New Policy: Minimum of Seven Hours of Nightly Sleep

The American Academy of Sleep Medicine (AASM) has recently introduced a new “consensus statement” that recommends 7 hours of sleep at night as the minimum duration for an adult. The basis of this consensus statement is a vast array of research that indicates fewer than 7 hours is associated with a huge number of medical and psychiatric symptoms.[1] 

To understand the value of a consensus statement, it is important to know that the highest levels of evidence (e.g. randomized double-blind, placebo controlled trials) are not routinely used to make consensus statements. If the highest levels of evidence were available on the number of hours of sleep needed, then the AASM would not be publishing a consensus statement. Instead, it would publish a practice parameters article and issue a new “standard” for the field, because standards are determined only with the highest quality research in which the results essentially prove the point investigated (e.g. using PAP therapy regularly reduces daytime sleepiness; thus, PAP therapy is a standard in the field to treat sleepiness related to sleep apnea). When evidence falls below that of a standard, the next level down is a “guideline,” and when evidence falls further, below that of a guideline, it is an “option.” Consensus statements could technically be described as something below all three of these categories; then again, a consensus statement may be listed in a practice parameter to clarify an approach to treatment.  

Clinical practice guidelines, a general term for the various categories described above have come under a great deal of scrutiny in the past decade for several reasons, including a “lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest.”[2] In addition, various bias may influence the development of guidelines wherein a certain approach to care may have gained “eminence” in its field despite a paucity of “evidence” to support its value.[3]

The most obvious concern regarding guidelines or consensus statements in particular is that they may be compiled by medical professionals who work closely with industry such as technology manufacturers or pharmaceutical companies. The authors of the consensus statements must declare their conflicts of interest, but it is not always clear whether these individuals were influenced more than they themselves might have realized while coming to terms with a final set of recommendations. Indeed, the greatest concern among many commentators on the topic of consensus science is the groupthink or herd instinct that may arise when recommendations are developed.   

On the AASM’s statement, about one-third of the authors have described prior (possibly current) relationships with pharmaceutical companies, but these disclosures do not prove there are conflicts of interests. Nonetheless, as will be discussed below, if a sleep medical expert is inclined toward a pharmaceutical approach to treat a sleep disorder, such as insomnia, then discussions about minimum duration of hours of sleep may fall within an area of practice in which this expert routinely prescribes medications. As such, a learned bias may exist, which might not otherwise be present among a clinician who infrequently prescribes sedatives.

One of the great public relations issues that arises when considering consensus statements is the vast majority of medical professionals who all too often readily accept these recommendations without further exploration. If a collection of medical experts convene to generate a consensus statement, then the final recommendations must be valuable enough to follow. Yet, recent research suggests that consensus statements are fraught with potential errors and omissions, which may not account for the individual care of a patient.[2;3]

To drive home this point, consider that some years ago the consensus treatment for low back pain was to get into bed and rest for some period of time, perhaps as long as a day or a week. Now, the consensus statement is just the opposite: do not get into bed to remain immobile, but instead maintain a degree of activity. In fact, attempt to return to normal activity levels as soon as feasible. Get this: prolonged time in bed is associated with a longer recovery! The question at hand should be: how could such treatment recommendations be polar opposites? The answer is clear: the original recommendation for bed rest may have been based on clinical practice, common sense, weak evidence or some combination leading to a “consensus among experts.” But, when others studied the problem in greater depth, they learned more facts to develop more nuanced theories; and, the result was that activity appears to be more important and helpful than bedrest. 

An even simpler example was the claim in the 1960s and 1970s that tonsillectomy was a potentially harmful procedure either because it might lead to lymphoma or removing such tissues from the throat would lead to more infections. Yet, clear-cut research shows that tonsillectomy in children and adults reduces the severity of sleep apnea—a very good thing! And, no evidence ever proved there were other side-effects to this surgical procedure, except for the obvious and sometimes dangerous side-effects of any surgery with general anesthesia. 

With this backdrop, it would be useful to look at one particular unintended consequence that might arise when sleep medical experts assert too much support for a policy of a minimum 7 hours of sleep per night. Through this exploration, we can gain a better understanding of how a consensus statement may appear to offer a well-intentioned and important perspective for individuals to consider, but which through the passage of time may prove inappropriate if not harmful to many individuals trying to sort out specific interests in their own sleep schedules and patterns.

To start, if there is a consensus that a minimum of 7 hours of sleep is needed, what should a sleep patient think or what should a primary care physician recommend to someone not reaching this number? Would the doctor tell the patient to spend more time in bed to gain more sleep? Would the patient listen to this advice and then get more sleep? What if patients claimed they could only sleep 6 hours and attempting to spend more time in bed led to more time in bed not sleeping, i.e. insomnia?

These kinds of scenarios are very likely to manifest, because most primary care physicians are not going to read much beyond the recommendation for 7 hours of sleep per night. Once that point of “sleep quantity” becomes entrenched in the consciousness of the vast majority of doctors, they are not going to spend lots of time perusing the literature to find some other nuanced approached, for example, one that explains how “sleep quality” is often more relevant to the patient than sleep quantity. Instead, most doctors might make a simple behavioral recommendation to spend more time in bed, but over time, many doctors will be greatly influenced by pharmaceutical companies that will now offer the obvious treatment plan for someone to achieve the 7 hours of sleep every night—to wit, prescription sleeping pills.

Indeed, with this recent AASM pronouncement, we should be seeing radio, television, print and internet advertisements bombarding our media on the incredible value of using sleeping pills every night so that you can be sure to get your 7 hours of sleep. Even if the barrage of ads does not meet the intensity that I am predicting, the concept of 7 hours will still seep into the medical consciousness of many primary care doctors, who for the most part will possess few alternatives to solve the problem in question. Both patients and doctors alike may naturally gravitate toward a prescription sedative approach, which will continue to steer patients toward the sleep duration model as the only or the most relevant metric.

Stepping back for a moment, an important question to ask is whether or not the predictions put forward here reflect an exaggeration of someone biased against the use of prescription sedatives and that, in reality, perhaps little downside would occur by the seven-hour/night policy.

It is a salient question, and no doubt my bias toward this slippery slope argument arises from my observations on the over-prescribing of medication to treat insomnia—a scenario in which we have repeatedly demonstrated a relationship between failing sleep aids and the covert presence of sleep-disordered breathing. In my general practice of sleep medicine, I would almost never (except for psychiatric emergencies) prescribe a sedative until a complete objective evaluation of sleep has been conducted in a sleep laboratory with the most up to date sensor technology. Therefore, I confess that I am not the person to the argue the other side of the debate, that is, perhaps sleeping pill prescriptions will drop because of this new policy, or this new consensus will clarify aspects of sleep that primary care physicians previously did not understand. No doubt, the many AASM authors who published this brief consensus statement will address all these issues and more in their forthcoming articles to be published in SLEEP and the Journal of Clinical Sleep Medicine later this year.

My argument, however, is based on related experiences from the past, which reveal how information is processed and applied in medicine in general and specifically with sleep medicine. In the area of sleep, we know the concept of 8 hours per night is already an entrenched idea. Will the 7 hours idea replace the 8 hours? If so, how beneficial will that be to individuals who currently sleep 8 to 9 hours but now wonder if they are sleeping too much, despite otherwise normal daytime functioning? Will these individuals be looking for a pill to make it possible to sleep only 7 hours and still maintain good functioning? In fact, there are such pills, and they are called stimulants. Indeed, stimulants are widely used to obviate the need for more hours of sleep. 

I cannot foretell how this policy will disseminate into clinical practice, but I would not be surprised to see a notable trend toward more medical therapy approaches coming into play among patients and non-patients who misinterpret the recommendation, believing 7 hours of sleep is either a must or all that’s needed. While we anticipate the forthcoming articles from these experts will clarify these points, it seems the more likely outcome will follow past experiences—the general public and primary care physicians will only hear about 7 hours per night and not much else, and then society will have to deal with the impact of this consensus science approach to sleep.

 

To read more about consensus science, including opposing viewpoints, here are some interesting links:

Consensus Science: The Rise of a Scientific Elite

Is there really a consensus? What does that mean, anyway?

Scientific consensus has gotten a bad reputation—and it doesn’t deserve it

 

Reference List

   [1]     Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep 2015;38(6):843-844.

   [2]     Clinical Practice Guidelines We Can Trust. Washington, D.C.: National Academies Press (US), 2011.

   [3]     Szajewska H. Clinical practice guidelines: based on eminence or evidence? Ann Nutr Metab 2014;64(3-4):325-331.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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