Physiological and Cultural Perspectives of Sleep Disorders' Impacts in Middle East Countries

C H A P T E R

1 Physiological and Cultural Perspectives of Sleep Disorders’ Impacts in Middle East Countries Deldar Morad Abdulaha,b Adult Nursing Department, College of Nursing, University of Duhok, Duhok, Kurdistan, Iraq

Abbreviations

behaviors functions.3e6 Sleep is a vital element for the general health of humans. The regular and sufficient sleep has been shown to be beneficial for human physiology in a number of various routes, from memory consolidation7 to free radical removal,8 and neurotoxic waste.9

AHI Apneaehypopnea index BDI Beck depression inventory BMI Body mass index CBI Caregiver burden inventory CBT Cognitive behavioral therapy CD Compact disc DTS Daytime sleeping ESRD End-stage renal disease FCs Family caregivers GPA Grade point average HD Hemodialysis HrQoL Health-related quality of life IBS Irritable bowel syndrome ICU Intensive care unit KSA Kingdom of Saudi Arabia LA Left atrial MCS Mental component summary NICU Neonatal intensive care unit OSAHS Obstructive sleep apneaehypopnea syndrome PCS Physical component summary PHC Primary health center PMR Progressive muscle relaxation PSQ Poor sleep quality PSQI Pittsburgh sleep quality index RLS/PLMD Restless leg/period/periodic limb movement disorder RTCs Road traffic collisions T2DM Type-2 diabetes mellitus TSD Total sleep duration UAE United Arab Emirates

PREVALENCE OF SLEEP DISORDERS IN MIDDLE EAST COUNTRIES Piro and Alhakem et al.10 determined a broad range of sleep disorders in a random sample of medical students in a large university in Iraqi Kurdistan. They found that more than seventy percent (75.2%) of the students had no sufficient sleeping hours/24 h (<8 h/24 h). The prevalence of various sleep disorders was 13.6% (sleep apnea), 25.0 (insomnia), 14.6% (affective disorders), 1.3 (narcolepsy), 30.7% (restless leg/period/periodic limb movement disorder- RLS/PLMD), 19.6% (circadian rhythm), 5.7% (sleepwalking), 6.6% (nightmares), 0.6% (sleep state misconception), hypersomnia (0.0%), and 52.2% (all sleep disorders or at least one sleep disorder). The sleep disorders did not differ substantially between male and female students. They found a high percentage of RLS/PLMD in the sample size (30.7%). This rate is so higher than its rate in the literature that is between 5% and 15% in the general population.11 It is so higher than its prevalence in Saudi school employees which is 8.4%12 and 5e15% in American and European populations.13e15 The authors mentioned the possible reasons for the high rate of RLS/PLMD in this region: (a) geographic/demographic discrepancies, (b) different diagnostic criteria of RLS/

INTRODUCTION The adequate sleeping had been documented to be essential for psychological well-being, cognitive processes,1,2 and a wide number of adaptive cognitive and a

ORCID https://orcid.org/0000-0002-8986-5793.

b

Google account https://scholar.google.com/citations?user¼q52Dbf4AAAAJ&hl¼en.

Neurological Modulation of Sleep https://doi.org/10.1016/B978-0-12-816658-1.00001-6

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© 2020 Elsevier Inc. All rights reserved.

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1. PHYSIOLOGICAL AND CULTURAL PERSPECTIVES OF SLEEP DISORDERS’ IMPACTS IN MIDDLE EAST COUNTRIES

PLMD, (c) secondary role of the sleep disorder, (d) founder effect of sleep disorders owing to ethnicity homogeneity, and (e) its correlation with insomnia and increased sleepiness.16 In addition, (f) RLS development at younger ages (35 years) and family history in subjects with idiopathic type.17 Vats and Mahboub et al.18 reviewed the obesity and sleep-related breathing disorders in the Middle East. They recognized that the obesity and its consequent sleep-related breathing disorders are rising in the region, including United Arab Emirates (UAE), Kingdom of Saudi Arabia (KSA), Bahrain, Kuwait, Qatar, and Oman. The study published by the London School of Hygiene and Tropical Medicine reported that Kuwait has the second most obese men in the world.19 A study conducted in a primary health center (PHC) setting in Dubai that estimated the prevalence of symptom and risk of obstructive sleep apneaehypopnea syndrome (OSAHS) found that 20.9% of patients who attended the clinic were at risk of OSAHS.20 Acay and Bal et al.21 recruited 112 patients diagnosed with irritable bowel syndrome (IBS), including 46 constipation-predominant patients, 17 diarrheapredominant patients, and 23 mixed IBS and 26 unsubtyped patients and compared with 106 healthy control in a caseecontrol study in Turkey. They found a higher presence of poor sleep quality (PSQ) and RLS; 13.4% and 8.9 versus 4.7% and 3.7% in the control group. The patients with IBS had a higher PSQI (Pittsburgh Sleep Quality Index) compared to the control healthy subjects, 7.61 versus 4.5. The limited number of studies reported that poor sleep quality and RLS are two comorbidities that substantially raised in patients diagnosed with IBS compared to healthy controls.22,23 However, the role of age in contributing to ethiopathogenesis should not be ignored in these kinds of studies, as the comorbidity of RLS and PSQ is increased with increasing age.24 Students who sleep 1e2 h less per day are more prone to “sleep debt” that lead to excessive daytime sleeping (DTS).25 Those persons have less than 6e7 h night of sleep deprivation have a considerable alteration in daytime alertness, damage to psychomotor and neurocognitive performance, including attention, focus, memory, problem-solving capability, academic performance, and critical thinking.25,26 Apart from the sleeping hours, sleeping time has been changed in people. Inadequate night sleeping and sleep compensation on weekends is a regular way of life in employees and students, particularly in college students. Daytime sleepiness is considered to be the most evident outcome of “sleep debt” and these persons are prone to chronic fatigue, cognitive impairment, negative modes, and physical complaints.27 The epidemiological studies have shown the sex differences in age-related sleep changes. The females

more likely to disturb sleep onset, while men report nighttime awakenings.28 The negative impacts of sleep disorders on quality of life and performance of the people must be presented in awareness activities. The sleeping quality and quantity of the students and employees must be improved through the establishment of awareness initiatives to enhance the job productivity in these countries.

Sleep in Patients and Caregivers The prevalence of burden of sleep quality in family caregivers (FCs) of patients diagnosed with malignancy was examined by several investigations. For example, Al-Daken and Ahmad29 found the total burden of 37.9 (measured by caregiver burden inventory [CBI] ranged 0e96, the higher value indicates the greater risk for “burning out”) in family caregivers of cancer patients in Jordan. Moreover, the poor sleep quality (M: 9.1) was found in FCs of the patients. They examined that 36% of the variance in burden is predicted by sleep quality of FCs, cancer stage, the presence of chronic illnesses in FCs, treatment side effects, and educational level of FCs. Akyuz and Ugur et al.30 found that those patients with advanced stage of lung cancer were more likely to suffer sleep problems and affect by their sleep quality negatively. The sleep disorders and associated risk factors in patients with leukemia undergoing chemotherapy were examined in Iran as well.31 They found the average sleep quality in most of the patients with the means score of 9.3 PSQI. The male patients had a better sleep quality. In addition, the sleep quality was improved with increased age. Family caregivers provide four types of support for patients and include (a) daily living activities, such as meal preparation and feeding, and transportation, (b) medical care, such medication management, wound acre, and injection, (c) social support, such as family and social communications, and (d) protection and advocacy, such advocacy in healthcare providers and insurance.32 The sustained caregiving to patients with malignancy or chronic diseases has been contributed to a high degree of physical burden owing to fatigue and physical strength loss.33 One of the physical burdens is sleep disturbance that makes a substantial challenge to FCs and it is associated with poor health of patients, complex treatment, high level of burden, and financial burden.34 The sleep quality, health-related quality of life (HRQoL), depression, and anxiety symptoms in patients with hemodialysis (HD) and their family caregivers were explored in a sample of the Middle East population. The study found poor sleeping in 73.9%, low Physical Component Summary (PCS), and Mental Component Summary (MCS) scores in 89.1% and

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

PREVALENCE OF SLEEP DISORDERS IN MIDDLE EAST COUNTRIES

76.3% of HD patients, respectively. However, 88% of caregivers were poor sleepers. In addition, 62% and 70.4% of the caregivers had low PCS and MCS scores, respectively. Interestingly, the study found that the caregivers had significantly higher mean PSQI scores, sleep latency, sleep efficiency, subjective sleep quality scores, sleep disturbance, sleep medication use, and daytime dysfunction scores compared to the HD patients.35 End-stage renal disease (ESRD) has been associated to considerable health impacts on sleep disorders, HRQoL, and depression. The clinical trials have documented the association between sleep disturbance and the HRQoL in HD and other chronically ill patients. In these studies, the sleep quality has been approved to be an independent factor in HRQoL in HD patients.36,37 The chronic diseases have impacts on both the patients and caregivers. Undoubtedly, the role of a caregiver is stressful and it has been shown to relate to an increased level of sleep disturbance and lower physical health.38 The caregivers have added responsibilities for the patients’ medical treatments, dietary needs, and clinic-related affairs, and psychosocial issues.39 The FCs encounter challenges in their lives that could affect their daily routines. These challenges and changes in daily lives are involved in their financial well-being, social relationships, physical and mental health that lead to sleep quality disturbances, HRQoL, and anxiety and depressive symptoms.40 C ¸ elik and Annagur et al.35 is one of the studies that showed the FCs of HD patients have a lower quality of sleep compared to the HD patients. The values of quality of sleep in HD patients and FCs were 7.7 versus 11.9 (global PSQI), 1.1 versus 2.2 (subjective sleep quality), 1.4 versus 1.8 (sleep latency), 0.8 versus 0.7 (sleep duration), 1.3 versus 2.2 (sleep efficiency), 1.7 vs. 2.4 (sleep disturbance), 0.7 versus 1.3 (use of sleep medications), and 1.0 versus 1.7 (daytime dysfunction), respectively. In Middle East culture, the caregivers of HD are usually members of the patient family. Family caregivers provide everyday assistance for a long-term situation. The FCs are “informal” caregivers and include family, partners, children, and others. They involve in direct care through assisting in independent and dependent activities of daily living and spend 18 h per week for their relatives and many of them have dependent children at home. These FCs may be employed either fulltime or part-time and are nonreimbursable caregiving expenses. The higher levels of stress, anxiety, sleep disturbance, and depression were found in mother and father of the infants in the neonatal intensive care unit (NICU), as well41,42 and poor sleep quality in 40% of cancer patients43 and 76% of family members with moderate or more serious sleep problems of adult intensive care unit (ICU) patients.44

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A critically ill is a group of patients that their clinical situations can be changed at any time. Their family members are inseparable parts of the treatment and care of the ICU patients. These patients may face a serious condition. The family members of these patients that are at a risk of mortality are more prone to stressful and traumatic process45 and result in sleeping problems, anxiety, fatigue, and depression.46e48 Even between 43% and 70% of family members have been reported to experience poor or poorer sleep quality.45,49 Fakih and Rahal et al.50 found a substantial increase in sleep disturbances during chemotherapy in patients with early-stage breast cancer; 36% of them reported poor sleeping versus 58% during chemotherapy. The clinical insomnia rose from 11% in pretreatment to 36% during chemotherapy in India in agreement in Bahrain51 and Jordan.52,53 The patients affected by insomnia were susceptible to fatigue, poor working performance, mood disturbance, and sleeping pills dependence.54 Ayranci and Orsal et al.55 reported prevalence rates of menopausal symptoms in 1551 Turkish women selected with a multistage area sampling method: a random sample of individuals aged 40e65 years. They found that sleep disturbances in postmenopausal is 88.2% (premenopausal), 87.6% (perimenopause), 78.9% (postmenopause-natural), and 98.4% (postmenopausesurgical). A non-Middle Eastern study showed that sleep duration is shortened in minority groups compared to native Dutch. Its prevalence was 11.3% in Dutch in contrast with 53.1% in Ghanaians. The age-adjusted prevalence ratios were between 3.38% in Moroccans and 4.78% in Ghanaian compared to Dutch children. The Dutch and Moroccans with short sleep duration were more likely to be overweight, but it was not significant following adjustment for socioeconomic status.56 It is unclear the exact reason for the higher prevalence of short sleep duration in an ethnic minority, but the sociocultural and environmental factors may be different in different ethnic groups. It has been hypothesized in the literature that may be culture, beliefs, and attitudes of adult parents about sleeping be transferred to the children.57,58

Physiological and Cultural Aspects of Sleep Disorders Obstructive sleep apnea syndrome (OSAS) is presented by repetitive obstruction of the upper airway during sleep. It has the nighttime effects like hypoxemia and sleep fragmentation.59,60 It is predominately among men with a male:female ratio of 8e10:1 or more.61 Boz¨ y et al.62 examined the gender differences in kurt and O body mass index (BMI) and apneaehypopnea index (AHI) during the sleeping time in persons with OSAS

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1. PHYSIOLOGICAL AND CULTURAL PERSPECTIVES OF SLEEP DISORDERS’ IMPACTS IN MIDDLE EAST COUNTRIES

in 244 Turkish patients. The diagnosis of OSAS in these patients was based on the overnight polysomnography (PSG). They found that male:female ratio of the subjects was 3.8:1. The males were younger in comparison with females, 48.87 versus 52.94 years. The similar BMI and AHI were found in male and female subjects; BMI: 29.52 versus 31.17 and AHI: 27.45 versus 24.77, respectively. However, the AHI was increased as BMI increased in both male and female patients. Apnea is defined as the airway cessation at the nostrils and mouth for more than 10 s. Hypopnea is defined as an oronasal airway reduction at least for 30% for 10 s or more followed by at least 4% fall from the baseline oxygen saturation (SaO2). AHI is the total number of apnea and hypopnea episodes in 1 hour of sleeping and it is calculated during total sleep time (TST). Female patients diagnosed with OSAS have smaller pharyngeal cross-sectional areas, whereas males have greater a reduction in pharyngeal caliber due to supine position.63 The difference in pharyngeal areas between males and females is disappeared in the supine position. Hence, the male patients have a greater tendency to airway collapse compared to females during wakefulness. Sankri-Tarbichi64 reviewed the prevalence of different types of sleep apnea and obstructive type in the United States and the Middle East. The exact mechanism of sleep apnea pathogenesis is not clear. Obesity was indicated to be the leading risk factor to upper airway narrowing and obstruction. In addition, it was determined to be the key contributor to the escalating prevalence of morbidity across the world and the Arab countries. Mahboub and Afzal et al.65 found the higher prevalence of obstructive sleep apnea syndrome (OSAS) in persons aged between 51 and 60 years in both genders. They reported that 70% of the high-risk persons had a BMI 30 kg/m2. The high prevalence of obesity has strongly been linked to a higher incidence of SDB (sleep-disordered breathing) and OSAHS. Therefore, it is critical to establish the screening strategies for this kind of population for early detection of morbid conditions.66 Restless legs (RLS) is higher in obese children aged 10e16 years (21.7%) than the overweight children (3.4%) and control group (1.5%) in the Middle East. In addition, the obese group with RLS had poorer sleep quality scores compared to the non-RLS obese group. Several symptoms of sleep disruption were shown to be more common in obese patients with RLS. RLS was indicated to correlate independently with a high PSQI score and an increased BMI Z-score.67 Other studies have shown that childhood obesity is related to a number of adverse outcomes, like poor academic performance, life-long obesity cardiovascular diseases, poor psychological well-being,68 and sleep disturbance.69

Akpinar and Celikoyar et al.70 evaluated the cephalometric characteristics and differences between habitual snorers and patients with OSAS in nonobese Turkish male population. They found that posterior airway space (PAS) in the control subjects (8.27 mm) is significantly greater than it in the habitual snorers (6.83 mm). In addition, the control subjects had a bigger mandibular plane and hyoid distance (MPH) (14.99 mm) compared to 19.09 mm in habitual snorers. This phenomenon was found between the control and OSA patients, as well. The total sleep duration (TSD) in Middle Eastern culture in 2669 school children was reported 10.20 h and the mean bedtime was 21.57 h.71 They showed that boys are prone to go to bed later and slept less than girls. The sleep disturbance duration was increased, while TSD decreased with age. The TSD and waking time were substantially decreased with higher socioeconomic status (SES) in both girls and boys. Habitual snoring, parasomnias, and daytime sleepiness were contributing factors to sleep fragmentation. The evidence suggests that there are certain types of personalities that are more likely to have insomnia than other.72 In this regard, Atalay73 found that those patients with personality cluster C were less likely to have a poor sleep quality (PSQI: 8.4) compared to the patients with personality cluster A (PSQI: 11.1). The personality cluster A included schizoid, paranoid, and schizotypal personality disorders and cluster C included dependent, avoidant, and obsessive-compulsive personality disorders. The cluster C is considered an anxious group. The sleep habits in children are different in terms of culture. BaHammam and Alameri et al.74 reported that 26% of Saudi school-aged children aged 5e12 years are sleeping with their parents (cosleeping). The prevalence did not include children with the chronic neurological disease, psychiatric, or chronic respiratory diseases. The predictors of cosleeping in the sample population were the school level of the child, enuresis, and nightmares. The cosleeping has not been investigated in other countries in Middle East region. The bed sharing decreases with advancing age owing to a decrease of nocturnal awakening with age.75 The sleeping of the children with their parents is different in accordance with age, ethnic, and sociocultural backgrounds.76 The culture of Saudi Arabia is different from Western societies. Generally, cosleeping of infants with their mothers is not discouraged and cosleeping of school-aged children with their parents is not encouraged in Saudi Arabia. Interestingly, the cosleepers had a higher prevalence of sleep problems in consistency with investigations in non-Middle Eastern countries.77,78 The cross-cultural differences in the sleep of preschool children were examined by Mindell and Sadeh et al.79 The investigators found that predominantly

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

IMPACTS OF SLEEP DISORDERS

Asian countries had significantly later bedtime, an increased parental perception of sleep issues, and shorter nighttime sleep compared to those children from predominantly Caucasian countries. Bedtime was different from as early as 7:43 p.m. in Australia and New Zealand to as late as 10:26 p.m. in India.

IMPACTS OF SLEEP DISORDERS Sleeping in Adolescence The period of adolescence has been accompanied by considerable alterations in physiology and neural networks.80,81 The sleep and its regulation had a seminal role in well-being and development of adolescents.82e85 The substantial public mental and physical health issues have been reported as the result of poor sleep in adolescence.86e88 The acute and chronic sleep loss during the development period were shown to persist along with negative impacts on physical and mental health of adolescents as reported in cross-sectional89,90 and longitudinal investigations.91e94 Poor psychological wellbeing may result in negative effects on sleep quality and quantity in adolescents.95e97 In other words, the relationship between sleep and psychological functioning is a bidirectional pathway. The sleeping patterns of adolescents are affected by a broad range of factors. The parents’ styles of sleeping are stable over time and establish an emotional climate in which the parents’ behavior is expressed.98,99 The primary evidence reports that perceived parenting styles have been seen to associate with sleep quality.98 The association of adolescents’ well-being and psychological functioning has been reported to relate with subjective general and mental health of parents.100,101 For example, Denissen and Van Aken et al.102 showed that the personalities and behavior of parents’ and adolescents pose a substantial effect on the quality of their mutual relationships. The adolescents are not isolated from the family context and it has an effect on sleep during adolescence. This role has been poorly studied in the literature. The literature has good evidence on the association of sleep behavior of children (3e11 years old) with sleep quality and mental health of parents.103e106 The role of sleeping patterns of parents on sleep and psychological functioning was investigated in 81 families, including 81 mothers and 78 fathers, and 130 children aged 12e20 years in northeastern Iran.107 They found that shorter sleep duration was substantially related to prolonged sleep onset latency (SOL) and more frequent awakening following onset of sleep for adolescents and mothers. Interestingly, unfavorable sleep patterns of adolescents were significantly correlated with unfavorable patterns of mothers, but not

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with fathers. The sleep patterns of mothers and fathers were independent of each other in this study. Unfavorable psychological functioning, including more considerable depressive symptoms and perceived stress, and unfavorable perceived parenting styles were found to associate with unfavorable psychological functioning of mothers. The sleep disturbances were shown to associate with poor psychological functioning, decreased favorably perceived parenting styles, and an increased unfavorable perceived parenting style. The authors showed that the sleep disturbances in adolescents were predicted by their perceptions of stress and high unfavorable parenting style, sleep disturbances, and perceived stress in mothers. Rado
sevic-Vidacek and Ko
scec108 found that shift working of parents (both mother and father) predicted an earlier wake-up time, a shorter sleeping time period, a later weekends’ bedtime, and a longer delay of bedtime in adolescents. The large discrepancy of sleep duration between weekdays and weekends was shown to be mediated through interparental conflict and early adolescent aggression resulting in irregular sleep patterns in adolescents.109 The similar findings were reported by Vignau et al.110 and Tynja¨la¨ et al.111 The total sleep time is increased with an earlier bedtime of parents.112 Those parents more involved in monitoring their adolescents’ sleep, their children will have less psychological distress and greater efficient sleep.113 The sleep onset latency, daytime sleepiness, and underpinning parents’ responsibility for schedules of adolescents are mediated by family disorganization.114 In summary, the compelling evidence confirms the adolescents’ sleep association with parents’ sleep, mental health, and monitoring as a dynamic relationship between them. Interestingly, Al-Houqani and Eid et al.115 showed that 5% of road traffic collisions (RTCs) are contributed to the sleepiness of drivers in UAE. I recommend that health professionals working in health centers or schools attempt to uncover these kinds of issues for families and use these results for the treatment of sleep complaints of adolescents. The family can play as a protective factor to encourage resilient adaptation among adolescents, especially in the case of exposure to stressful life circumstances.116,117 Obesity is rising in a dramatic way throughout the world. Environmental factors such as technology have a role in reducing physical activity and increasing sedentary lifestyles. One of these factors is Internet addiction that globally has been associated with growing health issues along with diminished physical activity and poor sleep quality. In the Middle East, the association of Internet addiction with adolescent obesity-related issues was investigated by Eliacik and Bolat et al.118 in a caseecontrol study. In this study, 71 obese adolescents with 64 age and gender-matched

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

1. PHYSIOLOGICAL AND CULTURAL PERSPECTIVES OF SLEEP DISORDERS’ IMPACTS IN MIDDLE EAST COUNTRIES

nonobese adolescents were included. The study found that those adolescents with obesity were substantially more likely to be Internet addicted, to have a lower quality of life, and higher daytime sleepiness. The Internet addiction and less physical activity were shown to relate to increased odds of obesity. The obese adolescents tend to use the Internet greater than 5 h per day, including weekdays and weekends. The association of sleep quality and depressive symp_ toms in 313 adolescents aged 14e20 years in Istanbul showed that there is a moderate positive correlation between the Beck Depression Inventory (BDI) and the Pittsburgh Sleep Quality Index (PSQI) scores. Moderateesevere depressive symptoms, family history of sleep issues, and smoking were contributed to the sleep quality in school children.119 The basic needs of the school children are required to provide for their physical and emotional development. Sleep is one of these needs and poor sleep quality can cause critical issues in adolescents.120 The adolescents need between 7.5 and 8.5 h per night.121  and Kutlu119 reported that only 57.8% of adolesDAG cents slept >7 h, 27.5% between 6 and 7 h, 8.9% between 5 and 6 h, and 5.8% less than 5 h. Inadequate sleep is the most common factor contributing to the daytime sleepiness in adolescents. These adolescents report a late bedtime and early wake-up on school days and substantial oversleeping on weekends.122 Even higher prevalence of prehypertension and hypertension has been reported in male and female primary and secondary schools with poor sleeping (sleep duration 8 h). Each unit increase in sleep duration (hours) have been shown to predict the decreased prehypertension and hypertension risk by 0.89 and 0.88 in both boys and girls, respectively123 in a Turkish sample, see Fig. 1.1. Hypertension and coronary artery disease were confirmed to be related to sleep duration in the adult population.124,125 Insufficient sleep in adolescents is the result of an interaction of biological factors (puberty) with extrinsic factors. Intrinsic factors are the results of the normal development in adolescents. The difficulty of sleeping in adolescents is owing to circadian rhythm. The timing of melatonin release is changed during puberty, resulting in late bedtime and change in circadian rhythm. The change in circadian rhythm is in a contrast with the extrinsic demands of adolescents to wake up early morning for school. Some activities such as sports and music insist the adolescents have a delayed bedtime.122 The adolescents spend excessive time on the computer that results in sleep quality deterioration and daytime sleepiness.121 The sleep pattern was indicated as a risk factor for cardiovascular disease in children and adolescents in a recent review.126 The impaired vascular endothelial adhesion markers and endothelial-dependent/ endothelial-independent microvascular reactivity were

120

Systolic Diastolic

110

mm Hg (95% CI)

8

100 90 80 70 60 <8

8-<9

9-<10 10 Hours or More

Sleep Duration

FIGURE 1.1 Systolic and diastolic blood pressure values according to sleep duration. © Copyright 2018, Journal of Clinical Research in Pediatric Endocrinology, Published by Galenos Publishing.

detected in young adults with acute total sleep deprecation.127 The American Academy of Sleep Medicine recommended the amount of sleep that teenagers aged 13e18 years need to promote optimal health is between 8 and 10 h per 24 h on a regular basis.128

The Impacts of Sleep Disorders in Adult Populations Abdulah and Piro129 examined the role of sleep disorders as primary and secondary factors in association with daily functioning in 317 undergraduate medical students in Iraqi Kurdistan. Of the students participated in the study, 50.2% of them had less than normal sleeping hours (7 h and above per day). Various sleep disorders were reported by students in this region. The statistical analyses showed that majority of them felt tried at getting up (82.1%), felt sleepy during the day, and struggled to remain alert (76.7%), would like to have more energy during the day (85.7%), easily irritated (66.7%), difficulty in concentrating at college (68.7%), worry about their sleep (64.7%), and sleep badly (63.3%). The factors that have been shown to predict sleep disorders were having no pleasure and entertainment, feeling sadness, alcohol drinking, amount of sleeping hours, smoking, age, a noisy or light bedroom, and substance abuse. This is the first study attempted to uncover that sleep can make a primary role (causing factor) and secondary factor (outcome) in human beings. The stress in family life has been shown to associate with sleep problems in undergraduate students aged 17e22 years. Bernert and Merrill et al.130 showed that increased insomnia and poor academic achievement

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

IMPACTS OF SLEEP DISORDERS

are highly associated with familial stress. Insomnia has been associated with depression, alcohol consumption, anxiety, suicide, drug abuse, and other psychological disorders. Insomnia can act as a stressor to develop other health issues and predispose to depression and substance abuse.131 Those persons with one or more symptoms of insomnia have a greater risk of meeting criteria of DSM-IV for chronic insomnia and are further at risk of somatic health issues, psychological issues and interpersonal, and daily activity difficulties.92 Daytime sleepiness and erratic sleeping are very highly prevalent sleep complaints among college students. Abdulah and Piro129 reported that 76.7% of a random sample of medical students felt sleepy during the day in various activities. Lower academic performance, academic failure risk, impairment in the mood, and risk of motor vehicle accidents are outcomes of daytime sleepiness, sleep deprivation,132 and alertness reduction.133 The students with sleeping issues require more time to solve mathematical issues with more mistakes compared to those students without sleep problems.134 Pilcher and Ginter et al.14 documented that sleep quality significantly more corresponds with sleepiness rather than sleep quantity. Again, Abdulah and Piro129 reported that 82.1% of the students felt tired getting up in the morning as the result of RLS, circadian rhythm disorders, and affective disorder. Feeling tiredness in college students is a critical issue that must be addressed with the appropriate strategies by a health profession professional. The impacts of different kinds of sleep disorders on academic performance have been investigated in a random sample of 316 medical undergraduate students in Iraqi Kurdistan.10 The authors found that the students with insomnia, affective disorders, or a combination of these sleep disorders had a lower grade point average (GPA) compared to their healthy compartments. Moreover, those students with multiple sleep disorders had a significantly lower GPA in comparison with those with one sleep disorder. Demirci and Akgo¨nu¨l et al.135 reported that smartphone usage has risen dramatically in college students, led to addiction and showed that the university students who used smartphones for longer time have a higher level of depression, anxiety, and daytime dysfunction. In addition, they found a positive correlation between the Smartphone Addiction Scale and depression and anxiety levels, and sleep quality scores in a sample population of 319 students in Turkey. Poor academic performance has been confirmed to associate with both self-reported snorings and being at high risk of OSA in Jordanian university students.136 Atalay73 found that patients with higher levels of poor sleep quality have a higher level of the Spielberger State and Trait Anxiety Inventory (STAI-1). Insomnia is an important public health issue that had a substantial

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negative effect on physical and social performance of persons and quality of life.137 Insomnia is considered to be the most prevalent sleep disorder in both the general population and psychiatric patients.138 It is projected that its rate is between 7.5% and 15% of the general adult population. Moreover, its rate is between 25% and 35% on a transient or occasional basis.139 Azzez and Abdulah et al.140 examined the effect of sleep severity and fatigue manifestation on the patiente doctor relationship in 123 physicians with different specialties and worked in various shifts in Iraqi Kurdistan. The authors found that close to half of the physicians (45.5%) were insomniac. The doctors slightly felt irritation in their communication with patients, slight compliance with their communication, dysphoria, and considered their communication with patients slightly as self-destructive. The mental fatigue was determined to be an indicator of dysphoria in doctors’ communication with their patients. Moreover, general and physical fatigue, night shift, and increased working hours were shown to be predictors of initiating patients in their communication with doctors. The increased working hours in the public sector was determined to be a predictor for having less compliance in the doctors’ communication with patients. The effect of sleep deprivation (SD) on left atrial dysfunction has been investigated by strain rate imaging in a Turkish sample of the population.141 The echocardiographic images of 27 healthy subjects were obtained following a regular sleep night and one night after sleep deprivation. The tissue Doppler-derived strain and strain rate were measured from the apical four- and twochamber views of the left atrium. Accordingly, the global values were calculated as the mean for all segments. The study did not find a significant difference in the traditional parameters of the atrial function and left atrial (LA) volumes. The similar systolic strain rate and late diastolic, and global atrial strain values following one night with sleep debt compared to the values of the night with regular sleep. However, the patients had significantly lower early diastolic (3.2 s1) compared to 3.7 s1. The early diastolic value was positively associated with sleeping time (r ¼ 0.554). Sleep deprivation has been shown to associate with an increased rate of adverse cardiovascular and metabolic disorders in human beings.142 The experimental and epidemiological investigations have documented that short sleeping is related with an increased rate of hypertension,143 type-2 diabetes mellitus,144 increased BMI,145 changes in blood lipid levels,146 and inflammatory parameters147 that result in an increased risk of cardiovascular diseases.148 Poor sleep has been shown to be an independent risk factor for the poor physical contents of HRQoL (OR 17.6) and mental contents of HRQoL (OR 3.2) in elderly men with nocturia in Egypt, and nocturia (OR 5.08) and

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1. PHYSIOLOGICAL AND CULTURAL PERSPECTIVES OF SLEEP DISORDERS’ IMPACTS IN MIDDLE EAST COUNTRIES

ischemic heart disease (IHD) (OR 3.5) were the independent risk factors for poor sleep quality.149 According to the International Continence Society, nocturia is defined as “as the interruption of sleep one or more times at night to void lasting for more than 6 months.”150 It has been documented that better self-reported sleep is related to better health outcomes, mental health, cognitive and physical health but not for sleep quality and neural health. Four sleep types were considered as “good sleepers” (most frequent in middle age), “inefficient sleepers” (most frequent in old age), “delayed sleepers” (most frequent in young adults), and “poor sleepers” (most frequent in old age),151 see Fig. 1.2. Moreover, there are nonlinear associations between sleep duration and anxiety and depression and general health (See Fig. 1.3).

Obstructive Sleep Apnea Syndrome and Diabetic Microvascular Complications The effects of OSAS on diabetic microvascular complications are the subjects of research throughout the world. However, this type of gap has been investigated

in Middle East populations. Buyukaydin and Akkoyunlu et al.152 evaluated the OSAS incidence in patients with type-2 diabetes mellitus (T2DM) in 52 subjects who were enrolled for the study purposes. Their BMI, fasting glucose, urea, creatinine, glycosylated hemoglobin, total lipid profile, and urinary albumin extraction were measured. In addition, their full PSG was performed to detect the sleep disorders. The diabetics patients included in this study were those with at least 2 years of disease with breathing shortness complaints, snoring, or subjective sleep complaints. The study found similar characteristics and laboratory findings between the patients with nephropathy and with no renal involvement. Of the total 54 patients, 35 of them (67.3%) met the diagnostic criteria for OSAS, including 25 patients (48%) with mild, 6 patients (11.5%) with moderate, and 4 patients (7.7%) with severe sleep disorders. No substantial association was found between respiratory obstructive indicators and microalbuminuria, while a significant correlation was found between lower levels of serum triglyceride and lower respiratory indices.

FIGURE 1.2 Good, inefficient, delayed, and poor sleepers in relation to age.151 Latent class analysis. Panel (A) shows the sleepquality profiles for each of the four classes. Panel (B) shows the conditional probability of belonging to each class across the lifespan. © Copyright 2017, BMJ Open, Published by BJM Publishing.

FIGURE 1.3 Curvilinear associations between sleep duration in hours and (A) Hospital Anxiety and Depression Scale (HADS) depression and (B) general health (self-reported).151 © Copyright 2017, BMJ Open, Published by BJM Publishing.

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

INTERVENTIONAL INITIATIVES

The clinical evaluation of the pathogenetic process indicates that the BMI grade is directly associated with the degree of OSAS.153 Diabetic nephropathy and the clinical processes that affect renal failure progression are the most common factors contributing to the chronic renal failure. The factors contributed to diabetic nephropathy are angiotensin II, platelet-derived growth factor, and thromboxane increment. The effect of these factors is on protein kinase c activity and consequently TGF-b and results in an increment in extracellular matrix and glomerulosclerosis.154 The left ventricular mass and myocardial performance index (MPI) in OSA patients were assessed in another study. They found higher blood pressures in the severe OSA compared to the moderate and mild OSA. The thickness of the IVSdinterventricular septum (11.6 mm), LVPWdleft ventricular posterior wall (10.7 mm), LVMdleft ventricular mass (260.9 g), and LVMIdLVM index (121.9 g/m2) was higher than in moderate OSA (9.4 mm; 9.9; 196.4; 94.7, respectively) and mild OSA (9.8 mm, 8.9 mm, 187.6 g, 95.8, respectively). In severe OSA, MPI (0.8) was significantly higher than in mild OSA (0.5 [P < 0.01]) but not significantly higher than moderate OSA (0.8).155 In another way, the cardiac abnormalities are worsened with the severity of apnea in patients with OSA. The exact mechanism of impairment in myocardial contraction and relaxation in OSA patients in not clear, but the increase in cardiac risk may be due to an imbalance of myocardial oxygen demand and supply owing to hypoxemia, hypercapnia, and increased sympathetic activation occurring during apnea.156

INTERVENTIONAL INITIATIVES According to the abovementioned reports on the prevalence of sleep disorders in this region, it is required that sleep disorders be addressed through the appropriate strategies in different populations. Some behavioral techniques such as cognitive behavioral therapy (CBT) have been widely used as nonpharmacological alternatives in patients diagnosed with insomnia. In this regard, El Kady and Ibrahim et al.157 examined the effectiveness of a CBT program following determination of insomnia prevalence in elderlies complaining sleep disturbance in a pretesteposttest design in Egypt. According to the findings of the study, 63.3% of them were poor sleepers and its percentage was decreased to 46.2% following the intervention. The CBT intervention program was for 120 min (four presentations/week each lasting for 30 min) and was presented to groups of 7e10 persons with insomnia on a weekly based way. In this program, a series of health-related themes were provided sessions about sleep hygiene including knowledge about sleep

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practices such as a regular schedule of sleepewake, using the bed for sleeping, exercising in the morning, and refraining from caffeine and presented in the form of workshops (lectures and discussion) and audiovisual educational materials. The following suggestions were presented to maintain and promote sleep issues. • Regular exercise (it must not be performed within 3e4 h of bedtime) • Avoiding sleeping following a poor night sleep • Not watching the clock • Limiting intake of fluid following the dinner (in the case of nocturia) • Not eating heavy evening meals • Avoiding tobacco and stimulants following 4e6 h prior to bedtime • Avoiding poor seeping environments, such as noncomfortable, light, and crowded bedrooms • Avoiding late-night stimulating activities along with eliminating bedroom clocks • Avoiding vigorous-intensity exercise close to bedtime • Avoiding noncomfortable tasks prior to bedtime • Promoting low-impact activities • Making a routine bedtime and wake time each day • Drinking a cup of warm milk at bedtime • Spending time in sunlight each day outside (but not the time between 12 and 15 p.m.). The authors determined that age, sex, marital status, educational level, past chronic diseases, medications used, drug adherence, and using self-medication are contributed to the improvement in sleep quality.157 Poor sleep quality is the most common complaint of older adults. Close to 58% of them report that they have sleep difficulties at least a few nights per each week.158 Some of the sleep disorders are more common and chronic and are the not an inevitable result of aging.159 The health policymakers should consider the suitable and practical intervention to address the sleep issues in older adults as these issues are escalated in long-term.160 A meta-analysis review established that various behavioral treatments, such as cognitive behavioral and relaxation therapies are effective strategies in older persons with chronic insomnia.161 The effect of sleep hygiene education and progressive relaxation exercises on postmenopausal women with insomnia was evaluated in a Turkish sample.162 The patients were randomly assigned either to experimental (n ¼ 81) and control (n ¼ 80) groups. The patients in the experimental group received sleep hygiene and progressive relaxation exercise training compared to the routine health care in the control group. The relaxation exercise training was performed for once a week for an 8-week period and its effect on insomnia symptoms was examined accordingly.

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

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1. PHYSIOLOGICAL AND CULTURAL PERSPECTIVES OF SLEEP DISORDERS’ IMPACTS IN MIDDLE EAST COUNTRIES

The materials of sleep hygiene were a booklet about principles of sleep hygiene and compact disc (CD) of relaxation exercises. A 30-minute sleep hygiene lecture was presented to the subjects in the experimental group in the first visit. The session included the factors contributing to insomnia in postmenopausal women and the required actions to address against it to obtain a better sleep. The booklets were given to the patients that included information about the sleep disorders, their causes, their associations with other factors, and sleep hygiene education.163,164 The experimental group was visited once again after the first home visit and they were given 45 min training on progressive relaxation exercises. The CD had three sessions: The first session was 10 min and explained the sleep relaxation purposes and the ways that exercises needed to be performed. The second session was 10 min and had information on relaxation exercises and verbal instructions along with the relaxation music (river sound). The last 10-minute session had some relaxation music without instructions. The subjects in the experimental group were requested to perform the progressive exercises once a day for an 8-week period in line with the information provided in the CD. The investigators found that the level of the Women’s Health Initiative Insomnia Rating Scale was significantly lower in the experimental group (SD: 7.09) compared to 14.03 in the control group. In addition, the rates of insomnia between the two study groups were substantially different. The sleep hygiene education and progressive exercises are considered simple, cost-effective, and safe interventions. They are appropriate for postmenopausal women and are practicable at home by selfmanagement. These kinds of intervention are easily implementable to the subjects at home. Progressive muscle relaxation (PMR) exercises are considered an alternative treatment method to decrease the insomnia symptoms. PMR is defined as “relative elimination of anxiety and musculoskeletal tension, or absence of physical or mental strain.”165 The subjects in this technique are assisted to calm down and fall asleep easily. In the technique, the large group of muscles is contracted and relaxed. The relaxation exercises are performed to entire body from head to foot or vice versa. The persons become aware of body tensions, can control the muscles, and can relax the stiff muscles of the body. Accordingly, they can implement this technique at home by themselves. The recent studies have confirmed the effectiveness of PMR on sleep improvement on quality and insomnia reduction.166,167 Demiralp and Oflaz et al.168 evaluated the electiveness of PMR training on sleep quality and fatigue in 14 patients diagnosed with breast cancer undergone adjuvant chemotherapy. The sleep quality and fatigue were measured through the Pittsburgh Sleep Quality Index

and Piper Fatigue Scale, respectively. The patients recruited in the experimental group experienced a greater increase in sleep and fatigue improvement compared to the control group. The substantial improvement in stressful feelings and overall health status of a sample of children with cancer participated in a creative art therapy, including painting and handcrafting group art therapy, was shown in our recent study.169

SLEEP CLINICS AND SLEEP MEDICINE EDUCATION The general knowledge and attitude of 209 PHC physicians in Riyadh, Saudi Arabia were assessed. Close to sixty percent (57%) of them agreed that sleep disorders are a distinct medical specialty. Forty percent of them reported that sleep disorders are common according to their clinical practice. The doctors recognized the serious outcomes of OSAS poorly. A small percentage of the doctors (15%) had attended the lectures on sleep disorders during postgraduate training/practice. These trained doctors were more likely to have patients with sleep disorders.170 The role of physicians in PHCs is important to diagnosis the sleep disorders, such as OSAS in the reduction of healthcare utilization.171 Since the health system in Middle East countries relies on referring the patients to the secondary/tertiary health center, the physicians in PHC have an important role, as the patients have the first exposure in these settings. Therefore, early detection and management of patients with sleep disorders depend on the knowledge and awareness of the general practitioners. BaHammam and Alenezi172 recognized 47 patients aged 28.9 years with narcolepsy between March 1998 and December 2005 in Riyadh, Kingdom of Saudi Arabia based on the International Classifications of Sleep Disorders Diagnostic and Coding Manual criteria. The mean age at symptoms onset was 20.5 years. The interval period between symptoms onset and diagnosis was 8.4 years. Only 22 of these patients were referred to the sleep disorders clinic by various specialties, and 25 patients sought directly the sleep clinics. Interestingly, three patients were referred with the correct diagnosis. There is no sufficient information on the status of sleep medicine services in Middle East countries owing to scarcity or nonpublished data. A national survey in KSA in 2007 revealed underdeveloped sleep medicine services in the KSA compared to developed countries. They identified nine sleep medicine facilities, in which, seven of them were sleep disorders centers. These centers provide clinical diagnostic and therapeutic services for patients with various sleep disorders. Two of them were sleeping laboratories that provide diagnostic and therapeutic services. Only two of the hospitals had

I. INTRODUCTION AND BACKGROUND OF SLEEP DISRUPTION

REFERENCES

pediatric sleep medicine services. All of the defined sleep services were administered under pulmonary medicine services.173 In 2013, the number of sleep facilities was 18 in KSA with 0.11 beds/tear/100,000 people and the per capita PSG rate was 18.0 PSG/year/100,000 people.174 In UAE, there is eight specialized sleep labs in tertiary level hospitals. These clinics are administered by certified sleep physicians. Still, there are a few qualified sleep technicians in these sleep clinics and the majority of them are serviced by respiratory therapists only.18 The knowledge of Saudi undergraduate medical students about sleep disorders and sleep medicine education was assessed in seven medical schools. Only 27.7% of the participants showed their interest in sleep medicine. The knowledge of the majority of them (greater than 80%) about sleep medicine was poor and only 4.6% responded correctly 60% of the questions. The time spent for teaching sleep medicine in the included schools was 0e8 h. The barriers to sleep medicine teaching were: (a) low priority of sleep medicine in the curriculum and (b) time constraints.175 Possibly, this leads to low recognition of sleep disorders in medical practitioners.170,176 The low knowledge about sleep medicine in medical students is the result of the limited time devoted to sleep education in medical schools.175

RESEARCH Based on the present review of sleep disorders in Middle East countries, it is evident that few interventions have been implemented to decrease the rates of sleep disorders and their adverse impacts on the people in this region. In addition, the author did not find that special governmental health promotion initiatives in Middle East countries apart from some sleep clinics in Saudi Arabia. Therefore, I recommend that the broad dimensions of sleep be investigated in a wide range in this region.

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