Substances• High protein foods have lots of L- tryptophan, butalso lots of substances which will feed the wakesystem also.• Eaten alone, high protein foods sort of cancelout.• Eating some carbohydrates along with theprotein seems to work best.• The carbs induce insulin which clears the systemand allows foods rich in tryptophan to work.

Foods Combos that Help• Turkey sandwich (modest size)• Whole grain cereal and milk• Cheese and crackers• Hard boiled egg and toast• Peanut butter on toast and milk• Banana and milk

Food No-Nos• Carbohydrates with too much sugar.(The sugar induces a sugar high, then a reboundsugar low, then stress hormone release).• HOT beverages –they raise body temperature• Caffeinated anything• Large meals of any kind• Spicy or fatty foods• Alcohol• Foods to which you may be allergic.

Sleep Apnea• Three general classifications of apnea:• 1) Obstructive or upper airway apnea -cessation of airflow despite respiratoryefforts• 2) Central apnea - termination of breathingdue to CNS malfunction• 3) Mixed apnea - cessation of breathingdue to both obstruction and CNS problems

Sleep Apnea Symptoms• Patients with sleep apnea invariablycomplain of un-refreshing sleep• They usually complain of grogginess,disorientation and mental dullness• These disorders are more prevalent inmales than in females• They are more prevalent in the middleaged and elderly than in the young

Obstructive Sleep Apnea• One of the most telling features is loudsnoring. The level of noise is extremelydisruptive to others sleeping in the same room(or house).• The snorer is largely unaware of the noises/he makes.• Repetitive throat airway blockage duringsleep.• Reduction in blood oxygen which starves braincells & results in wide-spread brain cell death.

OSA con’t...• The patient suffers from excessive daytimesleepiness. Sleep is unrefreshing• There are periods of interrupted breathingduring the night of sleep which can last from10 - 60 seconds or more.• This interrupted breathing induces repeatedshort periods of awakening in the night. (300-400 awakenings/night is not unusual)

Rules of Thumb• It is relatively easy to spot someone whoshould be checked for sleep apnea• 1) In men especially – neck size over 17• 2) Snoring so loud that no one wants to beon the same floor as the snorer.• 3) Individual is always tired.• 4) Falls asleep at inappropriate times.• 5) Loss of libido

Normal Throat

Blocked Throat

Con’t...• Obstructive sleep apnea has been treated bysurgical removal of tissue from throat airflowarea.• The long term success rate (2 yrs) has beenpoor (10%), although short termimprovement has been found to be as high as50-60%.• The problem is more complex than a smallthroat or obesity

Con’t...• The best treatment for OSA is ContinuousPositive Air Pressure (CPAP).• A mask is fitted over the nose and mouth ofthe sleeper. Air pressure through the mask isadjusted to force air into the lungs of thesleeper when s/he tries to breath in. The air isforced past the obstruction.• This treatment is non-invasive and works well.

S-9 Silent CPAP Apparatus

One Type of CPAP Mask

Oral Appliances for Apnea• Two basic kinds of appliances• One type holds the tongue forward• One type holds the lower jaw (and tongue)forward during sleep.• The patient must be capable of adjusting tothis device in the mouth and be free ofsuch disorders as teeth grinding, etc.

Provent• Another new device is a plug that goes over eachnostril. The device passage is open at inspiration.• It closes partially when the sleeper exhales, partof the exhaled air blows back into the throat.• This air holds the throat open for the next breath.Called Expiratory Positive Airway Pressure(EPAP).• Still being evaluated.

Provent Nose Plugs

Sleep and Pain• What can be done to enhance good qualitysleep if there is persistent pain?• Chronic pain is a common complaint.• 2/3 of those with chronic pain have poor andun-refreshing sleep.• Strong medications for the pain ofteninterfere with the quality of sleep (codeine,morphine).

Tips for Minimizing Poor Sleep• Eliminate caffeine completely• No alcohol in the evening.• Avoid vigorous exercise. Light exercise in theafternoon can be helpful.• Take a 20-30 minute afternoon nap.• Use of prescription medicated pain killers.• Acetaminophen (Tylenol) works for moderatepain and aids in reducing body temperature.• Try a relaxation technique.

Pharmacology of Sleep• Drugs can be used to try to induce sleep• Drugs can be used to ward off sleepiness.• Drugs can be used for other medical reasonsbut may interfere with normal sleep• Evaluation of how well it works is done bothby– 1) asking the subject how s/he feels after thenight of sleep– 2) examination of the overnight EEG.

Con’t...• Drugs which attempt to promote sleep orunconsciousness are called hypnotics.• The good hypnotic should have thefollowing qualities:• 1) Effective when taken orally• 2) Short half life (the drug should ideally beout of the system within a 24 hour periodso that there is no drug residue built up)

Con’t ...• 3) Amounts of REM and NREM sleep shouldnot be markedly suppressed or distorted(many hypnotics reduce %REM especially)• 4) The ease of awakening should remainunchanged and there should be no morninghangover.• 5) Other drug side effects (such as nausea,skin rash, diarrhea, head aches, hallucinations,depression, etc.) should be minimal.

Hypnotics• In the past, drugs used to promote sleepincluded barbituates.• Barbituric acid is the essential maincomponent of all of these compounds.• At high doses, most of these drugs canproduce anaesthesia.• They can be short acting (for sleep onsetproblems) or long acting (for maintenanceproblems)

Con’t...• These compounds allow normal NREMactivity, but partially suppress REM sleep timeas well as reduce REMs densities.• There is a drowsiness after-effect which oftenrequires the use of a morning stimulant.• Barbituates tend to be quite addictive overthe long term and overdosing is a commonproblem.

Con’t...• This class of drugs is named such that thelast two letters always end in - al• Several barbituates are as follows:1) Secobarbital (SECONAL)• 2) Pentobarbitol (NEMBUTAL)• 3) Amobarbital (AMYTAL)• There are over 30 variants of this class ofdrug and trade names vary

Benzodiazepines• Some types are especially good for sleeponset, while others are better for sleepmaintenance.• Triazolam (triazolobenzodiazepine) is widelyused for sleep onset (Trade name Halcion).• Brotizolam (triazolothienodiazepine) is usedfor sleep maintenance• Problem: Are addicitve, worsen sleeparchitecture and are associated with trafficaccidents.

Non-Benzodiazapines• Drugs like Zopiclone and Zolpidem (Ambien,Lunesta, Sonota) are considered to be good forsleep onset and possibly maintenance (less so).• They disturb sleep architecture less, but areaddictive.• Connected with car accidents and are an illegaldate rape drug.• Short term use (2-4 weeks) recommended.• Rebound insomnia can occur after withdrawl.

Non-Benzodiazapines• There may be morning grogginess• The body becomes tolerant to these drugs in3-4 weeks. The effectiveness of the samedosage then becomes no more helpful than asugar pill.• There are nasty sleep related behaviours likesleep walking, sleep eating and sleep driving.• They can induce depressive, suicidal thoughts.

Stimulants• In order to ward off “sleepiness”, stimulantsare often used.• Historiclly, the most commonly used class ofcompounds are amphetamines. The mostactive ingredient is D-amphetamine• While these substances do reduce sleepiness,they also tend to suppress sleep, especiallyREM sleep for the following night as well

Con’t...• These substances can also be addictive andover the long term damage internal organs• They were often used to treat hypersomniaand narcolepsy• Over the long term, the narcoleptic tended todevelop symptoms of addiction and internalorgans deteriorate.

Modafinil• Alternative to the amphetamines.• Trade Names: Alertec, Provigil• Used successfully for narcolepsy to enhancedaytime alertness.• Has a half-life of 14 hours and so can interferewith sleep onset if taken too late in the day.• Side effects include headaches, nausea, skinrashes, diarrhea, fever, shortness of breath toname some.

Over-the-Counter Sleeping Aids• These all tend to have the same ingredients.• The most common is an antihistamine.• Histamine alerts the body, so this drug willoften make the user drowsy.• Sometimes the drug will also contain a painreliever like Acetaminophen (Tylenol)• Some combine antihistamine with alcohol,like NyQuill.

Over-the-Counter Drugs• These have not proved to be of great potency,but there is a possible placebo effect.• They should only be used over the short term.• There are some side effects, such as:– Drowsiness during the day– Forgetfulness, clumsiness– Constipation, dry mouth– Blurred vision

Herbal Remedies• Valerian root and chamomile are twonaturally occurring substances that have beenrecommended for sleep induction.• Unfortunately, most have not been examinedin the way that drugs have been.• They may be better than man-made drugs,but not enough has been done to test this.• There is a placebo effect for all substances.

Herbal Remedies con’t…• If you believe that a substance will help you tosleep, then it probably will.• Over the long term, the substance may lose itspotency (or charm) as your body adjusts.• There is no guarantee that the naturalsubstance has no side effects.• Recommend short term (2-3 weeks) usage ofyour favourite herb, if you feel it works

Restless Legs Syndrome• RLS is characterized by disagreeable legsensations, usually prior to sleep onset thatcause an almost irresistible urge to move thelegs.• The uncomfortable prickling, tinglingsensation goes away with leg movement.• Often occurs in pregnant women or inpatients with rheumatoid arthritis• Pregabalin is used as a drug treatment

Periodic Leg Movements• Periodic Limb Movement Disorder (PLMS) -characterized by periodic and highlystereotyped limb movements that occurduring sleep.• The interval between movements is 20-40seconds. Actual leg movements last 1-5seconds. Awakening may occur, but oftendoes not. Seen in NREM, but not REMsleep

Causes and Treatments• Cause of Primary PLMS is unknown. It is treatedwith anticonvulsant meds, benzodiazapines,narcotics.• It can be worsened by antidepressantmedications.• Secondary PLMS may be due to other medicaldisorders such as diabetes, iron deficiency,anemia, uremia, spinal cord injury and others.• Treatments include Haldol, Sinemet, tricyclicantidepressants like amitriptyline.

Disorders of REM Sleep• REM sleep is characterized by a specialphysical state.• The brain is mentally active.• The large muscle groups in the body areparalyzed during REM sleep. Only the eyes canmove (Rapid Eye Movement)• There may be small muscle twitches of thefingers and face, as the muscles strain to beactive.

When REM Sleep Goes Wrong• REM Behaviour Disorder (RBD) is a disorderthat occurs in older individuals.• The disorder is often a stage in theprogression of Parkinson’s disease.• The system that normally prevents largemuscle groups from working – fails.• The sleeper often “acts out” the dreamphysically.

RBD Continued…• If the dreamer is having a dream about being afootball player – he may tackle the dresser. Thiscan lead to face scars, broken teeth, etc..• Worse – real life example – man dreams that hehas wounded a deer while hunting. In order toput it out of its misery, he grabs the deer by thehorns to snap its neck.• He is awakened by his panicked wife. He has hishands around her head and is squeezing her.

RBD Continued…• Fortunately she woke him up in time.• This disorder is dangerous for the dreamer.• It is also dangerous for the sleep partner.• It can be treated with medication.• Standard treatment is clonazepam• In severe cases, the mattress should be on thefloor, and room free of dangerous objects.• Sleeping alone is recommended.

Other REM Sleep Disorders• One fairly common experience is calledmorning paralysis.• The person wakes up and their mind is readyto go.• However, the body is still in a state ofparalysis as they have probably awoken fromREM sleep.• It may cause some panic.

Morning Paralysis• Techniques for ending this paralysis vary.• One common method is to imagine that ifthey can just move one finger, then the wholebody will then be able to move.• This is reported to work and the time inparalysis after awakening is usually in theorder of a few minutes.• If another person enters the room and talks,the paralysis almost always ends.

Hypnogogic Hallucinations• Another related disorder involves waking upwith the body ready to go, but the dreamcontinuing.• Less common than morning paralysis, butdream characters and activity may persist fora few minutes or longer after awakening.• The dream activity disappears after a shorttime.

REM Related Problems• Both morning paralysis and hypnogogichallucinations are the result of a slightlymalfunctioning REM sleep system.• The paralysis system acts too long after theend of the REM sleep period to producemorning paralysis.• The mental activity of the dream acts too longafter the paralysis system has ended toproduce hypnogogic hallucinations.

Continued…• Neither of these two things is particularlyserious alone.• If you have experienced one or the other ofthese things alone, and have done so for someyears, there is likely no no need to see doctor.• They occur in a fairly large number ofindividuals and the experience remains thesame over a long period of time.

Narcolepsy• Characterized by a cluster of symptomswhich include:• 1) Excessive daytime sleepiness2) Cataplexy3) Morning paralysis4) Hypnogogic hallucinations5) Sleep onset REM periods

Con’t...• This is a genetically related disorder withonset in adolescence or early adulthood.• The disorder usually first manifests asexcessive sleepiness during the day.• This is often accompanied by sudden andcomplete loss of muscle tone (cataplexy)• Also there is premature entry into REM sleep• Attacks are often triggered by emotion.

Treatment• A drug called modafinil is now used widely.• Provigil or Alertec are trade names.• The cataplexy (tendency to lose musclecontrol) is treated separately.• Clomipramine is one drug used to treat theloss of muscle control.

Dreams: Are They Important?• There are disorders which involve baddreams.• Many people do not remember their dreams.• When they do remember them, they don’tseem to make much sense.• However, some dreams may indicate healthor personal problems.

Dream Content• Modern dream researchers seldom speak ofFreud anymore.• A new method is to take a sample of at least 50dreams from an individual and count thecharacters and activities in them.• The scores are compared with those of hundredsof normal dreams from normal people.• These scores are a good description of thepersonality of the dreamer and may point tohealth problems.

Nightmares• The nightmare is a “bad” dream during REMsleep.• These dreams are often the only ones anyoneremembers. They can be so real, you arerelieved when you wake and find it is a dream.• The dream events are unpleasant and theyupset the dreamer.• They can be recurring. A recurring dream isprobably an unsolved problem.

Different Dreams for DifferentIllnesses• Research suggests that dreams sometimesportray health problems of the dreamer.• Specific health problems are described bydream images.• Dreams of individuals with heart problems arequite different than dreams of migraineheadache sufferers.

Common Features of Illness Dreams(Kataskin)• 1) Illness is associated with an increase indream recall.• 2) Dreams become distressful and includenightmarish images of war, blood, corpses,tombs, garbage, dirty water, hospitals,doctors, medicines. Almost always there isfrightening feelings attached to these kinds ofdreams.

Con’t...• 3) These dreams usually appear before thefirst physical signs of the illness (prodromal).• 4) Dreams caused by illness are longer thandistress dreams caused by ordinaryannoyances. They persist throughout thenight and for the duration of the illness.• 5) The content of the dream can reveal thenature, location & seriousness of the illness

Imagery• Dreams vary in how direct they are in“describing” the physical problem.• Thus the dreamer might dream about his/herheart or dream about someone else’s heartproblem.• S/he might also dream about a malfunctioningpump which somehow is very serious.• S/he might dream of pipes bursting and fluidescaping.

Example Health Dream• A patient, complaining of poor sleep, oncetold me this dream– I am at the cottage of my future parents-in-law. Idecide to jump off of the diving board into thelake. I dive down deep into the water and hit myhead on a stone. I have trouble getting back to thesurface and fear I will not make it.– I wake up frightened.

Continued...• At first this seemed like it might have to dowith a relationship.• However, when other dreams were added –– I am a sailor on a ship. Someone shoots me in thechest. I fall into the water and drown.– I am walking in the forest and someone shoots mein the chest five times.

Continued...• I was able to guess from these dreams thatthere might be a health problem.• On questioning, she mentioned that she oftenfelt short of breath on awakening.• This slim, 120 lb. girl of 21 years was testedfor sleep abnormalities and was found to havea severe case of sleep apnea.

Post-Traumatic Stress Disorder• PTSD sufferers tend to have very badnightmares and awaken in a panic.• PTSD usually originates after a very traumaticlife event.• Soldiers that have witnessed deaths of friendsoften return with PTSD.• A single recurring dream plays out over andover.• Extensive treatment is required.

Sleep and Memory• Good quality sleep is a must for memory oflearned material.• There are 2 basic kinds of memory systems.• 1) Declarative memory – memorization offacts. Much school work is of this nature.Conscious intention to memorize.• 2) Procedural memory – learning “how to”such as skating, bike riding… Learning detailsare not consciously remembered.

Procedural Learning• Procedural learning involves the acquisitionof techniques, strategies or skills.• Procedural learning is often learned implicitly(unconsciously).• Assessment of procedural learning is testedby observing the new behaviour.

Cognitive Procedural Learning• Cognitive procedural learning is one type ofprocedural learning.• This type of learning requires the learner todevelop a new cognitive strategy in order tosolve the problem (e.g. Tower of Hanoi).

Types of Tasks• Some procedural tasks do not involve muchmotor learning.• An example is the Tower of Hanoi• This task is conceptually difficult.• There is very little physical activity needed todo the task, just the understanding of how todo it.

Types of Tasks• Some tasks require learning a motorcomponent• An example is the Mirror Trace task• This task is conceptually difficult as well• It does require some difficult fine motoractivity to do it properly.

Cognitive Procedural Memory andSleep• Cognitive procedural tasks appear torequire REM sleep for most efficientlearning• Sleep following acquisition of the Tower ofHanoi and Mirror Trace tasks shows amarked increase in number of REMs andREM density.

Experimental Protocol• Subjects spend a baseline night of sleep inthe lab (acclimatization night discarded)Night 1• On the following evening, Subjects learn task.They then sleep over in the lab again. Night 2• Retest task 1 week later.

Total Number of REMsREMs180016001400120010008006004002000PRE*POSTp < .0001TESTCONTROLNight 1 Night 2

REM Sleep Deprivation• Selective REM sleep deprivation of such tasks as theTower of Hanoi and Mirror Trace result in memorylosses of 20 - 30 %.• Alcohol ingestion just before bed impaired REMsleep densities (but not time spent in REM sleep)• This resulted in approximately 30% memory loss forthe Wff Logic task and Tower of Hanoi on retest 1week later


REM Sleep Deprivation• Even moderate alcohol ingestion prior tobedtime can reduce REM sleep densities.• Moderate alcohol ingestion at bedtime caninduce memory loss the night of learningAND/OR 2 nights after the original learninghas taken place.• (Smith & Smith, Sleep, 26, 2003)

“Replay” Phenomenon• The basic idea is as follows:• Certain brain cells are very busy during thelearning of a task (when the subject is awake).• If the same cells are again busy during sleep, itmay be that they are busy sorting, storing andgenerally carrying out important memorystorage activities.

“Replay” in humans• Maquet et al. (2000) Subjects (right handed)were asked to learn a Serial Reaction TimeTask (SRT).• PET scans were taken during both learningand rest periods while subjects trained onthe SRT (48 blocks of 205 trials)• Distribution of regional cerebral blood flow(rCBF) was examined.

PET con’t…• Subjects slept in the PET scan overnight afteracquisition or after no acquisition (Controls).• Scans were taken during Stages 2, 3/4, REMsleep.• Activity during awake and during REM sleepwas similar in left cuneus, left premotorcortex, right cuneus and mesencephalon

Declarative Memory• Each kind of memory appears to need its ownkind of sleep.• Memorizing word list pairs goes better whendeep SWS occurs between learning and retest.• After a baseline night of sleep, subjects learn aword pair list.• Example: yard – prince, street – truck, etc…

Declarative Task• Subjects see 20 word pairs together forseveral exposures, 2 at a time• Test subjects sleep overnight in the lab andare retested next morning (12 hours later).• Control subjects do not sleep between testand retest (12 hours later).• At retest, all Subjects see one of the wordsand must name the word that goes with it.

Deep SWS vs. No Sleep• The Test subjects remember 25-30% more wordsthan the Control subjects that got no sleepbetween test and retest.• The sleep that was most important was the SWSor NREM (Stage 3/4).• The more a subject got of this kind of sleep, thebetter was the score.• Young people (who get lots of SWS) do betterthan older people. Memorization is easier for theyoung

Stage 2 Sleep Spindles• Sleep spindles are a major component ofStage 2 sleep• Spindles have been reported to be very stablewithin individuals (number and density pernight)• They are also known to vary in number anddensity between individuals.• The numbers decline with increasing age

The Stage 2 Sleep Spindle

Stage 2• 50% of the night is spent in stage 2 sleep.• It is the most constant of all sleep stages andlasts throughout the lifetime of the individual• It would appear to be important for storingmotor procedural memory.• There is more Stage 2 after practicing of a taskthat is already known and understood (golfswing, slap shot, tennis serve ….)

Pursuit Rotor Motor TaskMaterials• Pursuit Rotor– Thirty 30-second trials,32 RPM– Nondominant Hand• Sleep Recording– In-home units: C3-A2, C4-A1, EOG, EMG

Stage 2 Sleep• This kind of sleep is beneficial after practicinga motor sequence that is familiar but can beimproved.• Sleep after motor learning shows increasedStage 2 time and numbers of spindles.• The more spindles you see, the more you haveimproved on the task.

EFFECT OF SKILLS TASK LEARNINGON NUMBER OF SPINDLES1600*Learning GroupNon-learning ControlsTotal Number of SpindlesTotal Number of Spindles140012001000800600400200BaselinePostlearningSleep Night

The Stage 2 Spindle• We have found that there is a correlationbetween number of spindles and motor I.Q.• The more spindles in a normal night of sleep,the more likely will the individual be good atmotor activities such as sports.• This might be a way to check out who wouldbe the best choice for a spot on an Olympicteam??

Sleep Through the Ages• The kind and amount of sleep changesmarkedly over the lifetime of theindividual.• In the womb, the baby exhibits only 2states – awake and REM sleep.• The REM sleep shows lots of twitching ofthe fingers, face and toes.• There is no NREM or SWS sleep.

Amount of REM SleepAge Sleep/hr REM/hrs %ageBirth 16 8.0 508 months 13 4.3 33Young adult 8 2.0 25

NREM in the First YearAgeSleep/hrs. NREM/hr. %ageBirth 16 8 508 months 13 8.7 67Young 8 6 75Adult

EEG and Brain Development• REM sleep appears in greater amounts inthe neonate presumably because the brainstem neurons which generate REM sleepare already mature.• The reduction in twitching and bodymovements during REM sleep as the babyages is due to the maturation of the muscleinhibitory system of REM sleep

Con’t...• It is only by the third month after birth thatthe cortical neurons have become extensivelyinterconnected. Thus the higher amplitude,slow EEG of SWS only appears at this time.• Cortical-thalamic connections also mature inthe first few months. These connections arenecessary for the appearance of the spindle.

Cycles• The newborn (neonate) sleeps almostcontinuously with small intervals of waking• By 3-4 years, the child sleeps in a singleepisode of 8-9 hours /day with a nap period• Thus, the child begins to develop the normalconsolidation of sleep into a single episode atnight and waking episode during the day

Tips for Getting Newborns to Sleep• Learn to identify signs of sleepiness• Put the child in the crib or bed when theyappear drowsy, but before they go to sleep• The child should be placed on his/her back(new guidelines of CSS)• Encourage nighttime sleep

Tips for Getting 3-11 mo. Olds to Sleep• Young children reduce the amount of sleepthey need and it is quite variable.• Sleep needs drop to 9-12 hours with anafternoon nap of 1-2 hours.• Try to develop regular sleep times.• Make going to bed as happy an event aspossible (special treats, favourite stories)• Encourage your child to fall asleepindependently and become a “self soother.”

Tips for Getting Toddlers (1-3) to Sleep• Toddlers still need around 12 hours of sleepincluding a daytime nap. Nap time willdecrease.• Try to have consistent daytime and bedtimeroutines.• Communicate how important it is to go to bedon time and to sleep.• Use of security objects like blankets or toyshelps.

Childhood Sleep• Up until the age of 3, most children stilltake afternoon naps.• From age 4-5, napping disappears andsleep is done in a single nightly episode of9 -12 hours• By age 3, the stages of sleep are allrepresented and look the same as those foradults.

Tips for Getting Preschoolers (3-5) toSleep• Maintain a regular and consistent seepschedule.• Have a relaxing pre - bedtime routine thatends in the bedroom where the child sleeps.• The room should be cool and as dark aspossible.• No T.V. or other electronic devices should bein this room.

A Note on Lighting• We know that the darker the room, the betterthe sleep quality.• However, it is very likely that you will wantsome kind of lighting in your child’s bedroomfor them to see if they wake in the night.• The light frequency that most interferes withsleep cycles is in the BLUE range.• White light incudes this frequency as well asothers.

Lighting – Con’t…• There are several compromises that can bemade.• From the start, use lighting that is as minimalas possible.• As time goes on, gradually reduce theintensity of the white night light.• Utilize a red coloured light. This frequencydoes not affect the circadian clocks.

Ages 5-12• The number of hours of sleep (Total SleepTime - TST) drops from 10.5 to 8.5 hoursper night.• There is a lot of Stage III and IV. Childrenoften “skip” or miss the first REM period ofthe night at this age. This may be due tothe large amounts of deep SWS that seemnecessary

Sleep Tips for 5 – 12s• They need 9 -10 hours of sleep or more.• These children spend a lot more time informal learning situations.• There may be some sleep disruptions such asnightmares, sleepwalking, etc.• Keep a lid on T.V. and media time.• Large screen T.V. is often bright enough to setback sleep onset times.

5-12s Continued…• Tell your child how important sleep is to theirsuccess in school and sports.• This is no idle chat. It is now clear that themost successful kids are those that getadequate and regular sleep.• Keep the day and sleep time routines asconsistent as possible.• Keep the bedroom as dark and cool aspossible.

Ages 12 - 18• The large amounts of deep SWS continue• A number of hormones are released duringStages III/IV which include growth and sexhormones. These induce the rapid growthand development of puberty• Penile erections in males occur during REMsleep, vaginal blood flow fluctuations occurin females

Teenagers (12 -19s)• Should get 8-9 hours of sleep.• They will naturally gravitate to staying up laterand getting up later because their bio clocksdictate it.• This leads to clashes with the school system.• Kids get up early to catch the school bus or toget to a (8AM – 9AM??) class.• But they didn’t get to sleep until 1 AM.

Teenagers (12 -19s) con’t..• The teen may have to get up at 6 AM• They usually do not want to eat. (Remembertheir body temperature is still likely goingdown)• They may doze through the first hour or so ofclasses. Many do this.• Say good-bye to grasping course material(such as math and sciences) taught at thistime.

Teenagers (12 -19s) con’t..• By 11 AM these people have woken up.• They are hungry and may choose some nicecarbs to eat from the cafeteria or food court.• They often do not choose the healthy foodsyou would like them to have.• These sleep deprived individuals are in perfectposition to gain weight because they are sleepdeprived and eating all the wrong things.

Teenagers (12 -19s) con’t..• Try as much as possible to get your teenagerto bed early.• Try to avoid extreme sport or project timessuch as hockey at 10 PM or skating practice at4:30 AM.• If you can’t, encourage napping. Try to makethe routine consistent, whatever it may be.• Keep diet healthy and watch late nightsnacking. Just a little protein and healthy carb.

Ages 18-30• The amount of deep SWS moderates in thisgroup and sleep stabilizes at somewherebetween 6-8 hours per night• The number of hours of sleep and amounts ofeach stage seem to have a strong geneticcomponent.• Short sleepers (those that sleep less than 4hours per night) appear to have less stage IIand III than those that sleep longer.

Age 30-45• Sleep length tends to shorten and tolighten as aging occurs.• There is a marked drop in the amount ofStage IV, arriving about 10 years sooner inthe males than the females• There is an increase in the number ofawakenings in the night.

Ages 45-60• Sleep length decreases by about an hourfrom early middle age.• The number of awakenings and timeawake during the night increases for bothsexes.• Stages III/IV are almost completely absentin both sexes.• Stage I increases in amount

Ages 60+• The quality of sleep varies a great dealfrom person to person.• Sleep is reduced even more in terms oftime• Sleep efficiency - %E = [Total SleepTime(TST)/Time in bed (TIB)] x 100 drops• There are multiple awakenings and periodsof wakefulness during the night.

Definition of Parasomnias• The parasomnias are clinical disorders thatare not abnormalities of the processresponsible for sleep states.• They are undesirable physical phenomenathat occur predominantly during sleep.• Parasomnias are disorders of arousal,partial arousal and sleep stage transition

Con’t...• Somnambulism or sleepwalking consists of aseries of complex behaviours that are initiatedduring NREM sleep and thus are most likely tooccur in the first third of the night.• Behaviour can range from simple walkingaround the room to going to different roomsor buildings, operating stoves, cars. Engagingin cooking, dressing, etc. is possible

Con’t...• The sleepwalker may be difficult to awakenbut when awakened may be very confused.• The sleepwalker is capable of violentbehaviour on being awakened or partiallyawakened (e.g. Brad Park–famous Canadian)• Memory of the sleep walking episode isusually very poor to non-existent for the sleepwalker

Con’t...• Sleep walkers are usually children (4 - 12)but adults do this activity as well• “Talking” sleep walkers back to bed is thebest way to handle someone that iswandering around.• Sleep deprivation, stress and somemedications can induce an increasedincidence of sleep walking

Con’t...• Sleep Terrors - also called pavor nocturnusand incubus (adults) are characterized bysudden arousals from deep NREM sleep• There is a piercing scream or cryaccompanied by autonomic andbehavioural manifestations of intense fear• There is usually almost complete amnesiafor the episode

Con’t...• The autonomic changes are dramatic andinclude very rapidly accelerated heart rateand respiration• The subject is usually quite confused andunresponsive to external stimuli.• There is very little in the way of mentalcontent to report - just intense fear.

Con’t...• One of the best ways to treat bothsomnambulism and night terrors is toawaken the person about 25-30 minutesafter sleep onset (from deep NREM sleep)• Keep the subject awake for 5 minutes andthen allow them to go back to sleep• Follow this regime for 7-10 days. Sleepshould be trouble free after this time

Con’t...• Sleep Talking - utterance of speech orsounds during sleep without simultaneoussubjective detailed awareness of the event• Can occur in any of the stages of sleepincluding REM when there is REM sleepdisorder• Usually benign in nature with prevalencehigher in children than in adults

Con’t...• Sleep Bruxism - often called teeth grinding.• Loud grinding sounds as a result of veryhigh pressure grinding of the teeth.• Can result in wearing down of teeth andjaw pain. May require a mouthpiece.• May originate in any of the stages of sleep,even from REM sleep and may beassociated with stress.

Old Wives Tales• There are a number of interesting fables thatappear to be exist around the reasons forteeth grinding.• Teeth grinding does not indicate that theteeth grinder has “worms”.• It does not mean child abuse is taking place.• It does indicate considerable stress in theindividual.

Con’t...• Sleep Enuresis - also known as bedwetting.• Characterized by recurrent involuntarybedwetting from any sleep stage• More prevalent in children under the age of 6,where it spontaneously resolves itself.• It can persist into adulthood, where 1-3% of18 year olds continue to have this disorder.• It becomes rare in older adults.

Con’t...• One of the devices used to treat thisdisorder is the “alert pad”.• In the bottom of the crib or bed is anelectrical pad sensitive to moisture• When the infant wets, a loud sound orshock (not so popular anymore) occurs towake the infant (and certainly the parents)to his/her error

Con’t...• This arrangement is not a true conditioningparadigm and shouldn’t work.• A tone or sound should come before thesubject actually wets the bed. This signalshould then allow the individual to wakeup, avoid wetting and go to the bathroom• There are many claims that the device doeswork.

Other Possibilities• The basic problem is that the individual hastrouble being awake enough to detect thenerve signals from the bladder.• Sometimes bladder size is too small and onesimply has to wait until the child is older andmore mature.• Reduce fluid intake at bedtime, but make surethey get plenty of fluids during the day.

Other Possibilities• Medications will work as long as they are given.• Unfortunately there is usually a relapse when themedications are discontinued.• Motivational plans can help. Bargain for a certainnumber of “dry” nights after which the sleeperwill get some kind of special reward.• Problem may be secondary (e.g. if child has sleepapnea, then they are unable to detect fullbladder feelings as they have bigger problems.)

Sleep Apnea in Children• While sleep apnea has been considered to bethe problem of older individuals, it canhappen in children.• The cause of the difficult breathing is usuallytonsils/adenoids but this possibility is oftenmissed.• Because the child is sleep deprived, s/he maybe quite irritable and hyperactive.

Sleep Apnea Con’t…• These children have a high probability ofbeing diagnosed as hyperactive.• If they are so identified, they will be put onsuch things as Ritilan.• If this is not the problem, then the child willlose even more sleep as the drug preventsnormal sleep• School work suffers

Sleep Apnea Con’t…• In one study in the Chicago area, Gozal chosethe most poorly performing student in anumber of Grade 1 classes.• This would be (often a male) that was notexpected to pass Grade 1.• They were inattentive, disruptive andconsidered not to be very smart by theirteachers.

Sleep Apnea Con’t…• He tested these individuals for sleep qualityusing EEG.• He found that many had trouble sleepingbecause they could not breath properly. Theysnored and showed many signs of sleepapnea.• He invited the parents to deal with theproblem, which was usually problemtonsils/adenoids.

Sleep Apnea Con’t…• A large number of parents did deal with theproblem, which they had not known existed.• The children then were put back in their classand their progress was monitored.• Post op, their sleep was much more normal.• The children became less irritable and lesshyper.• Their scholastic performance markedlyimproved.

Some Resources• There are at least 2 reliable on-line sources forinformation.• Canadian Sleep Society (CSS)• National Sleep Foundation (NSF) (American)• Clinics in Manitoba –• Miseracordia Hospital (specializes in apnea,respirology)• Health Sciences Centre (full clinic)

Health Sciences Centre• Dr. Norvenson (204-787-7424) - HEALTHSCIENCES CENTRE• Specializes in a variety of sleep disorders anddoes a lot of work with rural populations.• Referrals can to her can be made by your ownphysician.• There are telehealth and online programsavailable for such things as insomnia.

May Your Sleep Be as Good as These Kittens

Some Sources in Winnipeg• Manitoba Sleep Disorders Center• Respiratory Hospital Health Science Centre• RS303 - 810 Sherbrook Street• WINNIPEG. MB• R3A 1R8• Tel: 204-787-2063/2054• Fax: 204-787-1220• Children's Program: Pasterkanp, Dr. Hans• Chernick, Dr. Victor• Health Science Centre Paediatric Sleep Apnea Program• CS 520, 840 Sherbrook Street• WINNIPEG, MB R3A 1S1• Tel: 204-787-4374• Read more:

Sources in Winnipeg•• Rigatto, Dr. H.• Health Sciences Centre Infant Sleep Lab• WR 125 - 735 Notre Dame Avenue• WINNIPEG, MB R3E 0L8• Tel: 204-787-1977• Fax: 204-787-2747• Corne, Dr. S.• Sleep Laboratory, Respiratory Hospital Health Science Centre• RS303 - 810 Sherbrook Street• WINNIPEG. MB• R3A 1R8• Tel: 204-787-2063/2054• Read more:

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