健康與科技 : 以睡眠為例

蕭富仁

Sleeping and Waking• 猜猜看？那件事我們大約每天花 8 個小時，每週 56 小時，每月 224

小時，每年 2,688 個小時，來從事這項活動？• 王子望著沈睡中的公主，忍不住地親了公主一下；就在那時侯沈睡一

百年的公主竟醒過來了！

What Is Sleep?

• Sleep is biologically regulated• Circadian rhythms• Melatonin secretion linked to light-dark cycles• Some adults report needing 7-9 hours a night• 70-year-old “Miss M.” gets by on one hour per

night!

Sleep Is an Altered State of Consciousness

• Sleep: Awareness of the outside world is turned off (mostly)

• So why don’t we fall out of bed? • EEG: The brain is active in sleep

Stages of Sleep

• Sleep is not an “on-off” event• Sleep stages• Historically: 5 distinct stages• Currently: Stages 3 & 4 are now joined

REM Sleep

• The sleep cycle reverses after about 90 minutes

• Enter REM (paradoxical) stage• Most dreaming occurs in REM sleep• Amount of time spent in REM increases • Cycle through this pattern around 5 times per

night

Infant Sleep Patterns• Infant mammals show a large percentage of REM sleep• In human, 50% of sleep in the first 2 weeks of life is REM sleep

(premature infants: up to 80%)• Human infants can move directly from an awake state to REM sleep, by

about 4 months of age, REM sleep is entered through a period of SWS• REM sleep of infants is quite active: 可能與腦部神經之刺激與發育有關

睡眠與年齡• 隨著人老化，睡眠的型態也跟著改變。嬰兒的睡眠時間

較長，而且其快速動眼期也比大孩子和成人來的高。• 例如：新生嬰兒每天大約睡 16 小時，其中有一半的

時間是在快速動眼期。老年人 (50-85 歲 ) 每天只睡5.75-6 小時，其中 13.8-15% 的時間是快速動眼期。

Pattern of Sleep in Elderly Persons• 貓空夜未眠！• A decline of total amount of sleep• Increase in the number of awakening during a night• Lack of sleep or insomnia （失眠）• Dramatic progressive decline is in stage 3 and 4 sleep (by age 90,

stages 3 and 4 has disappeared, causing sleep dissatisfaction)

Young adult Elderly person

How I hate to get out of bed in the morning!

Sleep Is an Adaptive Behavior

• Sleep serves important biological purposes:– Restoration– Circadian rhythms– Facilitation of learning

Restoration and Sleep Deprivation

• Restorative Theory: Sleep allows the body to rest and repair itself

• The evidence:– Sleep increases after strenuous physical activity– Growth hormones secreted in sleep– Replenishes the brain’s energy stores – Strengthens the immune system

Restoration and Sleep Deprivation

Effects of sleep deprivation: • Mood problems (e.g., irritability)• Decrements in cognitive performance (e.g.,

attention and short-term memory lapses)• May compromise the immune system• Falling asleep for a few seconds to a minute

(microsleeps) can impair ability to perform critical tasks (e.g., driving)

Nap• 瞌睡

– 可愛小孩– 可愛小貓

• 瞌睡– 防瞌睡系統

17

S2 SWS Wake

SSS

rat

ing

0

1

2

3

4

Before NapAfter Nap

*** *

: S2 vs. Wake, p < 0.001

S2 vs. SWS, p = 0.009

: SWS vs. Wake, p = 0.006

***

**

***

**

Nap on refreshment and memory

S2 SWS Wake

Incr

ease

in S

leep

ines

s

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

S2SWSWake

S2 vs. Wake, p < 0.001

S2 vs. SWS, p = 0.014

SWS vs. Wake, p = 0.002

*

**

S2 SWS Wake

Incr

ease

in W

ord

Pair

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

S2SWSWake

: S2 vs.Wake, p = 0.005*

*

S2 SWS Wake

Incr

ease

in S

peed

(Se

q / T

rial

)

0

1

2

3

4

5

S2SWSWake

: S2 vs.Wake, p = 0.001*

*

MemoryRefreshment

Circadian Rhythms

Circadian rhythm theory: • Many creatures are quiet and inactive during

the night because darkness is the time when danger is highest

• Reduced risk of exposure to predators • Humans: Are adapted to sleep at night

because our early ancestors were more at risk in the dark

Facilitation of LearningSleep: Strengthens neural connections needed for learning

to occur• Research shows memory in participants who slept was

greater than those who didn’t (Drosopoulos, Schulze, Fischer, & Born, 2007)

• REM and slow-wave (stages 3 & 4) important for learning to take place

• Participants who completed a complex task and later dreamed about it subsequently performed better on the task than non-dreaming participants (Wamsley, Tucker, Payne, Benavides, & Stickgold, 2010)

• Students spend more time in REM during exam periods

preattentive scanning vs. focal attention(visual discrimination)

Visual discrimination learning requires sleep after learning

Maquet, Nature Neurosci., 3, 1235-6, 2000.Stickgold et al., Nature Neurosci., 3, 1237-8, 2000.

Two-stage improvement during sleep after learning

Gais et al., Nature Neurosci., 3, 1335-9, 2000.

Karni and Sagi, Nature, 365, 250-2, 1993.

Miller, Science, 315, 1360-1363, 2007.

EEGs during waking and sleep

31

EEG ×2EOG ×1EMG ×1

Airflow ×1

ECG ×1Respiratory Bands ×2

SaO2 ×1

TI CC2430Time1 8051

ADC RAM

TI CC2430Time1 8051

ADC RAM

TI CC2430Time1 8051

ADC RAM

StoringMicro-SD Card

StoringMicro-SD Card

StoringMicro-SD Card

Block diagram

SpO2 × 1

32

眼罩型睡眠記錄分析

People Dream while Sleeping

• Dreams: Products of an altered state of consciousness in which images and fantasies are confused with reality

REM Dreams and Non-REM Dreams

• REM dreams: More likely to be bizarre and include intense emotions, visual and auditory hallucinations, and uncritical acceptance of illogical events

• Non-REM dreams: Relatively dull (e.g., what

sweater should I wear?)

REM Dreams and Non-REM Dreams

Explanation: • Non-REM: General de-activation of many

brain regions• REM: Brain structures associated with

motivation, emotion, reward, vision are active; pre-frontal cortex is not

What Do Dreams Mean?Freud: Dreams contain hidden content that represents unconscious conflicts• Manifest content: The plot of a dream; the way the dream

is remembered• Latent content: What a dream symbolizes; the material

that is disguised in a dream to protect the dreams from confronting direct reality

• No scientific evidence that dreams represent hidden conflicts or for the special symbolic meaning of dream images

Activation-Synthesis Theory

The theory:• The brain tries to make sense of random brain

activity that occurs during sleep by synthesizing the activity with stored memories (Hobson et al., 2000)

• Emotion centers (limbic system) in the brain are active, which explains the intense emotions; frontal cortices are not active, which explains the uncritical acceptance of illogical events

Activation-Synthesis Theory

The critics: • Dreams are not as chaotic as the activation-

synthesis theory suggests (Domhoff, 2003)• Often similar to “everyday life” waking

experience

Evolved Threat-Rehearsal Theory• Thought question: Why do people often dream

about threatening events? • Answer: Perhaps dreams help us prepare to cope

with real waking events. • Dreams sometimes simulate threatening events

so that people can rehearse strategies for coping (Revonsuo, 2000)

• Dreams may have adaptive value if rehearsal helps us survive and reproduce

Sleep Disorders

• Insomnia: Difficulty falling or staying asleep[12-20% adults, female > male, elderly > young]

• Obstructive Sleep Apnea (OSA): Breathing may stop hundreds of times per night

• Narcolepsy: Sufferers unexpectedly fall asleep• REM Behavior Disorder: Sufferers act out their

dreams• Somnambulism: Sleep walking

Clinical Features of OSA

打鼾

白天嗜睡

無法熟睡

注意力不集中

晨醒頭痛夜間頻尿

性情改變

Obstructive sleep apnea and treatment

Obstructive sleep apnea and continuous positive airway pressure (CPAP)

insomnia 失眠症

• Most common sleep disorder• primary insomnia( 原發性失眠 ) >1 month secondary

insomnia ( 次發性失眠 ) --- about 80% ( heart and lung diseases, pain, anxiety, depression, sleep

apnea, restless legs syndrome)• PSG ---- R/O apnea, RLS• lifestyle changes, avoid substances, good bedtime habits

include, cognitive-behavioral therapy, medicines

46

失眠治療的方式藥物治療

衛生署許可的藥物治療，常見的有 benzodiazepine (BZD) 、 non-BZD 用藥 ( 台灣一年吃下的安眠鎮靜藥丸超過 13 億顆，藥費超過 10 億元。藥物治療雖然能幫助入睡，但患者隔天的精神、活動力都大受影響，也易有藥物依賴的困擾。 )

off label use( 適應症外使用 ) 如鎮靜性抗鬱劑、抗癲癇劑、抗精神病劑、抗組織胺和褪黑激素可供使用

非藥物治療包含了認知和行為方面的治療，方法有：刺激控制治療法 ( stimulus control instructions )睡眠限制治療法 ( sleep restriction therapy)放鬆訓練 (relaxation trainings)生理回饋法 (biofeedback)認知治療 (cognitive therapy)光照治療 (light therapy)