Tuesday, March 13, 2012

We Snooze, We Lose!

     Over the last couple of months that I haven't been working, I've become well-acquainted with the rude sound of Spartacus's cell phone's snooze alarm. It appears to be set to alarm about 45 minutes before he really wants to wake up. Aside from its annoying ring tone, this alarm will sound every 15 minutes, which he usually sleeps right through. Since the phone is on his side of the bed, I have to stir him from his catatonic, hibernation-like slumber to ask him to turn it off. This wouldn't be a problem, except that I'm wide awake after the first alarm. Once we're both up, having our coffee, he'll remark that he feels more tired than he did when we went to bed. I've often wondered, why isn't he waking up, refreshed and recharged after a full night's sleep? We go to bed together between 10 and 10:30 pm, and are up by 0620, which adds up to about 8 hours of sleep. I'm convinced his perpetual tiredness is a function of snoozing. I understand that he likes the idea of having a few more minutes to sleep, but why not just sleep until a) you wake up or b) the alarm goes off? Snoozing gives one the illusion of having more time to sleep, but all it really does is interrupt your natural sleep cycle, and disturb your sleeping partner. What is modern society's fascination with snoozing, anyway?
     From the day I started residency, sleep became a precious commodity, something I coveted. As a surgical intern, I sometimes wouldn't get home in the evenings until 8 pm, and would have to be back in the hospital, ready to pre-round with the senior residents and fellows by 0500 or shortly thereafter. (Real rounds with our attending surgeon occurred later in the morning.) This meant getting up around 0330 every day, throwing back a cup of coffee, showering, and hitting the road, so that I could see and examine the patients on our service, and get all my intern notes written for the day. Accordingly, my alarm was set for 0330, and when that alarm went off, I immediately bolted out of bed. I remember only one or two times where I had mistakenly set the alarm for "p.m.", instead of "a.m.", sleeping a few minutes past my normal rising time, making me late. I attribute the rarity in which I was late to the fact that I was usually awake a few minutes before my alarm went off, in much the same way as I still am today. For example, in order for me to get to the hospital by 0615 at my most recent job, I'd arise at about 0515, no alarm necessary on most days. This gave me plenty of time to enjoy my usual two cups of coffee in absolute quiet and solitude, check my e-mail, eat some breakfast, and get ready for work without having to hurry.
     What exactly happens during six to eight hours of sleep, which seems to be the universal recommendation in avoiding the much-dreaded (and dangerous) state of neurologic dysfunction called sleep deprivation, which arises from accrual of a sleep debt? Sleep consists of two stages: non-rapid eye movement (NREM) or restorative sleep, and rapid eye movement (REM) sleep, which is where active dreaming occurs. NREM sleep is further divided into three stages: N1, N2, and N3, with N3 being the deepest sleep state. Each sleep cycle lasts about 90 minutes with four to six cycles per night. Deeper sleep tends to occur earlier in the night's cycle, while REM sleep predominates in the latter part. In general, sleep architecture progresses from N1 to N2 to N3 to REM and back to N2. In N1, which lasts about 5 minutes, we are transitioning into sleep, and are easily awakened. In this stage, the brain's wakeful alpha waves are replaced by slower theta waves. The eyes are moving slowly beneath the eyelids, muscle activity begins to slow down, and consciousness starts to wane. It's not uncommon for people to experience "hypnic jerks" or hypnogogic hallucinations (waking dreams) during N1.(1,4,5) The first true stage of sleep is N2. Lasting between 10 and 25 minutes, N2 is where we spend approximately 45-55% of a typical night's sleep. This "light sleep" is characterized by the appearance of sigma waves (sleep spindles) and K-complexes on the EEG, oscillatory bursts of brain activity, often followed by muscle twitching, which are thought to assist the brain in maintaining tranquility, screening out external stimuli, and refreshing our ability to learn. In N2, the heart rate slows, body temperature decreases slightly, and eye movement ceases.(1,4,5) The deepest sleep occurs in N3, accompanied by extremely slow delta waves, and a redirection of blood flow from the brain to the muscles, which is thought to restore energy. If you are awakened during N3, you're likely to feel  somewhat disoriented for a few minutes. People with parasomnias, or sleep disorders, such as nightmares, night terrors, and sleepwalking, as well as those with nocturnal enuresis (bed wetting) experience these problems in N3 sleep.(1,4,5) About 70 to 90 minutes after falling asleep, we enter the REM phase, spending approximately 20-25% of a night's sleep in this cycle. REM is characterized by rapid eye movements and a low voltage EEG. Our arms and legs are "paralyzed." Breathing becomes shallow, heart rate and blood pressure increase, and we experience active, memorable dreaming. Whereas NREM sleep is restorative to our bodies, REM sleep is where our brains and minds are refreshed.(1) This is where we integrate information we've learned over the course of the day into learning and the formation of new memories, strengthen existing memories, and replenish mood-boosting neurotransmitters.(1,4, 5) Below is a sleep architecture diagram(1), which depicts how much time we spend in each of the stages, and how the cycles shorten or lengthen during a typical night of sleep:
     Disruptions in NREM sleep, caused by altered circadian rhythms (night shift work), external stimuli (crying babies, a partner's snoring), or substances like alcohol, tobacco, and caffeine,  rob our bodies of energy and cause us to awaken feeling tired. If these alterations in deep sleep persist over the course of a few days, it can lead to a state of sleep deprivation. What are the signs, symptoms, and ill effects of sleep deprivation? Here is a helpful list, borrowed from an online article entitled How Much Sleep Do You Need?(1)

You may be sleep deprived if you... 

  • Need an alarm clock in order to wake up on time
  • Rely on the snooze button
  • Have a hard time getting out of bed in the morning
  • Feel sluggish in the afternoon
  • Get sleepy in meetings, lectures, or warm rooms
  • Get drowsy after heavy meals or when driving
  • Need to nap to get through the day
  • Fall asleep while watching TV or relaxing in the evening
  • Feel the need to sleep in on weekends
  • Fall asleep within five minutes of going to bed 
 The effects of sleep deprivation and chronic lack of sleep...
  • Fatigue, lethargy, and lack of motivation
  • Moodiness and irritability
  • Reduced creativity and problem-solving skills
  • Inability to cope with stress
  • Reduced immunity; frequent colds and infections
  • Concentration and memory problems
  • Weight gain
  • Impaired motor skills and increased risk of accidents
  • Difficulty making decisions
  • Increased risk of diabetes, heart disease, and other health problems
     Yep, my suspicions are confirmed: poor Spartacus is sleep-deprived! His reliance on the snooze button, his self-reports of fatigue, sluggishness and problems concentrating, which begin upon arising and last until he goes to bed, and his 12-14 hour weekend sleep-a-thons are all consistent with inadequate restorative sleep. Before meeting me, he was a night owl. Even though we go to bed together now, he often gets up in the middle of the night to eat ice cream and watch TV because he can't sleep. Once he finally does come back to bed, he's only getting a few hours of sleep before the alarm goes off at 0550, the quality of which is debatable. I, on the other hand, also seem to have some features of sleep deprivation. Spartacus says I fall asleep once my head hits the pillow. I also tend to get sleepy after lunch, and enjoy taking afternoon naps, but I prefer to think that this is a function of my belief that humans are still hard-wired for biphasic sleep and because I endorse the custom of siestas, which have been demonstrated to decrease levels of the stress hormone, cortisol. Hey, it worked for us as cavemen, and still seems pretty effective in the siesta-taking cultures of today! I don't hear the global community complaining about uptight Spaniards; maybe it's because they honor their body's natural biorhythms, instead of subscribing to the Western "go-go-go" mentality. OK, I'll get off my siesta soapbox. Once we've established that we are indeed sleep-deprived, what can we do to prevent it from exacting a toll on our health?
     This may come as a surprise, but it is impossible to catch up on sleep by sleeping in on the weekends. Short term solutions like this don't fix the underlying problem, which is a deficiency in quality, restorative sleep. Neither do sleeping pills! The only way to reduce one's sleep debt burden is to alter his or her sleep hygiene. For most of us, this means aiming for about 7.5 hours of sleep per night.(1) Although 3% of the population has a mutated "sleep clock" gene which allows them to require two hours less sleep per night, the other 97% of us need closer to eight hours. Good sleep hygiene can be achieved by making some simple changes, and sticking to them. The most important intervention consists of establishing and maintaining a regular, daily sleep-wake pattern. If you normally go to bed at 10 p.m., and awaken at 0600, try to sticking to those times, even on the weekends. While you may be able to pay off a short term sleep debt by going to bed a little earlier, or waking up a little later a couple of days in a row, if you are chronically sleep-deprived, it makes more sense to go to bed earlier or wake up later on a daily basis, to accommodate your need for more sleep. If you can, try going to bed earlier for a couple of weeks, waking up naturally without an alarm. Maintain a sleep diary during this time, and you'll soon be able to objectively assess what your sleep needs really are. If you find that, despite getting a full 8 hours of sleep, you're still waking up tired when the alarm goes off, you may be waking up in N3 sleep. Try resetting your alarm for a multiple of 90 minutes, so that you awaken at the end of a sleep cycle, which is when your body is primed for wakefulness. For example, if you normally go to bed at 10 p.m., set your alarm for 5:30, instead of 6:00 or 6:30.(1) In the evening, start dimming the lights to support your body's diurnal light cycle and Circadian rhythms, all of which have an impact on sleep. Use your bed for sleep and sex. Watching TV, messing around on your laptop, and even reading can all impair your ability to fall asleep. Make sure you get plenty of exercise during the day. The recommendations for avoiding vigorous exercise four hours before bedtime have recently been disproven, so even an evening workout shouldn't interfere with the onset of sleep. Avoid eating a heavy meal right before bedtime; your body has to work hard to digest it, which can prevent the onset of sleep. Alcohol, caffeine, and nicotine all disrupt sleep architecture, so it is best to avoid those substances for several hours before going to bed. Obviously, because stress is positively correlated with insomnia, it's best to reserve emotionally charged topics and conversations for earlier in the day, and to avoid ruminating about them as you're trying to drift off to sleep. Ensure that your room is neither too warm or too cool, and that it's dark enough to promote sleepiness. Finally, establish a relaxing bedtime ritual, whether it's a warm bath, a glass of milk, meditation, or a few moments of intimacy.(2)
     Spartacus and I definitely have some work to do on our bedtime routine. We've recently gotten into the habit of watching late night reruns of "Seinfeld" in bed, which I now realize is a sleep hygiene "no-no." We're also bad about leaving the lights on around the house, mostly because we have a lot of lamps, all of which are compact fluorescent and don't eat up a lot of energy. It's a pain in the ass to go around and turn them all off, but I guess that's another thing we could do to improve our home's sleep ambience. The only real point of contention that lingers between us is that godforsaken snooze alarm and the disrupted, fragmented sleep it yields. As counter-intuitive as it may seem, snooze addicts who have trouble going to sleep early may actually benefit from waking up earlier, allowing the morning light to reset their body clocks.(3) Placing the alarm on the other side of the room can also be helpful. That way, you are forced to get up out and out of bed, instead of rolling over and hitting "SNOOZE." Unfortunately, super-gluing the snooze button, a clever idea recommended for extreme cases of snooze addiction, isn't an option for Spartacus's cell phone. Like any other issue in a relationship, this is going to take some compromise. The bottom line is this: we snooze, we lose! If Spartacus and I make just one or two of the changes I've listed above to improve our sleep hygiene and reduce our sleep debt, I'm confident that confounding snooze alarm will enjoy a swift trip into obsolescence!


  1. This is a really cool subject. I suffer from sleep apnea, so I have been to more than one sleep study. It is interesting watching brain function on one side of the screen and a video of yourself sleeping and moving in relation to it. Many do not realize the importance of sleep, myself included. I get about 3 to 4 hours of sleep at night due to working two jobs. It wears a person down mentally, emotionally, physically, and in health.

    Btw, very cool post. :)

    1. Thanks,man! Do you have to use a CPAP machine for your sleep apnea? That's an entire topic in itself, one that is a huge concern for anesthesiologists/anesthesia providers. So many of us suffer from sleep deprivation, and don't even know it!

  2. Ever since the 1980s, when I used to spend up to 12 hours a day in front of one of those old green-screen computer monitors and I would reach a point where my eyes couldn't take it any more, I've taken an afternoon nap. The old monitors may be gone, but the habit hasn't.

    1. I'm a huge fan of the siesta as well! Even just 45 minutes or so is refreshing!

  3. I had not read this post till just now and it has some very good points and I also never have understood the Snooze button. Its annoying and totally agree if you're using the snooze you loose.

    Thanks for the info., it was and is very interesting.