NINR Sleep Research Means Wake-Up Call for Policy

Researchers at the University of Pennsylvania have turned on its head a century of what we thought we knew about sleep loss. Earlier studies had people convinced that they adapted to repeated sleep loss and so it posed no great risk. Today, rigorously controlled laboratory investigation funded by the National Institute of Nursing Research shows that “that’s categorically not the case,” says APS Member David Dinges.

His finding that chronic sleep loss comes at a high price in cognitive performance is now being applied to work rules for truck drivers and airline pilots, astronauts and medical interns. The Department of Transportation, National Transportation Safety Board, Air Force, National Aeronautics and Space Administration and the Accreditation Council on Graduate Medical Education all are using his data to inform policy.

At Brown University, Mary Carskadon and her team are also studying sleep loss under an NINR grant, but in adolescents. After following young people’s transition from starting classes at 8:25 a.m. in ninth grade to 7:20 a.m. in tenth grade, she found their circadian rhythms out of sync with the change. “Imposition of an early school start time,” she wrote, “may require unrealistic – if not unattainable – bedtimes to provide adequate time for sleeping.” The resulting sleep loss, she warns, could lead to academic, behavioral and psychological problems and increased risk for accidents and injuries. Her findings have persuaded school systems to start classes later rather than earlier as adolescents age.

Dinges and Carskadon are but two examples of how researchers funded by NINR are producing results that impact real world situations. Having such an impact – NINR calls it “making a difference” – is a concept imbedded in the Institute’s philosophy and strategic planning. In fact, NINR has twice published a report by that name detailing research that has had real-world impact. (See related story)

“One would never be able to say there is enough translational research going on,” says NINR Director Patricia Grady. “As long as there are improvements that are needed, we have issues to study and work to be done.”

The Institute’s translation of scientific findings into practice is “many-pronged,” says Grady. It includes dissemination of findings not only in research journals, but also as brief summaries in “places where it will reach the people who can put it into practice,” such as the American Journal of Nursing and WebMD’s Medscape. It also involves outreach to – and feedback from – clinical nursing organizations and patient-care settings.

Grady meets annually with a National Nursing Research Roundtable, composed of representatives from major nursing organizations, including the recently formed Coalition of Nurse Practitioners. The roundtable raises important issues and advises the director on how to deal with them. One year the focus was on reducing the lag from research to practice.

Another form of outreach is through NINR-funded investigators. “When our investigators go to speak at scientific conferences around the country,” Grady says, “we encourage them to also talk at local hospitals” to explain their findings and their applications.

She has also prodded journals into shortening the lead time to publish research. When she became NINR director in 1995, the typical lead time was two years. Now, for example, it’s a little less than a year at the widely circulated Journal of Nursing Research, she reports.

“Also, it’s important that study design be done in such a way that the results you get are applicable to the setting in which you want to channel them,” she says. “That’s why we think it’s important for that link to the clinical setting to be maintained and to be strong. Very often, it’s the clinician who identifies the problem. If the person designing the study is in close contact with the person in the clinical setting, that can improve the design.”

A MODEL FOR SUCCESS
NINR encourages investigators to ally themselves with organizations that can make a difference, precisely the strategy used by Kate Lorig, Director of Stanford University’s Patient Education Research Center.

When Lorig, who has a master’s in nursing and a doctorate in public health, developed and tested what became the Arthritis Self-Help Course, she took it to the American Arthritis Foundation. The Foundation has since disseminated the course to thousands of patients in the U.S., and it is now also widely used in Canada, Australia, New Zealand, Great Britain, South Africa, Scandinavia, and elsewhere.

The course was the prototype for others Lorig developed – the Chronic Disease Self-Management Program (CDSMP), the Positive Self-Management Program for HIV/AIDS, and the Back Pain Self-Management Program, among others.

She demonstrated that the CDSMP, like her self-management programs for specific illnesses, brought about significant advances in health status and health behaviors and reduced health care utilization for those afflicted with chronic conditions. It’s now in use in some 250 programs in the US, including the Kaiser Permanente HMO system. Great Britain’s National Health Service has made it part of its “Expert Patient” program in primary health care nationwide, and it is in use in Holland, Switzerland, Norway, Sweden, Australia, New Zealand and Hong Kong. Lorig’s study was even adapted to Chinese culture and replicated in Shanghai.

With an NINR grant, Lorig modified the CDSMP for Spanish-speaking people and tested it on 500 San Francisco Bay Area subjects with heart disease, lung disease or Type 2 diabetes. (Addressing health disparities among minority populations is a major NINR theme. See story) She says she produced “outcomes very similar to those among English speakers.” The results are scheduled to be published in Nursing Research in autumn.

Lorig has now engaged the El Paso Diabetes Association in a partnership that is replicating that study among some 300 Spanish speakers and 100 English speakers along the Mexican border with Texas and New Mexico, where she says she is again getting “good strong results.” The Spanish-version CDSMP is also in use in Seattle and by Kaiser Permanente of Southern California, and New York’s Mt. Sinai Hospital plans to use it as part of yet another study.

The secrets to her success? For one thing, the program was designed with replicability in mind. “We developed very detailed training manuals so that disseminating it would not depend on the skill of one or two people,” says Lorig.

Perhaps even more important, “we actually set up a system by which things can be translated. We have a system whereby people can either come to us for training that we do two or three times a year, or if people want, we will go to them. Some of our staff did the training in Hong Kong and England, Canadians did the training in Shanghai, and the Norwegians came here to Stanford.”

CDSMP relies on a pyramid of trainers – “leaders” who teach it to patients, “master trainers” who teach the leaders, and “trainers of master trainers” at the top. At Stanford, they train master trainers. “It’s more efficient if we train master trainers, then get out of the way and leave people with the capacity to train leaders themselves.”

YOU DON’T ADJUST TO SLEEP LOSS
Success attracted attention to her program. Much the same happened to Dinges and his sleep deprivation research: the findings created interest.

“Over the last 100 years,” he says, “there were some studies of prolonged chronic sleep restriction but most were uncontrolled. The subjects didn’t stay in the lab, so we didn’t know how much sleep they actually got, or whether they took stimulants, like caffeine. What NINR funded was a Herculean effort.”

Forty-eight healthy young adult volunteers were recruited to live in the lab. Twelve were denied sleep for 88 uninterrupted hours. The other 36 had a normal eight hours of sleep nightly for three days at the beginning to establish baseline measures and again at the end to recover lost sleep, but during 14 days in between they were randomly distributed to three sleep “dosages” – four, six and eight hours in bed nightly. They were not allowed to sleep at any other time and were forbidden all vigorous exercise or stimulants, including caffeine.

Their cognitive performance – behavioral alertness, working memory and responses in basic arithmetic trials – were measured every two hours from 7:30 a.m. to midnight, a total of 830 24-hour protocols.

“What we found was that there was a steady increase in cognitive impairment,” Dinges says. “Things were getting worse across days in the four- and six-hour conditions compared to the eight-hour controls, and the four was worse than the six.”

Those sleeping only four hours reached alertness and memory impairment levels equal to those of subjects who got no sleep at all for two nights, and their ability to do simple math problems dropped to the level of those who’d been denied all sleep for one night. Among those getting six hours of sleep nightly, alertness and working memory declined to the levels of those deprived all sleep for one night.

Dinges found no evidence that the subjects were adapting to their sleep loss. “It appears,” he and his colleagues wrote in the journal Sleep, “that even relatively moderate sleep restriction – if sustained night after night – can seriously impair waking neurobehavioral functions in healthy young adults,” just the population that is most likely to work nights, take second jobs, or find themselves in occupations that require long hours, such as medical and surgical residents or military personnel.

Yet, when they were most impaired, those getting too little sleep reported that they were only modestly tired or sleepy. “The lack of reports of intense feelings of sleepiness,” the researchers reported, “…may explain why sleep restriction is widely practiced – people have the subjective impression they have adapted to it because they do not feel particularly sleepy.”

As policy-makers became aware of his work and its safety implications, they invited Dinges to talk about it. “I am a basic scientist, not a clinician,” he says, “but I believe we have an obligation to transition work in areas where it has applied relevance. And since this field has implications with potentially catastrophic outcomes. …”

He leaves the thought incomplete, but it is clear he answered the call, traveling not only to Washington, D.C., to explain his findings to U.S. policy makers, but as far as Europe and Australia as well.

“We still have a long way to go. The good news is that these agencies have become more data driven, they will listen and try to use the data to come up with better schemes.” He acknowledges that his data are combating “terrific economic and social pressures” for longer work hours and night shifts to increase productivity, but “it is rewarding to me that the science in this area is having an impact.”