Public health implications of sleep loss: The community burden

Abstract

Poor sleep imparts a significant personal and societal burden. Therefore, it is important to have accurate estimates of its causes, prevalence and costs to inform health policy. A recent evaluation of the sleep habits of Australians demonstrates that frequent (daily or near daily) sleep difficulties (initiating and maintaining sleep, and experiencing inadequate sleep), daytime fatigue, sleepiness and irritability are highly prevalent (20%-35%). These difficulties are generally more prevalent among females, with the exception of snoring and related difficulties. While about half of these problems are likely to be attributable to specific sleep disorders, the balance appears attributable to poor sleep habits or choices to limit sleep opportunity. Study of the economic impact of sleep disorders demonstrates financial costs to Australia of $5.1 billion per year. This comprises $270 million for health care costs for the conditions themselves, $540 million for care of associated medical conditions attributable to sleep disorders, and about $4.3 billion largely attributable to associated productivity losses and non-medical costs resulting from sleep loss-related accidents. Loss of life quality added a substantial further non-financial cost. While large, these costs were for sleep disorders alone. Additional costs relating to inadequate sleep from poor sleep habits in people without sleep disorders were not considered. Based on the high prevalence of such problems and the known impacts of sleep loss in all its forms on health, productivity and safety, it is likely that these poor sleep habits would add substantially to the costs from sleep disorders alone.

Full text

Sleep disorders
S7MJA 199 (8) · 21 October 2013
The Medical Journal of Australia ISSN: 0025-
729X 21 October 2013 199 8 7-10
©The Medical Journal of Australia 2013
www.mja.com.au
Supplement
leep is a basic and necessary biological process that
demands to be satisfied as much as our need for
food and drink. Inadequate sleep can occur if insuf-
ficient time is allowed for it or if a disorder is present that
disturbs sleep quality. It is only recently that we have
begun to understand the scale of the health and social
consequences of insufficient sleep and sleep disorders.
Sleep loss from these problems is associated with distur-
bances in cognitive and psychomotor function including
mood, thinking, concentration, memory, learning, vigi-
lance and reaction times.1,2 These disturbances have
adverse effects on wellbeing, productivity and safety.
Insufficient sleep is a direct contributor to injury and death
from motor vehicle and workplace accidents.3 Further,
relationships have been demonstrated between shortened
sleep and a range of health problems including hyperten-
sion,4 type 2 diabetes,5 obesity,6 cardiovascular disease7,8
and total mortality risk.9 Specific sleep disorders such as
insomnia,10 obstructive sleep apnoea (OSA)11 and restless
leg syndrome12 have also been associated with increased
morbidity and mortality. These sleep-related problems
incur financial costs relating to health and other expendi-
tures and non-financial costs relating to loss of quality of
life. This article considers the prevalence and economic
impacts of sleep problems in Australia.
Prevalence of sleep problems
There have been very few studies of the prevalence of
disturbed sleep in Australia. A small survey (n=216) of
sleeping difficulties, daytime sleepiness and hypnotic
medication use was conducted in Adelaide more than 20
years ago.13 A larger survey (n= 535) was conducted in
Newcastle, New South Wales, in 1996 but was limited to a
question about insomnia and hypnotic medications.14
Another small survey (n= 267) in rural Victoria among
Australian day workers was heavily weighted to men.15
More recently, a large NSW mail survey (n= 3300) reported
that 18.4% of participants slept less than 6.5 hours a night
and 11.7% complained of chronic sleepiness.16 A recent
study of the insomnia burden suggested a prevalence of
5.6%, with increased use of health care.17
To further characterise sleep quality in a large represent-
ative sample of Australians, in 2010, the Sleep Health
Foundation (www.sleephealthfoundation.org.au) commis-
sioned a national survey of sleeping difficulties and nega-
tive daytime consequences of poor sleep. It was modelled
on the Sleep in America surveys conducted by the National
Sleep Foundation, in part to allow international compari-
sons. A national polling organisation (Roy Morgan
Research) was commissioned to perform the work. It
conducted a national landline telephone survey of adoles-
cents and adults (14 to > 70 years of age) across successive
weekend evenings. The survey contained 14 questions
about sleep: five about sleeping difficulty, two about snor-
ing and OSA, one about restless legs, one about sleeping
medication, three about daytime impairments usually
associated with sleep disturbance, and two about noctur-
nal sleep duration (weekdays and weekends) (Box 1).
There were 1512 respondents from all states and ter-
ritories, both urban and rural, with sampling proportionate
to the populations of those areas, sex and age.
Box 1 shows the proportions of respondents reporting
current sleep difficulties and daytime impairments at least
a few times per week (indicative of significant problem), as
well as average self-reported sleep duration for the popu-
lation overall, for males and females, and for each age
group. The results illustrate that a considerable proportion
of Australians report frequent sleeping difficulties. Overall,
20% of respondents had frequent difficulty falling asleep,
which was more prevalent among females and younger
age groups. Frequent waking during the night was
reported by 35% overall, again more commonly among
females but increasing with age. Thirty-five per cent
reported waking unrefreshed and 24% reported inade-
quate sleep. Daytime sleepiness, fatigue/exhaustion and
irritability were common issues (19%–24%).
Symptoms were examined to determine likely pre-
valence of insomnia by selecting those with specific self-
Public health implications of sleep loss:
the community burden
S
David R Hillman
MB BS, FANZCA, FRCPE,
Sleep Physician1
Leon C Lack
PhD,
Professor of Psychology2
1 Department of Pulmonary
Physiology and Sleep
Medicine, Sir Charles
Gairdner Hospital,
Perth , WA.
2 School of Psychology,
Flinders University,
Adelaide, S A.
David.Hillman@
health.wa.gov.au
MJA 2013; 199: S7–S10
doi: 10.5694/mja13.10620
•Poor sleep imparts a significant personal and societal
burden. Therefore, it is important to have accurate
estimates of its causes, prevalence and c osts to inform
health policy.
•A recen t evaluation of the sleep habits of Australi ans
demonstrates that freque nt (daily or near daily) sleep
difficulties (initiating and maintaining sleep, and
experiencing inadequate sleep), daytime fatigue,
sleepiness and irritability are highly prevalent (20%–
35%). These difficulties are gene rally more prevalent
among females, with the exception of snoring and
related difficulties. While about half of these problems
are likely to be attributable to specific sleep disorders, the
balance appears attributable to poor sleep habits or
choices to limit sleep opportunity.
•Study of the economic impact of sleep disorders
demonstrates financial costs to Australia of $5.1 billion
per year. This comprises $270 million for health care
costs f or the con ditions them selves, $5 40 millio n for care
of associated medical conditions attribu table to sleep
disorders, and about $4.3 billion largely attributable to
associated productivity losses and non- medical costs
resulting from sleep loss-related accidents. Loss of life
quality added a subs tantial further non-financial cost.
•While large, these costs were for sleep disorders alone.
Additional costs rel ating to inadequate sleep from poor
sleep habits in people without sleep disorders were not
considered. Ba sed on the high prevalence of such
problems and the known impacts of sleep loss in all its
forms on health, producti vity and safety, it i s likely th at
these poor sleep habits would add substantially to the
costs from sleep disorders alone.
Summary
Online first 17/10/13

MJA 199 (8 ) · 21 October 2013S8
Supplement
reported sleep difficulties plus daytime impairment18 to
derive a score that very closely simulates the Insomnia
Severity Index, a highly reliable and valid tool to identify
clinical insomnia.19 This suggested an overall presence of
severe insomnia (Insomnia Severity Index, > 14) of 6.9%,
8.7% in women and 5% in men (Box 1).
Prevalence of sleep apnoea was derived by determining
the proportion of respondents who snored loudly at least a
few times a week and had observed breathing pauses
during sleep at least a few times a month. An overall
prevalence of 4.9% was noted, but in this case, prevalence
was higher among males (6.4%) than females (3.6%).
While these prevalences of specific sleep disorders were
derived from combinations of questionnaire responses,
they are similar to the prevalences determined from other
population-based studies.10,20 These findings suggest that
specific sleep disorders may account for about half of the
complaints of daytime sleepiness and fatigue and exhaus-
tion noted in our survey. While other health problems can
disturb sleep, particularly in older patients, much of the
balance may be due to insufficient sleep duration by choice
or through circumstances that result in sleep being given a
lower priority than work, social or family activities. Sleep
duration estimates are significantly below the putative
average adolescent sleep requirement of 9 hours a night
and adult sleep requirement of 7.5–8 hours a night for both
men and women, particularly among those between the
ages of 35 and 65 years.21 Insufficient sleep at least a few
times a week was reported by 23.7% of the sample, more
frequently by females, and more commonly in the younger
to middle-aged groups. Perhaps relevant to this, a study of
young adults has shown that those with shorter habitual
sleep patterns carried the highest sleep debt, suggesting
self-selected sleep restriction.22
The general point that emerges from these data is that
inadequate sleep (duration or quality) and its daytime
consequences are widely prevalent in Australians, either
because of a specific sleep-related disorder or from volun-
tarily shortened sleep through choice or circumstance.
Although there are limitations with telephone surveys (eg,
low response rates to landline phone calls), the results are
very comparable with those observed in similar surveys
conducted elsewhere, such as the 2008 Centers for Disease
Control and Prevention study, which reported that 28% of
United States adults had insufficient sleep or rest (< 7 h/
night) on most nights over a 30-day survey period.23
Economic impact
Poor sleep and its consequences result in significant costs
to the community. Although there have been no detailed
economic evaluations of the costs associated with insuffi-
cient sleep in otherwise healthy individuals, analyses have
been undertaken for those with sleep disorders.24,25 OSA
provides an example of a widely prevalent sleep disorder
with significant comorbidities, including impaired daytime
alertness, increased accident risk, hypertension, vascular
1 Proportions of survey respondents experiencing sleep difficulties, sleep disorder symptoms and daytime impairments a few times a week or more
(often), overall and by sex and age group
Sex Age group
Difficulty experienced often Overall Male Female 14–17 years 18–24 years 25–34 years 35–49 years 50–64 years ⭓65 years
Weighted proportion of total 100% 49.4% 50.6% 6.4% 11.7% 17.4% 26.0% 21.9% 16.5%
Sleeping difficulty
Difficulty falling asleep 19.6% 16.9% 22.4%* 33.6 %†32.2%†17.6% 20.0% 14.6% 13.5%
Waking a lot during night 34.9% 3 0.4% 39.3%†21.2% 28.1% 32.6% 42.6%†31.8% 39.5%†
Waki ng up too e arly 25.3% 22.9% 27.7%* 19.5% 23.4% 20.3% 29.1%* 25.5% 27.9%*
Waki ng feelin g unre fre shed 34.7% 31.8% 37.6%* 38.1%†44.0%†42.0%†39.8% †28.5% 19.3%
Did not get adequate sleep 23.7% 17.9% 29.4%†24.9%†29.3 %†25.3%†24.5%†21.4% 19.3%
Snoring, obstructed breathing
Frequent or loud snoring‡21.2% 26.4%†12.1% 8.4% 8.6% 21.7%†23.5%†20.0%†20.0%†
Pauses in breathing in sleep‡6.6% 6.2% 5.1% 2.9% 4.4% 3.8% 4.6% 7. 8%* 8.4%*
Restless legs 9.4% 8.6% 10.3% 4.0% 5.3% 11.2%†7.2% 10.7 %†14.5%†
Prescribed sleep medication use 3.6% 4.0% 3.1% 3.5% 2.5% 1.8% 2.4% 5.8%†5.4%†
Daytime symptoms
Daytime sleepiness 19.0% 15.7% 22.3% * 24.6%†26.2%†21.1%†22.4%†13.6% 11.4%
Fatigue or exhaustion 23.5% 20.0% 27.0%†22.8% 27.7%†27.7%†29.1%†18.8% 14.2%
Irritable or moody 18.8% 18.2% 19.3% 18.8% 19.2% 27.9%†22.9%†12.9% 9.8%
Sleep duration
Weeknights (Sunday–Thursday), h 7.16 7.1 5 7.1 7 8.24†7.49 * 7.1 8 6.86 7.01 7. 14 *
Weekend n igh ts (Friday, Sa turday ), h 7.37 7. 3 7 7. 37 8.45†7.3 7 7.5 4 7.19 7.29 7. 14
Overall, h 7.2 2 7. 2 1 7. 23 8.30†7.4 6* 7.2 8 6.95 7.09 7.1 4 *
Sleep disorder estimates
Severe clin ical ins omni a§6.9% 5.0% 8.7%* 2 .0% 11.3 %* 4.2% 10.1%* 6.9% 3.8%
Sleep apnoea‡,¶ 4.9% 6.3%* 3.6% 0 2.2% 2.1% 4.7% 7.7%* 7.0%*
* P<0.05. †P<0.001. ‡ Adjusted for the 10%–11% who “can't say”. § Estimated Insomnia Severity Index > 14, derived from data for sleeping diculty and daytime symptoms.
¶ Estimates derived from data for frequent breathing pauses and loud snoring. ◆

Sleep disorders
S9MJA 199 (8) · 21 October 2013
disease and depression.20 The associated costs include the
direct care-related health costs of the sleep disorder itself
and the costs of medical conditions occurring as a result of
them. In addition, there are substantial indirect financial
and non-financial costs. Other financial costs include the
non-health costs of work-related injuries, motor vehicle
accidents and productivity losses — all common conse-
quences of insufficient sleep. Non-financial costs derive
from loss of quality of life and premature death.24
In 2011, the Sleep Health Foundation commissioned
Deloitte Access Economics, a national economics consul-
tancy with a strong health economics background, to
undertake an analysis of the direct and indirect costs
associated with sleep disorders for the 2010 calendar
year.25 The methods used were similar to those that they
had used in a previous evaluation.24 Such an analysis
requires robust data relating to the prevalence of the sleep
disorder under consideration, the prevalences and costs
associated with conditions with which it has a causal
relationship, and the risk ratios describing the strength of
these relationships. Using these data, the proportion of
each condition attributable to the sleep disorder (the
attributable fraction) can be derived. Specifying the preva-
lences and odds ratios used to calculate attributable frac-
tions imparts transparency to the assumptions involved in
calculating them. The fraction can then be used to derive
the share of the costs associated with that condition that is
attributable to the particular sleep disorder under consid-
eration. Using these methods, Deloitte Access Economics
examined costs associated with the three most common
sleep disorders — OSA, primary insomnia and restless legs
syndrome — as the robust data required for analysis were
available.25 It estimated total health care costs of $818
million per year for these conditions, comprising $274
million for the costs of caring for the disorders themselves
and $544 million for conditions associated with them. Of
these costs, $657 million per year related to OSA: $248
million for OSA itself and $409 million for the health costs
of conditions attributable to OSA. These conditions
include hypertension, vascular disease, depression, and
motor vehicle and workplace accidents. The analysis sug-
gested that 10.1% of depression, 5.3% of stroke, 4.5% of
workplace injuries and 4.3% of motor vehicle accidents are
attributable to a sleep disorder.
The indirect financial and non-financial costs associated
with sleep disorders are much greater than the direct costs.
The indirect financial costs were estimated to be $4.3
billion in 2010. These included $3.1 billion in lost produc-
tivity and $650 million in informal care and other indirect
costs resulting from motor vehicle and workplace acci-
dents. Of these indirect costs, OSA accounted for 61%
($2.6 billion), primary insomnia for 36% ($1.5 billion) and
restless leg syndrome for 3% ($115 million).
The report also estimated the effect of sleep disorders on
loss of quality of life in terms of disability-adjusted life-
years. These costs were calculated using the proportion of
total national health costs attributable to sleep disorders to
proxy the proportionality of the total national disease
burden attributable to these problems. A dollar cost was
calculated from the product of these years lost (190 000)
and the value of a statistical life-year ($165 000). This
added a further non-financial cost of $31.4 billion to the
total economic cost of sleep disorders (Box 2). The non-
financial nature of this cost gave it less tangibility than
financial costs, but the calculation does draw attention to
the substantial burden associated with the loss of quality of
life resulting from sleep disorders.
As large as they are, these costs are likely to significantly
underestimate the total cost to the community of sleep-
related problems. Deloitte Access Economics evaluated
costs associated with common sleep disorders. The costs of
accidents and illnesses associated with sleep loss resulting
from poor sleep habits from personal choice and/or from
conflicting priorities such as work, social or family activities
were not considered as they are difficult to estimate.
Further, the analysis used conservative estimates of the
prevalence of sleep disorders. For example, the base preva-
lence of OSA used was 4.7%, which is below the propor-
tion of moderate OSA observed in many contemporary
studies, a proportion which is likely to increase further as
the population ages and becomes more obese.20 The
prevalence of insomnia used in the analysis was also low at
3%, a figure based on primary insomnia estimates.26 Sec-
ondary insomnias resulting from other causes were not
considered. Our own estimate including all insomnia from
a representative Australian sample (Box 1) was closer to
7%. Potential comorbidities of sleep disorders, even if
reasonable evidence for an association existed (such as
metabolic disorders in the case of OSA), were also
excluded from consideration. Finally, the analysis did not
cost some aspects of the known comorbidities of sleep
disorders, such as the impact of presenteeism (being
present at work but operating suboptimally) on productiv-
ity and safety. The reason for this omission was the
difficulty in reliably quantifying its effects.
Conclusion
Poor or inadequate sleep is very common among Austral-
ian adolescents and adults, affecting over 20% on a daily or
near-daily basis. Epidemiological studies suggest about
2 Summary of the annual costs of sleep disorders and
associated conditions, 201021
Varia bl e AUD (mil lion)
Direct health care co st
Sleep disorders 274
Associated conditions* 544
Indirect fina ncial cost
Productivity 3132
Informal care for accident victims 129
Other cost of mot or vehicle a ccidents 465
Other cost of workplace acc idents 53
Deadweight loss to taxation system 472
Tot al fi na nc ia l co st 5069
Non-financial cost
Loss of disab ility-adj usted life-years 31 350
Total economic co st 36 419
* Hypert ension, v ascular dis ease, depr ession, motor vehi cle injur ies and
workplace injuries. ◆

MJA 199 (8 ) · 21 October 2013S10
Supplement
half of this problem can be attributable to common sleep
disorders such as OSA and insomnia, as together they
affect about 10% of the community. The balance appears
likely to be the result of inadequate sleep arising from
other health problems or issues such as poor sleep habits
or sleep loss because of competing demands on time from
work, social or family activities. Economic estimates dem-
onstrate that sleep disorders are associated with large
financial and non-financial costs. Given that the greatest
financial costs appear to be non-medical costs related to
loss of productivity and accident risk, it is likely that
inclusion of the effects of sleep restriction from poor sleep
habits or choice could add considerably to these already
substantial amounts.
Competing interests: No r elevant disclosu res.
Provena nce: Commissioned by supplement editors; externally peer reviewed.
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