Sleep Across The Life Cycle

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Sleep Across the Life Cycle

• Syeda Shakeela Munir M.D.
• Sleep Medicine

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Objectives

• Discuss the changes that occur in sleep from
  infancy through adulthood.
• Discuss the normative data of sleep parameters
• Discuss sleep changes across the life cycle in
  women
• Discuss sleep in older Adults

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Sleep Definition

• sleep is a reversible behavioral state of
  perceptual disengagement from environment
  unresponsive to the environment.
• Series of physiological behavioral process.
• Normally associated with postural recumbence,
  behavioral quiescence ,closed eyes occasionally
  unusual behavioral activities.
• Greek God Hypnos Sleep.

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Sleep Across the life cycle
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Sleep Patterns 0-12 Months

• Sleep -major portion of lives of newborns,
  infants children.
• A newborn typically sleeps ( 70 of every 24 Hr)
  / adults spend 25-30 of their lives sleeping.
• Distributed equally across the day night.
• Gain ability to sustain longer periods of sleep
  waking.
• Total sleep duration about 14 hours.
• Developmental mile stones of sleeping through
  the night ( i.e. at least 8 hours at night) is
  achieved by 6-9 months.
• By age 3 ,the average child will have spend more
  time asleep than awake.

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Sleep Patterns 0-12Months

• Infants have a sleep cycle periodicity of 50-60
  minutes.
• Sleep periods of 2-4 hours initially in infancy
  with REM. usually being the initial stage of
  sleep onset.
• Infants usually spend 50 of night into REM.
• At age 3 months REM becomes organized NREM
  finally dominates the sleep cycle.
• NREM stages emerges in the first year.
• Sleep spindles arising at 4 weeks.
• High voltage slow waves at age 3 months.
• K complexes at 6 months.

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Sleep Patterns 0-12 months

• EEG features not discernible in new born
  infants.
• Combination of EEG Behavioral Criteria used to
  assign sleep stages .
• Quiet sleep( i.e. NREM sleep)
• Active Sleep( i.e. REM sleep)
• Indeterminate Sleep
• Active sleep dominates initially with
  respective percentage for preterm full term
  infants of 60 50.
• By age six months, active sleep declines to 25 .
  
• After 6 months, NREM divided into 4 stages Stage
  1,2,3,4.
• EEG voltage significantly increases in first yr,
  with attenuation in 9-16 yrs.

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Sleep Patterns 0-12 months
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Sleep Patterns 0 12 months

• REM sleep, NREM sleep based on EEG, EOG, EMG.
• Newborn Transitional sleep with disorganized
  quiet and active sleep.
• 1-6 Months REM is active sleep, NREM is quiet
  sleep.
• NREM sleep low frequency, high voltage EEG
  activity, low muscle tone, absence of eye
  movement.
• REMS Desynchronized cortical EEG activity,
  absence of muscle tone, irregular heart and resp
  rate, episodic bursts of phasic eye movements.
• Trace alternant seen in very young high voltage
  activity with near electrical silence.

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Sleep Patterns in 0-12 months

• When infants fall asleep, experience sleep onset
  REM after 3 months, drift towards NREM sleep
  onset.
• SWS greatest is early childhood, decreasing
  abruptly in puberty and further declines
  throughout life.
• This change reflects EEG amplitude that may be
  related to age-specific programmed alterations
  in synaptic connectivity among neurons and
  changes in neuron
• , neurotransmitter, or neuro -receptor
  properties.

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Sleep Patterns of 0-2 months
Active Sleep State
Analogous to REM, low voltage irregular pattern,
HR,RR variable
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Sleep Pattern o-12 months
Quiet Sleep State
Analogous to NREM, Discontinuous EEG pattern,
intermittent bursts of electrical activity
alternates w/quiescent periods, regular HR, RR,
few body movements
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Sleep Patterns 0-12 Months
Quiet sleep and tracé alternant (TA)
NREM sleep pattern at term, 2-6 sec burst of high
amplitude slow waves separated by 4-6 secs of low
voltage mixed activity, disappears by 4 weeks
post term
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EEG TRACING FROM AGE 2 WEEKS TO 15 years.
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Sleep Patterns in 2-6 years

• Changes in sleep structure during this period are
  more gradual.
• Sleep becomes consolidated into a long nocturnal
  period of approx 10 hour.
• During 2-3 years day time sleep is replaced by
  short day time naps.
• All children stop napping between ages 3-5 years.
• Sleep is generally consolidated into a single
  nocturnal period.

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Sleep Pattern in 2-6 year old
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Sleep Pattern in 2-6 year old
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Sleep Patterns in 2-6 years

• Changes in uniformity duration of REM periods
  i.e., The first REM of Night becomes shorter ,
  while succeeding periods longer associated with
  more intense phase activity.
• REM usually occurs one hour after a sleep.
• By 4-5 year of age REM decreases to an Adult
  level of 20-25 .
• Children of this age usually have 7 cycles during
  each nocturnal sleep period.
• Sleep onset between 15-30 minutes.
• SWS usually occur during the first third of night.

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Sleep pattern 2-6 years

• Decrease in sleep duration across early childhood
  results from fewer daytime naps.
• Night waking common in toddlers/preschoolers
  (20 wake once a night, 50 once a week).
• Can be considered normal.
• Thought to be consequence of nocturnal arousals
  driven by Ultradian rhythm of sleep cycles (50-90
  mins.).
• Self soother vs non self soother.

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Sleep Pattern in 2-6 years

• Child development influence sleep behaviors.
• gt Increased mobility leads to reactive
  co-sleeping.
• gt Cognitive development produce fears and
  interests.
• gt Separation anxiety.
• gt Drive for autonomy.
• Parents perception important factor.
• Bedtime routine important.
• Lifestyle co-sleeping with siblings/parents.

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Sleep Patterns 6- 12 years

• Growth development continues to be constant.
• Sleep continues to develop into a more mature
  pattern.
• Total sleep time 9-11 hours.
• Sleep pattern becomes more stable, night to
  night consistency.
• Low level of day time sleepiness naps rare.
• School life styles influences-later bedtimes
  earlier. rise times, irregular sleep /wake
  schedules.

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Sleep Pattern in Adolescent

• Sleep duration decreases but need does not
  decline (average. 9.30 hrs).
• Delay of sleep phase stay up late, wake later in
  am.
• Circadian Relative phase delay
• Environmental factor
• Advanced wake times
• Decreased sleep /wake regularity.
• discrepancy between weekdays/ weekend sleep
  cycle.
• Increased sleep tendency at mid puberty.
• Due to autonomy, peer pressure, academic
  demands, employment, extracurricular activities.

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Sleep Regulation in Childhood

• Theoretical models describe 2 intrinsic
  regulatory processes determine timing of sleep
  and waking.
• Homeostatic process-represents the drive for
  sleep that increases during wakefulness and
  decreases during sleep.
• Circadian process- with distinct neuroanatomical
  locus.

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Sleep Regulation in Childhood
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Sleep Regulation in Childhood

• Homeostatic process.
• Dynamics of sleep homeostatic mechanisms appear
  to slow down during development.
• Thus decreasing sensitivity to sleep loss and
  increase tolerance to sleep pressure.

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Sleep Regulation in Childhood

• Homeostatic process
• Theta activity may be marker for HSP in
  children.
• Age at which it become SW-activity unknown.
• Adolescent sleep deprivation similar to that
  of young adults EEG changes.
• Rise rate of HSP during the day slower in
  mature. adolescents compared to pre (early)
  pubertal children.
• Nocturnal dissipation of sleep pressure does
  not differ.

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Sleep Regulation in Childhood

• Circadian Process
• Sleep-wake independent clock-like process.
• Distinct neuro -anatomical locus in bilateral
  supra -chiasmatic nuclei of anterior
  hypothalamus.
• Appears to be functional in utero not
  working well at birth.
• 1st month- 24h core body temp rhythm emerges.
• 2nd month-more sleep at night.
• 3rd month-melatonin and cortisol start to
  cycle in 24h rhythm.

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Sleep Regulation in Childhood

• Circadian process- Changes appear during puberty.
• Three mechanisms
• -Delay in intrinsic circadian phase.
• - Mature children show later timing of
  melatonin secretion onset and offset phases.
• -Delay may be related to lengthening of
  intrinsic period of circadian clock.
• -Heightened sensitivity to pm light or
  decrease sensitivity to am light.

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Sleep patterns of adults

• Young adult usually sleep 7.5-8.5 hours/Night.
• First NERM-REM cycle is 70-100 minutes.
• Subsequent NERM-REM cycle is 90-120 minutes.
• Sleep length partially determined by genetics,
  volitional determinants circadian rhythm.

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Sleep Architecture of the normal young adult

• Sleep is made up of the two physiological states
  NREM REM.
• Sleep begins with NERM.
• SWS predominates in the first third of night.
• REM sleep predominates in the last third of
  night.
• Break down of sleep stages
• NERM ( 75- 80 )
• WASO stage I 5
• Stage N1- StageII-2-5
• Stage N2-Stage III-45-55
• Stage N3-Stage IV-13-23
• REM-(20-25)

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Sleep Patterns in Young Adults
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Sleep Patterns In Adult
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Sleep Stages PSG
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Normal Sleep Patterns

• Published in Sleep 2004.
• Meta analysis of Quantitative Sleep parameters
  from Child hood to old age in Healthy
  individuals.
• Meta analysis of 65 studies,,3577 subjects,
  ages5-102.
• Published articles bet 1960-2003.
• non clinical Participants.
• Used all night PSG or Actigraphy to measure TST,
  Sleep Latency, Sleep Efficiency, Stage I, II,
  SWS, REM sleep, REM Latency, WASO.

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Normal Sleep Patterns
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Normal Sleep Patterns
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Normal Sleep Patterns
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Normal Sleep Patterns
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Normal Sleep Patterns
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Normal Sleep Patterns

• Results
• In children Adolescent, TST decreased with age
  (on school days).
• of slow wave sleep was negatively correlated
  with age.
• of stage 2 NREM REM sleep significantly
  change with age.
• In Adults TST, Sleep Efficiency, of SWS, of
  REM Sleep REM Latency all significantly
  decreased with age While Sleep Latency, of
  Stage 1 sleep, of Stage 2 sleep and WASO
  significantly increased with age.
• Only Sleep Efficiency continued to significantly
  decrease after 60 years of age.

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Are there gender differences in Sleep?

• Increase in subjective sleep complaints but
  relatively few differences in sleep architecture.
• Despite the fact that sleep complaints are about
  twice as prevalent in women of all ages compared
  to men, 75 of the sleep research has been
  conducted with males.
• HORMONAL EFFECT ON SLEEP
• Estrogen Primary effect on REM.
• Decrease SOL,WASO, Increase TST.
• Progesterone primary effect on NERM-
  Benzodiazepine like effect.
• Decrease SOL, WASO.

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Sleep Patterns in Women

• Sleep in women with normal Menstrual cycle.
• subjective longer sleep latency, lower sleep
  efficiency sleep disruption was associated with
  luteal phase. Severity of premenstrual symptoms
  was co-related with day time sleepiness.
• Objective PSGfinding-Stage 2 was higher in luteal
  phase also increase frequency of sleep
  spindles.
• Dysmenorrhea associated with decrease sleep
  efficiency.

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Sleep Patterns in pregnant Women

• Pregnancy, child birth early motherhood
  physiologically psychologically affect a
  womans sleep.
• Contributing factors hormonal alterations
  during early pregnancy , enlargement of fetus in
  late pregnancy postpartum infants feeding
  sleeping cycles.
• Reports of altered sleep during pregnancy range
  from 13-80 in the first trimester ,66- 97
  in third trimester.

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Sleep Pattern In Pregnant Women

• First Trimester disrupted sleep but TST
  increases in first trimester back to prepreg
  level in 3rd trimester.
• Sleep is not much affected in 2nd trimester.
• Increase number of awakening, disrupted sleep
  Decrease TST in third trimester post partum.
• Increase stage 2,WASO,Slight decrease in REM
  SWS
• Decrease Sleep Efficiency.
• Snoring increases, Increase incidence of OSA/RLS.

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Sleep Patterns in Women

• SLEEP MENOPAUSE
• Prevalence of insomnia increases form 33-36 to
  44- 61 in pre post menopausal women.
• Postmenopausal women have more subjective
  complaints of disturbed sleep but had better
  sleep documented on full night polysomnography
  longer total sleep time, increased amount of SWs,
  less time awake in bed.

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Sleep Pattern in Women

• SLEEP MENOPAUSE
• Increase in SOL 20 reports sleepinglt 6 hours.
• Difficulty in Sleep Maintenance.
• Role of nocturnal Hot flashes more frequent
  arousal awakening, decrease SE, Increased SWS.
• OSA increased prevalence severity Post
  menopausal
• HRT may improve SE OSA symptoms.
• Insomnia may become conditioned despite HRT role
  of various replacement protocols.

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Sleep in Older Adults

• Many elderly people C/O Disturbed sleep.
• Need for sleep does not Change.
• The ability to sleep does decrease with age.
• Causes are multi-factorial.
• Change in timing consolidation of sleep.
• Medical psychiatric illnesses.
• Medications.
• Presence of specific sleep Disorder.
• Physiologic Changes that occur in older adults.

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Sleep in Older Adults

• Change in Sleep with Age
• Subjective Reports
• Spending too much time in bed.
• Spending less time asleep.
• Increase number of Awakenings.
• Increase in time to fall asleep.
• Increase in tiredness during the day.
• Less satisfaction with sleep.
• Longer more frequent naps.

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Sleep In Older Adults
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Sleep In Elderly Population

• OBJECTIVE FINDINGS
• Decrease NREM Sleep.
• Decrease REM Sleep.
• Increase in awakening.
• Increase Frequency of sleep D/o.
• Decrease in Sleep Efficiency.
• Increase in day time sleepiness.
• Increase number of naps.

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Sleep pattern in older Adults

• Changes in sleep Architecture with age
• Total sleep 7 hours.
• Decrease of SWS ( 2 per decade of age).
• Decrease REM sleep REM latency.
• Decrease sleep spindle density K complex.
• Sleep Efficiency continue to decrease till age
  90.
• Increase stage shifts.
• Fewer stage shifts.
• Fewer cycles.

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Sleep In Older Adults
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Sleep in Older Adults

• Causes of disturbed sleep in elderly
• Insomnia
• pain-arthritis, Cancer
• neurological disorder- RLS, Parkinsons,
  dementia
• organ system failure- lungs, CHF, GI, BPH
• Depression, GAD.
• Pts with disease more likely to be less satisfied
  w/sleep than healthy pts.
• Medication use

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Sleep in Older Adults

• Common primary sleep disorders in adults
• -OSA
• -25 have apnea index of 5 or gt
• -62 have AHI of 10 or gt
• -Increased prevalence due to decreased resp
  
• muscle strength, decreased expiratory flow
  
• rates, diminished compliance of chest wall
• -Changes in anatomy of airway
• -RLS PLMs prevalence increase significantly
  with age

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Sleep In Older Adults

• Total amount of sleep does not change.
• Timing of sleep changes.
• Advancement of circadian rhythm and age related
  changes in output of circadian pacemaker
  contribute to sleep complaints.
• ZEITGEBERS Inconsistency of external cues eg-low
  exposure to light, irregular mealtimes, decreased
  exercise.
• Melatonin levels decrease with age contributing
  to poor sleep.

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Sleep Pattern in Older Adults

• Age related deterioration of the hypothalamic
  nuclei that drives CR also affects sleep
• Older adults wake up earlier and fall asleep
  earlier in relation to nightly melatonin
  secretion
• Aging assoc with adv of sleep and CR, decreased
  melatonin release, and change in internal phase
  relationship b/w sleep-wake cycle and output of
  circadian pacemaker
• Increase in cortisol level
• Diminished sleep related growth hormone release
• Reduction in retinal sensitivity to light.

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Sleep In Older Adults

• Associations with disturbed sleep.
• EDS can cause social and occupational
  difficulties, reduced vigilance, cognitive
  deficits- decreased concentration, slowed
  response time, memory difficulties.
• Impaired Mood.
• This can be interpreted as dementia or exacerbate
  mild or moderate cognitive impairment.

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Subjective Objective Sleep Quality Aging in
Sleep Heart Health Study

• Objectives To examine the extent to which
  Subjective objective sleep Quality are related
  to age independent of chronic health conditions.
• Participants 5470 Adults, Mean age 63
  range-45-99 52 women
• Measurement Home PSG Sleep Questionnaire
• Results Older age was associated with shorter
  sleep time, diminished sleep efficiency, more
  arousal in Men women In men age was
  independently associated with more stage 1 ,2
  sleep less SWS REM sleep , In women older age
  was less strongly associated with sleep stage
• Po0r subjective sleep Quality was not associated
  with men but older women

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Sleep Heart Health Study

• Sleep Heart Health Study in thousands of adults
  aged 40-98 who had sleep disordered breathing
• -AHI gt 15 increased with age
• - 10 at 45 yrs and 20 at 60 yrs
• Prevalence of PLMS and RLS increases with age
  from 5-6 in younger adults to 45 in older
  adults
• Increased incidence of RBD
• - PET scan show a decrease in binding to
  presynaptic dopamine transporter

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SLEEP QUIZ

• REM sleep is first evident at what stage of
  development?
• In utero
• Immediately post-partum
• At 1month of age
• At 3 months of age
• At 1year of age
• Total REM sleep decrease from 50 at birth to
  the normal adult range 20 by what age?
• Infancy
• Preschool
• School
• Adolescence
• Adult

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• Sinusoidal waves at9-11 HZ are recorded in the
  EEG during which of following circumstances?
• Wakefulness with eyes closed.
• Wakefulness with eyes open.
• Light sleep.
• Deep sleep.
• Which of the following muscle group is flaccid
  or atonic during REM sleep?
• Anti- gravitional muscles in upper lower
  extremities
• Extensor muscles in back arm
• Abdominal inter-costal muscles
• Proximal girdle muscles.

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• The most common cause of excessive day time
  sleepiness in adolescent is
• Depression
• Substance use or abuse
• OSA
• Inadequate amount of sleep
• Delayed sleep phase d/o
• Which of the following statement characterizes
  changes in sleep associated with aging
• The average total time spent a sleep in 24 hour
  decreased
• Total time in REM sleep decreases
• REM latency increases
• Delta wave amplitude decrease less time is
  spent in stage 3 4

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• Which of the following sleep stage is the most
  important in restoring the altered functions that
  result from prolong sleep deprivation
• REM Sleep
• Stage 1 NREM
• Stage 2 NREM
• Stage 3 and 4 NREM

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Bibliography

• Principles and Practice of Sleep Medicine Kyger,
  Roth Dement
• Basics of Sleep Guide SRS Charles J. Amlaner, D.
  Phil, and Patrick M. Fuller Ph. D.
• Sleep Medicine Essentials Teofilo L. Lee-Chiong
• Subjective and Objective Sleep Quality and Aging
  in the Sleep Heart Health Study Mark L. Unruh
  M.D., Susan Redline, M.D., Ming-Wen An, Ph. D.
• Meta-Analysis of Quantative Sleep Parameters
  From Childhood to Old Age in Healthy
  Individuals Developing Normative Sleep Values
  Across the Human Life Span Mary A. Carskadon Ph.
  D., Michael V. Vitiello Ph. D.

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The END!!!!!!!!?