Sleep: A lever for improved
wellness and productivity
Summary
This project is an initiative of
Prepared in collaboration with
Knowledge into action
Made possible thanks to the support of
Desjardins Insurance refers to Desjardins Financial Security Life Assurance Company.
INTRODUCTION
Work environments are becoming increasingly competitive, so it is not surprising that companies are
looking for ways to improve their efficiencies. Workplace health programs are among the strategies
innovative organizations are implementing. As sleep can be problematical for employees, it is a good
idea to learn more about the impacts of this issue, and to be aware of what other companies are doing
to improve sleep and evaluate their results.
This initiative involved an international review of conclusive data, best practices and promising
initiatives. The project focuses on the quality of sleep of the majority of employees. However, there are
problems specific to night-shift workers that will not be addressed in this document.
The document features 4 sections:
1. The definition of sleep disorders: to provide a good description of the phenomenon and establish
uniform definitions.
2. The epidemiology surrounding sleep disorders: to understand the extent of the problem and how
prevalent it is among employees.
3. The determinants of sleep disorders: to fully understand the underlying factors.
4. The impacts of sleep disorders: to estimate the costs for society and organizations.
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PART 1 –
Defining sleep disorders
In this section, we will describe the biological need for sleep and its role in human physiology, and
then define what sleep disorders are.
Sleep is known to be just as vital for the body as eating and exercising. Sleep allows for physical,
psychological and intellectual recuperation.
Some of the main roles of sleep include:
• Stimulating and strengthening the body’s immune system
• Regulating mood and stress
• Maintaining learning and memory functions
• Maintaining cognitive capacities
• Replenishing the energy reserves in muscle and nerve cells
• Regulating certain functions, such as blood sugar levels (difficulty metabolizing sugar can lead
to weight gain and diabetes)
• Eliminating toxins
A night’s sleep is comprised of a succession of cycles (often four to six) of about 90 minutes each.
Every cycle has several phases and each plays a distinct role.
Phase 1, slow-wave sleep, is characterized by slower brain activity and its function is physical repair. It
is subdivided into four stages:
• Stage I (drowsiness): sleepiness and relaxation.
• Stage II (light sleep): represents between 45% and 55% of the sleep cycle and seems to be for
consolidating memory.
• Stages III and IV (deep sleep): Stage III represents 3% to 8% of the sleep cycle and Stage IV
represents 10% to 15%. The sleeper is isolated from the outside world and it is difficult to
wake them up. At this point in the sleep cycle, the person recuperates from physical fatigue
and the body repairs and regenerates tissues, builds bone and muscle and strengthens the
immune system. This is a very important phase, as the entire body and the brain are at rest and
recuperating.
Phase 2, REM sleep (rapid eye movement sleep): REM is the dream period, characterized by intense
cerebral activity. Its function is psychological recovery and repair.
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• REM sleep represents about 25% of a person’s total sleep time
• The person shows signs of very deep sleep and wakefulness (facial expressions, irregular
breathing and elevated cardiac activity)
• Dreaming occurs in this phase
Several scientific sources recommend seven to eight hours of sleep a night. Less than that is
considered insufficient.
The internal clock or “circadian rhythm”. In addition to the various sleep phases, we have to take our
own “internal clock” into consideration, as it varies from person to person. The circadian rhythm spans
24 hours and acts as an internal mechanism that regulates the wake-sleep cycle. It modulates physical
activity and the absorption of nutrients, and it regulates body temperature, muscle tone and the
secretion of hormones throughout the day.
Three sleep disorders have a particular impact in the workplace.
1. Trouble sleeping
2. Diagnosed insomnia 3. Diagnosed obstructive sleep apnea (OSA)
We will examine their definitions and prevalence in the following section.
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PART TWO –
The epidemiology of sleep disorders
In this section we will provide data on the prevalence of the three sleep disorders identified in the previous
section. The rates of prevalence reveal the extent to which sleep disorders affect a large segment of the
population.
A. Prevalence of sleep disorders
In Canada, the 2016 Canadian Sleep Review revealed that:
• 74% of Canadians say they get less than seven hours of sleep per night
• 67% would like to improve the quality of their sleep
• 59% state that they do not get as much sleep as they would like every night.
B. Prevalence of diagnosed insomnia
To be diagnosed with insomnia, the following three conditions must be met:
1. The person reports one or more of the following sleep problems: a) trouble falling asleep; b) trouble
staying asleep; c) waking up early; d) unrestful sleep.
2. These issues occur at least three nights per week, for at least three months, despite good sleep
habits and suitable sleeping conditions.
In Canada, 40% of the population suffers from trouble sleeping or insomnia
that includes both condition 1 and condition 2.
3. The person reports having at least one of the following daily consequences related to their sleep
problems:
• Fatigue/discomfort
• Attention, concentration and memory problems
• Problems interacting socially or poor performance at work
• Mood issues/irritability
• Daytime drowsiness
• Decreased motivation/energy/initiative
• Tendency to make mistakes/have accidents at work or when driving
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• Tension headaches or general discomfort related to lack of sleep
• Worried or preoccupied about sleep
We should note that, while certain authors use the term insomnia, others talk of chronic insomnia.
In Canada, 13% to 19% of the population suffers from chronic insomnia.
C. Prevalence of OSA
Obstructive sleep apnea (OSA) is a sleep issue characterized by mild interruptions in breathing during
sleep. These occur when the upper respiratory passages are blocked. The body realizes that breathing
has stopped and the person wakes up to breathe. This cycle is repeated several times during the night,
sometimes as many as 50 to 100 times per hour.
There are several degrees of OSA, depending on the number of respiratory arrests (apneas) or the
number of shallow breaths per hour of sleep.
OSA is diagnosed by means of a test called polysomnography, which is conducted either at home or in a
sleep clinic.
According to the literature we reviewed,
2% to 10% of the adult population seem to be affected by OSA
HOWEVER
according to a U.S. study,
more than 80% of individuals who suffer from OSA will not be diagnosed.
That’s why it is so important to ensure that employees verify their condition – the consequences are
serious.
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PART THREE –
Determinants of sleep disorders
In this section we will identify the determinants of insomnia and OSA. That is, the factors that increase
a person’s risk of suffering from insomnia or OSA, but which may not necessarily be the direct cause of
sleep disorders.
The main factors influencing insomnia are:
• Age: risk increases with age
• Gender: women are more susceptible than men
• Depression: among those suffering from insomnia, 10.8% of cases are directly related to a
depressive syndrome, and 33.1% are related to anxiety
• Physical illnesses: illnesses affecting the respiratory passages, rheumatism, chronic pain and
cardiovascular disease increase the risk
• Having non-standard or staggered work schedules
Other factors may also cause problems, for example when an individual:
• Uses psychoactive substances (tobacco, alcohol): 3% to 7% of cases
• Is experiencing a stressful financial situation: 2.2 times higher risk for people in a difficult
situation
• Is a victim of violence: 1.7 to 2 times higher for victims of violence
• Is in psychological distress: 5 times higher
• Is experiencing stress: 23% of people who indicated that most of their days were somewhat
to extremely stressful suffered from insomnia; more than double compared to people who
indicated that they did not feel stressed
Key factors influencing OSA are:
• Age: risk increases with age
• Gender: men are more susceptible than women
• Obesity: 60% to 90% of those suffering from OSA are obese
• Physical characteristics: receding chin, large neck
• Depression
• Physical illness: ear, nose and throat (ENT) irregularity
• Use of tobacco and alcohol
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PART FOUR –
Defining the impacts
The various sleep disorders have a major impact on people’s health and on organizations.
Impacts on a person’s health
Sleep disorders have repercussions on various aspects of a person’s health: physical health, mental
health and cognitive health. These impacts may be the consequence of sleep disorders or of an illness
caused by sleep disorders.
• Impacts on physical health: Aside from the disorder itself, which could cause discomfort
(daytime drowsiness) or a reduced quality of life, it could also cause certain illnesses and health
conditions, particularly diabetes, obesity, hypertension and cardiovascular disease (CVD). The
following table shows some of the data found in the research on the three sleep disorders
analyzed.
Major impacts on physical health
A – Lack of sleep
B – Insomnia
C – OSA
•CVD: less than 5 hours of sleep,
risk is 1.45 times higher for
women and 1.18 times higher
with less than 6 hours
•CVD: risk is 1.33 times higher
•CVD: risk is 2.2 times higher
•Myocardial infarction (type of
CVD): risk is 1.41 times higher
•Non-fatal CVDs: risk is 3.17
times higher for people with an
apnea hypopnea index (AHI) of
30 or higher (people suffering
from severe apnea)
•Hypertension: increased risk
with less than 6 hours of sleep
•Obesity: higher risk of obesity
with less than 6 hours of sleep
•Diabetes: increased prevalence
of type 2 diabetes and glucose
intolerance reported in
numerous studies conducted
on groups of subjects who get
less than 6 hours of sleep
•Hypertension: risk is 1.8 times
higher
•Diabetes: 20% of diabetic
Canadians suffer from insomnia
compared to 12% of nondiabetics
•Cardiac failure: 1.1% due to
OSA
•Heart attacks: 5.3% due to OSA
•Hypertension: risk is 1.8 times
higher
•50% of people with OSA suffer
from hypertension
•Diabetes: risk is 2.5 times
higher
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• Impacts on mental health: According to the Public Health Agency of Canada, mental health is
defined as “the capacity for each of us to feel, think and act in ways that enhance our ability to
enjoy life and deal with the challenges we face”. Here, we are talking about the impact of sleep
disorders on depression and anxiety.
Impacts on mental health
B – Insomnia
C – Obstructive sleep apnea
•1/3 of people suffering from insomnia
report having mood disorders or anxiety
(vs. 12% without insomnia)
•6.2% of depressions are attributable to
OSA
•Adult Canadians with OSA experience
mood disorders (depression, bipolar
issues, mania or dysthymia) 2.2 times
more often
•2.9% of depressions are attributable to
insomnia
•Strong correlation between insomnia
and anxiety/depression (ratio = 2.42
for anxiety and 1.99 for depression)
• Impacts on cognitive health: According the Quebec neuropsychologists’ association cognitive
functions are our brain’s capacity to allow us to, in particular, communicate, perceive our
environment, concentrate, remember an event or accumulate knowledge. The cognitive
functions controled by the brain are attentiveness, executive functions, intellectual functions,
visuospatial functions, recognition, language, memory, the coordination of movements and the
speed at which we process information.
We can see in the table below that the deterioration of cognitive functions – the functions that
make it possible to be productive and alert at work – are affected by insomnia.
Impacts on cognitive health
A and B – Insomnia/Lack of sleep
•Attention
C – Obstructive sleep apnea
Impacts on:
•Reaction time
•Errors in judgment
•time management
•Memory
•performance of work duties
•Concentration
•workplace social interactions
•Etc.
Deterioration of 20% to 50%
with insomnia
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In fact,
• Decreased attentiveness and concentration affect our capacity to be results-oriented.
• Decreased creativity and reasoning affect our ability to solve problems.
• Decreased learning, memory and decision-making skills affect our capacity to be able to take a
step back and see different perspectives.
• Decreased capacity for managing emotions and developing connections with colleagues
or clients affects our capacity to work with colleagues and respond to clients’ needs.
Impacts on the organization
Sleep issues also impact organizations. Here are a few of the impacts documented in the literature we
reviewed.
Health expenses: refers to the portion of health expenses linked to the impacts on employee physical
health, some of which are the responsibility of the organization (consultations, medications, tests,
hospitalization)
• Health expenses per individual are, on average, 75% higher for people suffering from severe or
moderate insomnia, compared to those who do not suffer from insomnia: $1,323 versus $757 (a
significant difference).
• An individual suffering from undiagnosed OSA costs between $2,700 and $3,300 more in health
expenses than average.
Driving accidents
• Nearly 20% of fatal road accidents are associated with drowsiness or fatigue, not including cases
where alcohol was consumed
• 4.3% of car accidents are attributable to OSA
• Individuals whose OSA is not treated are 2 to 3 times more likely to be in a car accident
Accidents in the workplace
• 3.9% of work-related accidents are attributable to insomnia
• People with insomnia syndrome are more likely to have accidents (not including driving
accidents): 12.5% vs. 6.4% for good sleepers
• 0.6% of workplace accidents are attributable to OSA
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Presenteeism: refers to employees who are present in the workplace but unable to carry out their
tasks, or whose work pace or quality of work is reduced.
• 2.8 days per year for good sleepers, 6.2 for those with symptoms of insomnia and 27.6 for those
with insomnia syndrome.
Absenteeism: refers to employees who are absent from work due to illness or fatigue
• 0.3 days per year for good sleepers, 1.6 days for those with symptoms of insomnia
(without daytime consequences) and 4.4 days for those with insomnia syndrome.
Errors: medical errors, errors in judgment, etc.
• A study measured the impacts on a police force and identified that, generally, members with
sleep disorders are 1.39 times more likely to make administrative errors, 1.58 times more
likely to fall asleep at the wheel, and 1.76 times more likely to make errors or commit safety
violations.
Work environment: relations with colleagues and clients. In the context of sleep, this aspect of the
issue has not yet been the subject of scientific study so we cannot quantify the impact.
Depending on your industry or the type of work performed in your organization, these numbers can be
used to convince decision makers that it is important to implement solutions to reduce the impact of
sleep disorders.
By tracking the total cost of sleep disorders to society (health care systems and employers) we found
two types of costs: direct costs and indirect costs.
Direct costs include healthcare costs associated with disorders, such as consultations for insomnia; or
with health conditions resulting from sleep disorders such as obesity. Sleep disorders are a source of
discomfort (daytime drowsiness) or reduced quality of life that could induce a person to consult doctors
in order to resolve or better understand their disorder. As a result of these medical consultations,
physicians could prescribe medications, diagnostic tests or treatments. In addition, the illnesses arising
from these disorders (diabetes, cardiovascular disease) could themselves result in consultations, use of
medications and treatments. Direct costs are generally costs related to medical consultations (family
doctors and specialists), medications, medical devices, diagnostic tests and hospitalization.
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Indirect costs include, primarily, losses in productivity and the financial consequences of accidents.
Productivity losses are measured in terms of absenteeism and presenteeism, and are represented in
numbers of days. The cost of these two indicators is equal to the number of days multiplied by the
average salary. The cost of road accidents is the amounts claimed in insurance for damages. Costs
related to accidents in the workplace could include property damage, the administrative cost of
insurance, compensation, loss of revenue and reduced quality of life. The costs of premature death and
unpaid care (e.g., provided by a relative) can also be considered indirect costs.
Several studies conducted in Canada, Australia, and the U.S. measured the direct and indirect costs,
but the most relevant study is one that estimated the costs of insomnia at several different levels of
severity (symptoms of insomnia and insomnia) and compared them to the costs related to people who
slept well.
A person with symptoms of insomnia costs 3.3 times more
in direct and indirect costs, and a person with insomnia syndrome
costs 12.3 times more than a good sleeper.
More than 95% of these costs are absorbed by the organization,
since they are related to presenteeism and absenteeism.
Impacts of initiatives implemented in the workplace
We have identified two studies of interest that looked at programs designed to address sleep disorders
in the workplace and analyze their impact on employee absenteeism and/or presenteeism. They
indicate that employees who participated in the program set up by their organization displayed fewer
symptoms of presenteeism and were less likely to be absent from work.
There are also workplace programs designed to detect, diagnose and treat OSA. These programs
usually include a questionnaire to identify employees at risk of OSA. These employees are then referred
to specialists or sleep clinics for a polysomnography diagnostic test (on-site or at home) and, if needed,
ongoing positive-pressure ventilation treatment.
Several companies have evaluated the impacts of this program on their health and accident-related
expenses. Among these, an insurance company evaluated savings of as much as $200 per month per
individual treated for OSA. The long-term savings could be even more if the reduction in associated
comorbidities, such as diabetes or hypertension, were included in the analysis.
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Impacts of programs on presenteeism and injuries
Program
(comparative)
Company
Online cognitive
behavioural
therapy
A Fortune 500
Company
Decreased perceived presenteeism: % of employees
indicating 3 days and + (out of 7) wherein their productivity
is affected by poor sleep quality (from 11.2% to 7%)
Healthy Sleep for
Healthy Living
American
Express
Firefighters who attended the educational sessions
had 24% less chance of completing an injury report
(as compared to those who did not attend the training
session).
Sleep Health
Education
Firefighters
Key results
Decreased perceived presenteeism (from 1 to 10,
how would you rate the impact of your sleep on your
productivity?): 15.4% for the group with the program
and 2.4% for the group without the program (DS)
Slight, but not significant decrease in absenteeism
A complete bibliography of all sources used in the preparation of Levia’s full report is included in the following pages.
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