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Chapter 5. Sleep
1. ■ if pulling an all-nighter is worth it?
1. ■ why it sometimes takes so long to fall asleep?
1. ■ if it's okay to exercise right before sleep?
College students often have a reputation for missing early-morning classes or falling asleep in class. It doesn't necessarily mean that they've been out partying. Most young adults have a circadian rhythm—an internal daily cycle of waking and sleeping—that tells them to fall asleep later in the evening and to wake up later in the morning than older adults. These circadian rhythms, accompanied by a demanding college environment, make college students vulnerable to chronic sleep deprivation. Most adults need about 8 hours of sleep each night, but the typical college student sleeps only 6 to 7 hours a night on weekdays.1 Lack of sufficient sleep impairs academic performance. According to a survey by the American College Health Association, 23 percent of college men and 25 percent of college women rated sleep difficulties as the third major impediment (after stress and illness) to academic performance.2 Unfortunately, sleeping in on the weekends does not fully recapture lost sleep. Colleges and universities are exploring ways to help their sleep-deprived students. Duke University, for example, has eliminated classes that start before 8:30 a.m. Other colleges and universities are including programs on sleep and health as part of summer orientation for freshmen. According to the 2009 Sleep in AmericaPoll3 conducted by the National Sleep Foundation (NSF), many Americans are not sleeping enough to sustain optimum health. Of the poll's respondents—adults aged 18 to 54—72 percent reported sleeping less than 8 hours on weekdays, and 20 percent said they slept less than 6 hours. On average, the respondents reported sleeping about 6.7 hours on weekdays and 7.1 hours on weekends.3 Many people are unaware of the vital role that adequate sleep plays in good health. -------------------------------------------------
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Chapter 5. Sleep
Sleep and Your Health
Sleep is commonly understood as a period of rest and recovery from the demands of wakefulness. It can also be described as a state of unconsciousness or partial consciousness from which a person can be roused by stimulation (as distinguished from a coma, for example). We spend about one-third of our lives sleeping, a fact that in itself indicates how important sleep is. HEALTH EFFECTS OF SLEEP
Sleep is strongly associated with overall health and quality of life. During the deepest stages of sleep, restoration and growth take place. Growth hormone stimulates the growth and repair of the body's tissues and helps to prevent certain types of cancer. Natural immune system moderators increase during deep sleep to promote resistance to viral infections. When sleep time is deficient, a breakdown in the body's health-promoting processes can occur. Sleep deprivation and sleep disorders are often associated with serious physical and mental health conditions, including these: * Cardiovascular diseases (congestive heart failure, hypertension, heart attacks, strokes) * Metabolic disorders (diabetes mellitus)
* Endocrine disorders (osteoporosis)
* Immunological disorders (influenza)
* Respiratory disorders (asthma, bronchitis)
* Mental health disorders (depression, suicide)
* Overweight and obesity (the mechanism for this connection is still unknown) Sleeping less than 7 hours—sometimes called short sleep—increases the risk for negative health outcomes in both men and women. (Sleeping 10 hours or more—long sleep—has not been found to have negative health outcomes.) Studies strongly support the conclusion that sufficient quantity and quality of sleep are as vital to a healthy lifestyle as are good nutrition and exercise.4–7 SLEEP DEPRIVATION
Sleep deprivation refers to sleep of shorter duration than the average basal need of 7 to 8 hours. Most of us know what it feels like when we don't get enough sleep—we feel drowsy, our eyes burn, we find it hard to pay attention. The effects of sleep deprivation can be much more serious than this, however. Studies have shown that individuals with severe sleep deprivation (staying awake for 19 to 24 hours, for example) score worse on performance tests and alertness scales than do people with a blood alcohol concentration (BAC) of 0.1 percent—legally too drunk to drive.
■ Michael Jackson's chronic sleep problems led the pop star to become dependent on powerful anesthetics, which he used to help himself fall asleep. He died of an overdose of propofol, an anesthetic normally used to sedate patients for surgery. Page 88
Sleep deprivation has effects in all domains of functioning. Heightened irritability, lowered anger threshold, frustration, nervousness, and difficulty handling stress are some of the emotional effects. Reduced motivation may affect school and job performance, and lack of interest in socializing with others may cause relationships to suffer. Performance of daily activities is affected, as is the brain's ability to learn new material. Reaction time, coordination, and judgment are all impaired. Individuals who are sleep deprived may experience microsleeps—brief episodes of sleep lasting a few seconds at a time—which increase their risk of being involved in accidents.6,8–10 The impact of sleep deprivation on memory is well documented. Sleep scientists believe sleep is the time when the hippocampus and neocortex (two brain memory systems) communicate with each other. Initial memories are formed in the hippocampus. To be retained, the formed memory must be transmitted from the hippocampus to the neocortex, where it is stored as a long-term memory. Sleep provides the optimal time for this transmission. Some sleep experts believe that for every two hours a person stays awake, his or her brain will need an hour of sleep to support communication between the hippocampus and neocortex.11 Individuals with severe sleep deprivation score worse on performance tests and alertness scales than people who are legally too drunk to drive. Sleeping less than you need causes a sleep debt.12 Your sleep debt accumulates over time, so that sleeping 1 hour less than you need every night for a week, for example, feels to your body like staying up all night. College students are especially vulnerable to building up a sleep debt, such as by pulling an all-nighter to prepare for an exam. (See the box “Study and Stimulants: Taking a Risk.”) Many college students and others who build up a sleep debt during the week—night-shift workers, for example—try to cancel the debt by sleeping more on the weekends. This “solution,” however, can actually worsen sleep deprivation during the week by disrupting sleep structure.5,13,14 Getting the same sufficient amount of sleep each night strengthens sleep structure. Challenges & Choices
Study and Stimulants: Taking a Risk
When an exam is coming up or a paper is due, many college students reach for some kind of caffeine product to stay awake—whether standards like coffee, Coke, or Mountain Dew; the newer energy drinks like Red Bull, Jolt, Venom, or Adrenaline Rush; or items like caffeinated gum, caffeinated lip balm, or NoDoz. Although caffeine increases alertness and decreases feelings of fatigue, consuming too much can cause anxiety, irritability, a racing heart rate, sleep disruption, and a caffeine crash when the drug wears off. Experts advise not consuming more than 300 mg of caffeine per day. A growing number of students, between 4 and 35 percent, are turning to a different source when they want to keep going without sleep—stimulant medications prescribed for conditions such as attention deficit/hyperactivity disorder (ADHD), chronic fatigue, and depression. Among the more commonly abused of these drugs are Ritalin, Adderall, and Provigil. These medications work by affecting the levels of different neurotransmitters in the brain, including dopamine, serotonin, and norepinephrine. They can cause irregular heartbeat, high blood pressure, high body temperature, seizures, heart attacks, and strokes. They can also be psychologically and physically addictive, and their long-term effects are not known. Some college administrators are concerned that students may fake symptoms of ADHD to obtain prescription stimulants for their own use, to share with friends, or to sell, even though selling the drugs is a felony. On some campuses, physicians won't prescribe them or will only prescribe a supply for 15 or 30 days at a time. Many students resist the message that stimulant drugs can be dangerous. They view the illegal use of such drugs as morally acceptable since they are primarily used for academic performance rather than social recreation. They say the drugs help them focus better, give them an extra edge, and help them meet the time demands of active social lives and academic schedules. Health experts warn that the risks aren't worth it. Sources: Data from “Illicit Use of Prescription ADHD Medications on a College Campus: A Multimethodological Approach,” by A.D. DeSantis, E.M. Webb, and S.M. Noar, 2008, Journal of American College Health, 57(3), pp. 315–323; “Prevalence and Motives for Illicit Use of Prescription Stimulants in an Undergraduate Sample,” by C.J. Teter, S.E, McCabe, J.A. Cranford, et. al. 2005, Journal of American College Health, 53, pp. 253–262; “Performance and Alertness of Caffeine, Dextroamphetamine, and Modafinil During Sleep Deprivation,” by N.J. Wesenton, D. William, S. Kilgore, and T.J. Balkin, 2005, Journal of Sleep Research, 14(3), p. 225. Page 89
How can you tell if you are getting enough sleep? A prime symptom of sleep deprivation is daytime drowsiness. If you feel alert during the day, you are probably getting enough sleep. If you are sleepy in sedentary situations such as reading, sitting in class, or watching television, you may be sleep deprived. Another measure of sleep deprivation is how long it takes you to fall asleep at night. A well-rested person will need 15 to 20 minutes to fall asleep.5 If you fall asleep the Top of Form
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Chapter 5. Sleep
What Makes You Sleep?
Over the course of the day, your body undergoes rhythmic changes that help you move from waking to sleep and back to waking. These circadian rhythms are maintained primarily by two tiny structures in the brain, the suprachiasmic nuclei (SCN), located directly behind the optic nerve in the hypothalamus (Figure 5.1). This internal “biological clock” controls body temperature and levels of alertness and activity. These controls are active in the daytime, increasing wakefulness, and inactive at night, allowing the body to relax and sleep. They are also less active in the early afternoon. In addition, the SCN control the release of certain hormones. They signal the pineal gland to release melatonin, a hormone that increases relaxation and sleepiness, and they signal the pituitary gland to release growth hormone during sleep, to help repair damaged body tissues. figure 5.1
Brain structures involved in sleep and waking.
Also important in maintaining circadian rhythms are external, environmental cues, especially light. Neurons in the SCN monitor the amount of light entering the eyes, so that as daylight increases, the SCN slow down the secretion of melatonin and begin to be more active.12 This process keeps your sleep/wake cycles generally synchronized with the changing lengths of day and night. The process is sensitive to artificial light as well as natural light, and even relatively dim lights in the evening (for example, from a lamp or a computer screen) may delay when your biological clock induces sleepiness. The biological clock operates even without the cues of daylight or darkness, though not in perfect synchrony with a 24-hour day. Without the stimulation of light and dark, human beings would have a daily cycle several minutes longer than 24 hours. Every morning your body resets your biological clock to adjust to the next 24-hour period.5 Your body easily tolerates a 1-hour adjustment. However, when bedtimes and awakening times differ greatly from their established norms, the adjustment is more difficult. Working night shifts and flying across several time zones, for example, can wreak havoc with your biological clock.12,15 instant your head hits the pillow, there is a good chance that you are sleep deprived.
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Chapter 5. Sleep
The Structure of Sleep
Studies have revealed that sleep consists of distinct stages in which muscle relaxation and nervous system arousal vary, as do types of brain waves and levels of neural activity. The brain cycles into two main states of sleep: non–rapid eye movement sleep, divided into four stages, and rapid eye movement sleep. NREM SLEEP
You spend about 75 percent of your sleep time in non–rapid eye movement (NREM) sleep, a time of reduced brain activity with four stages. Stage 1 of NREM sleep is a transitional, light sleep—a relaxed or half-awake state. Your heart rate slows and your breathing becomes shallow and rhythmic. This stage may last from 10 seconds to 10 minutes and is sometimes accompanied by visual imagery. People awakened in stage 1 often deny that they were asleep.12,16 In stage 2, your brain's activity slows further, and you stop moving. This lack of movement decreases muscle tension and brain stem stimulation so that sleep is induced. Stage 2 lasts about 10 to 20 minutes and represents the beginning of actual sleep. You are no longer consciously aware of your external environment. People awakened in stage 2 readily admit that they were asleep.12,16 During stages 3 and 4 your blood pressure drops, your heart rate and respiration slow, and the blood supply to your brain is minimized. If you were suddenly awakened during stage 4, referred to as deep sleep, you would feel momentarily groggy. You usually spend about 20 to 40 minutes at a time in deep sleep, and most of your deep sleep takes place in the first third of the night.12,16 REM SLEEP
Rapid eye movement (REM) sleep begins about 70 to 90 minutes after you have fallen asleep. As you enter this stage, your breathing and heart rate increase, and brain wave activity becomes more like that of a waking state. REM sleep is characterized by noticeable eye movements, usually lasting between 1 and 10 minutes. During this period you are most likely to experience your first dream of the night. Although dreams may occur in all stages of sleep, they generally happen in REM sleep.5,12 When you dream, there are periods when you have no muscle tone and your body cannot move, except for your eyes, diaphragm, nasal membranes, and erectile tissue (such as penis or clitoris).5 This state is referred to as REM sleep paralyis. If you were not immobilized, there is a danger that you would act on—or act out—your dreams. REM sleep is sometimes called paradoxical sleep, because the sleeper appears peaceful and still but is in a state of physiological arousal. Dreams and dreaming have long intrigued people in every part of the world. Probably the best-known theory of dreams in Western culture is that of Sigmund Freud, who believed that the purpose of dreaming was the gratification of unconscious desires. By dreaming about them in disguised, symbolic form while we are sleeping, we fulfill wishes we would find unacceptable during waking life. At the opposite pole is a theory proposed in the 1970s that dreams are the product of random neural activity that goes on during REM sleep. According to this theory, dreams have little or no meaning.5 Still, many people believe that dreams do have some meaning and relevance to daily life, often reflecting changes or shifts in emotions. By examining your dreams, according to this view, you may gain insight into the mental and emotional processes you are applying to problems or events in your life. Page 91
Besides giving us time to dream, REM sleep also appears to give the brain the opportunity to “file” important ideas and thoughts in long-term storage, that is, in memory. This reorganization and consolidation may account for the fact that we are able to solve problems in our dreams. Scientists further believe that creative and novel ideas are more likely to flourish during REM sleep, because we have easier access to memories and emotions. Because ideas are filed in long-term storage during REM sleep, memory may be impaired if sleep time is insufficient. As a result of such memory impairment, the ability to learn new skills is also impaired. Performance in learning a new skill does not improve until an individual has had 6 hours of sleep; performance improves even more after 8 hours of sleep.5,17,18 The importance of REM sleep to the brain is demonstrated by what is called the REM rebound effect. If you get inadequate sleep for several nights, you will have longer and more frequent periods of REM sleep when you have a night in which you can sleep longer.18 If you were not immobilized during REM sleep paralysis, there is a danger you would act on—or act out—your dreams. SLEEP CYCLES
After your first REM period, you cycle back and forth between REM and NREM sleep stages. These cycles repeat themselves about every 90 to 110 minutes until you wake up. Typically, you experience four or five sleep cycles each night. After the second cycle, however, you spend little or no time in NREM stages 3 and 4 and most of your time in NREM stage 2 and REM sleep (Figure 5.2). After each successive cycle, the time spent in REM sleep doubles, lasting from 10 to 60 minutes at a time.5,12 figure 5.2
One night's sleep cycles.
The sleep cycle pattern changes across the lifespan, with children and young adolescents experiencing large quantities of NREM stages 3 and 4 sleep (deep sleep). Sleep needs are constant across adulthood, but as people get older, high-quality sleep may become more elusive, and older adults may experience less deep sleep and REM sleep and more NREM stage 1 sleep and wakefulness.5 The production of melatonin and growth hormone declines with age, and the body temperature cycle may become irregular. All of these changes decrease total nighttime sleep.19 Medical conditions also affect sleep in older adults. Sleep is disrupted by such conditions as arthritis, heartburn, osteoporosis, Parkinson's disease, heart and lung diseases, dementia, incontinence, and cancer, as well as by some of the drugs used to treat these conditions. Additionally, sleep disorders are more common in middle and later life (see the next section). However, many healthy older individuals have few or no sleep problems.20 Some experts believe sleep problems are caused more by lifestyle choices—changes in diet, lack of exercise, decreased mental stimulation, daytime naps, and going to bed too early—than by biological changes. Older adults who maintain healthy lifestyle practices may still be able to get a good night's sleep. There are also some gender differences in sleep cycles. Some of these differences begin as early as 6 months of age. Although the structure of sleep is essentially the same for men and women, women tend to have more slow-wave sleep (NREM stages 3 and 4) than men do and to experience more insomnia. Men have more REM periods. Men and women also tend to have some differences in habits and behaviors related to sleep. For example, women tend to get less sleep than they need in order to feel alert during the week, and men tend to get more sleep than they need. A majority of women (60 percent) say they do not get enough sleep most nights of the week.21 However, men and women get about the same amount of sleep on the weekends.21
■ Women are more likely than men to get insufficient sleep. New mothers are particularly at risk for sleep deprivation.
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Chapter 5. Sleep
The National Institutes of Health estimate that at least 40 million Americans suffer from long-term sleep disorders each year; another 20 million experience occasional sleep problems (see the box “Sleep Problems”). Because many sleep disorders are undiagnosed or not reported to physicians, many people who are chronically exhausted may not know why. Sleep disorders can be divided into dyssomnias and parasomnias. DYSSOMNIAS
Sleep disorders associated with difficulty in falling asleep or staying asleep or with excessive sleepiness—the timing, quality, and quantity of sleep—are labeled dyssomnias. Insomnia
In a poll conducted by the National Sleep Foundation (NSF), 30 to 40 percent of adults reported experiencing one or more symptoms of insomnia—defined as difficulty falling or staying asleep—at least a few nights a week (see the box “Sleeping Smart”).2 Clinical symptoms of insomnia include (1) taking longer than 30 minutes to fall asleep, (2) experiencing five or more awakenings per night, (3) sleeping less than a total of 6½ hours as a result of these awakenings, and/or (4) experiencing less than 15 minutes of deep/slow-wave sleep.22 Page 93
Who's at Risk?
* Sleepwalking is more common among children aged 4–12 than among adults. It usually disappears during adolescence. * Men are more likely than women to experience sleep apnea. Being obese and having a large neck circumference also increase risk. * Insomnia is more common among women than men. Women also have higher rates of depression, a condition that can cause insomnia. * Whites are more likely to say they rarely or never get a good night's sleep compared to African Americans, Asians, and Hispanics. * Whites, Blacks, and Hispanics are all about twice as likely as Asians to have a sleep disorder. Sleep apnea occurs more frequently among Blacks than within any other ethnic group * More than other ethnic groups, Hispanics report that their sleep is disturbed at least a few nights a week by concerns about employment, relationships, money, and health. * Older adults are at particular risk for sleep disruption if they consume alcohol. The ability to metabolize alcohol slows after age 50, causing higher levels of alcohol to remain in the blood and brain than when the same amount of alcohol is consumed at younger ages. Sources: From “Sleepwalking,” MedlinePlus, 2009, retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000808.htm; “Sleep Apnea Facts,” American Association for Respiratory Care, retrieved from http://www.yourlunghealth.org/lung_disease/sleep_apnea/facts/; “Insomnia,” The National Women's Health Information Center, 2010, retrieved from http://www.womenshealth.gov/faq/insomnia.cfm#c; “Drug and Alcohol Related Sleep Problems,” WebMD, 2008, retrieved from http://www.webmd.com/sleep-disorders/drug-alcohol-related; “Sleep in America, 2010,” The National Sleep Foundation, 2010, Washington DC: National Sleep Foundation. Public Health in Action
The National Sleep Foundation (NSF) has partnered with the pharmaceutical company Sanofi-Aventis U.S. to launch the Sleeping Smart campaign. Sleeping Smart targets Americans with sleep problems and aims to educate them about the importance of good sleep behaviors and the negative consequences of insomnia. It also seeks to motivate them to talk to their doctor about their sleep problems and help them understand how to safely and appropriately use sleep medications. The 2009 Sleep in America Poll was conducted as part of the campaign to raise awareness about the prevalence of sleep problems. According to the poll, 64 percent of Americans reported experiencing a sleep problem at least a few times a week, and 41 percent reported sleep problems every night of the week. However, half of those who reported sleep problems had not talked with their doctor about them. Insomnia was the primary sleep problem reported. To kick off the campaign, the NSF released America's Sleep Report Card, based on the results from its 2009 sleep poll. Key findings included: 1. More than one-third of Americans are at increased risk for insomnia. 2. Although most survey respondents could identify health and performance consequences of insomnia, most did not have a clear understanding of insomnia itself. 3. Two-thirds of respondents at increased risk for insomnia did not consider themselves to have insomnia. 4. Many respondents who were at increased risk for insomnia engaged in stimulating activities an hour before getting into bed at least a few nights a week: 90 percent watched TV; 33 percent used the computer or Internet; and 43 percent did household chores. 5. Respondents at increased risk for insomnia reported this condition impacted their personal lives: 73 percent said it affected their mood; 63 percent said it affected their attention/concentration; 42 percent said it affected their family relationships; and 36 percent said it affected their job performance. Insomnia can be a serious health condition. To help combat this problem, the Sleeping Smart campaign Web site includes a “study hall” and “faculty lounge.” The study hall informs people of the many treatment options available for insomnia, which include behavioral or cognitive therapy, relaxation training, and medication. The faculty lounge features video clips of sleep professionals discussing when and how to talk to your doctor about a sleep problem and why it is important to seek treatment for insomnia. You can access this campaign at www.sleepfoundation.org. Source: From “National Sleep Foundation: Sleeping Smart,” retrieved March 7, 2010, from www.sleepfoundation.org/sleep-facts-information/sleeping-smart. According to the NSF, insomnia can be caused by stress, anxiety, medical problems, poor sleep environment, noisy or restless partners, and schedule changes (due to travel across time zones or shift work, for example).23 For adult women, more than half of whom report symptoms of insomnia during any given month, additional causes may include depression, headaches, effects of pregnancy, premenstrual syndrome, menopausal hot flashes, and overactive bladder. Often the person with insomnia has become distressed by his or her inability to fall asleep, which increases arousal and makes it even harder to fall asleep. In time, the bedroom, bedtime, or sleep itself becomes associated with frustration instead of relaxation, and a vicious cycle sets in. Chronic insomnia is difficult to treat, but individuals may be able to break the cycle and experience relief through such approaches as improving their sleep habits and sleeping environment and using relaxation techniques such as deep breathing and massage. See the section “Getting a Good Night's Sleep” later in this chapter for more strategies and tips on dealing with insomnia. Sleep Apnea
Also known as breathing-related sleep disorder, sleep apnea is a condition characterized by periods of nonbreathing during sleep. Some health experts estimate that almost 40 percent of the U.S. population have some form of sleep apnea and that half of those afflicted may have a severe condition. Some 80 to 90 percent of these cases are undiagnosed. The condition occurs in all ethnic, age, and socioeconomic groups, although men are more at risk for developing sleep apnea than women are.3,24–26 Scientists have distinguished two main types of sleep apnea, central sleep apnea and obstructive sleep apnea. In central sleep apnea, a rare condition, the brain fails to regulate the diaphragm and other breathing mechanisms correctly. In obstructive sleep apnea, by far the more common type, the upper airway is obstructed during sleep.3 Individuals with obstructive sleep apnea are frequently overweight and have an excess of bulky soft tissue in the neck and throat. When the muscles relax during sleep, the tissue can block the airway (Figure 5.3).
Obstructive sleep apnea.
(a) Normally, the airway is open during sleep. (b) When the muscles of the soft palate, tongue, and uvula relax, they narrow the airway and cause snoring. (c) If these structures collapse on the back wall of the airway, they close the airway, preventing breathing. The efforts of the diaphragm and chest cause the blocked airway to become even more tightly sealed. For breathing to resume, the sleeper must rouse enough to cause tension in the tongue, which opens the airway.
■ In 2010 former president Bill Clinton was briefly hospitalized for a blocked artery. After he was released, Clinton reflected that his hectic schedule over the past month, during which he got little sleep, had probably contributed to his heart problems. Page 94
In obstructive sleep apnea, the individual stops breathing many times during sleep, often for as long as 60 to 90 seconds. The person's breathing pattern is usually characterized by periods of loud snoring (when the airway is partially blocked), alternating with periods of silence (when the airway is completely blocked), punctuated by sudden loud snores or jerking body movements as the person awakens for a few seconds and gasps for air. The individual is usually not aware of this pattern of snoring and gasping, although bed partners and other members of the household often are. The chief complaint of those with obstructive sleep apnea is daytime sleepiness, not nighttime awakening. Other symptoms include difficulty concentrating, depression, irritability, sexual dysfunction, and learning and memory difficulties. Obstructive sleep apnea is a potentially dangerous condition; occasionally, it is even fatal. It is frequently seen in association with high blood pressure, and it can increase the risk of heart disease and stroke. Oxygen saturation of the blood decreases and levels of carbon dioxide rise when a person stops breathing, increasing the likelihood that heart and blood vessel abnormalities may occur. If sufficient oxygen is not delivered to the brain, death may occur during sleep.25, 27, 28 In children, sleep apnea is usually associated with enlarged tonsils. In adults, obstructive sleep apnea occurs most often in overweight, middle-aged men, although it becomes almost equally common in women after menopause. It is associated with larger neck circumferences (greater than 17 inches in men and 16 inches in women). People with the disorder often smoke, use alcohol, and/or sleep on their backs. There is sometimes a family history of sleep apnea, suggesting a genetic link. If sleep apnea is not severe, it can be addressed with a variety of behavioral strategies. They include losing weight, forgoing alcoholic nightcaps or sedatives, avoiding allergens, not smoking, using a nasal decongestant spray, using a firm pillow and mattress, and not sleeping on the back. In addition, adjustable mouthpieces are available that extend the lower jaw, adding room to the airway. They are expensive, however, and may not be covered by health insurance.5 In cases of severe sleep apnea, one treatment option is a continuous positive airway pressure (CPAP) machine. Through a comfortable mask, a CPAP machine gently blows slightly pressurized air into the patient's nose. Other treatment options include surgery to cut away excess tissue at the back of the throat and a new technique called samnoplasty that involves shrinking tissue in the back of the throat with radio-frequency energy.29 Narcolepsy
The neurological disorder narcolepsy is characterized by frequent, irresistible “sleep attacks,” in which the individual unintentionally falls asleep in inappropriate situations, such as while driving a car. A person with narcolepsy experiences excessive daytime sleepiness, falls asleep for 10 to 20 minutes, and awakes feeling refreshed. Within 2 to 3 hours, however, the person once again feels sleepy. In obstructive sleep apnea, the individual stops breathing many times during sleep, often for as long as 60 to 90 seconds. Narcolepsy affects about 3 to 6 people in 10,000. Nearly 80 percent of cases of narcolepsy are not diagnosed. A person who has a relative with narcolepsy has a 3 percent chance of developing this disorder—a risk 60 times greater than that of someone with no family history of narcolepsy. If a person has one parent with narcolepsy, the odds are 1 in 20 that the person will have the disorder. Narcolepsy occurs as early as age 3 but usually does not begin until puberty, which suggests that maturation of the brain may play an important role in onset.5, 30 Page 95
There is no cure for narcolepsy, but symptoms may be reduced by taking a 10- to 20-minute nap every 2 hours throughout the day, avoiding alcohol and sleeping pills, and getting sufficient sleep on a regular basis.30 Stimulant medications such as amphetamines have been used to treat pervasive daytime sleepiness. Restless Legs Syndrome
As the name suggests, restless legs syndrome (RLS) is a sleep disorder characterized by disagreeable sensations in the limbs, usually the legs. These uncomfortable and sometimes painful feelings, such as creeping, tingling, or burning, create an almost irresistible urge to move the legs. Discomfort is relieved by vigorously stretching and crossing the legs and, sometimes, walking about for a short time. The symptoms and the individual's responses to them can delay and disturb sleep, leading to daytime sleepiness. Sleep experts estimate that about 10 percent of the population have this syndrome.30,31 Taking iron and vitamin E supplements may help reduce RLS symptoms. Avoiding late-night alcohol and engaging in moderate exercise are also encouraged.31 PARASOMNIAS
Whereas dyssomnias involve the timing, quality, or quantity of sleep, parasomnias involve physiological functioning or behavior during sleep. Body systems become activated as if the person were awake, usually during specific stages of sleep. Sleepwalking Disorder
People with sleepwalking disorder rise out of an apparently deep sleep and act as if they are awake. They do not respond to other people while in this state, or, if they do, it is with reduced alertness. Sleepwalking affects between 1 and 15 percent of the general population.32 Sleepwalking takes place during the first third of the night's sleep. Episodes typically last less than 10 minutes.5 If sleepwalkers are awakened, they are often confused for several minutes; if they are not awakened, they may return to bed and have little or no memory of the episode the next day. Although there may be a genetic link to sleepwalking, most sufferers do not have a family history of this disorder. Episodes may be brought on by excessive sleep deprivation, fatigue, stress, illness, excessive alcohol consumption, and the use of sedatives.5,32 Nocturnal Eating Disorder
A person with nocturnal eating disorder rises from bed during the night and eats and drinks while asleep. About three quarters of people with this disorder are female. The person may consume bizarre concoctions but has no memory of these experiences in the morning. Fifty percent of people suffering from this disorder binge eat without awakening. Although they may binge up to six times a night, they do not experience indigestion or feelings of fullness after the binge.5,7
■ Night-time eating can be associated with a sleep disorder. People with nocturnal eating disorder binge eat without waking up; people with night eating syndrome consume a large portion of their daily calories during the night. Page 96
Distinct from nocturnal eating disorder is a newly identified sleep disorder, night eating syndrome, in which affected persons binge eat late at night, have difficulty falling asleep, repeatedly awaken during the night and eat again, and then eat very little the next day. Some people with night eating syndrome consume more than 50 percent of their daily calories at night. Sleep experts estimate that the syndrome's frequency is about 1.5 percent in the general population and up to 10 percent among obese people seeking treatment for their weight. Treatments include medications and behavior management techniques.5,7 Sexsomnia
Sexsomnia involves masturbating, fondling another person, or actual intercourse with a nonconsenting person while asleep. Most people who experience sexsomnia have no memory of the event. An intriguing legal question is whether a person committing a sexual assault while asleep has committed a crime. The judicial system has been inconsistent in its decisions concerning sexsomnia and sexual assaults. Curbing alcohol use and maintaining a regular sleep cycle are prevention factors. This condition is one of the remote side effects of the sleep drug AmbieTop of Form
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Chapter 5. Sleep
Evaluating Your Sleep
How can you tell if you have a sleep problem? First, get a sense of your general level of daytime sleepiness by taking the sleep latency test (a measure of how long it takes you to fall asleep) in Part 1 of the Personal Health Portfolio activity for Chapter 5 at the end of the book. Next, check to see if you have any symptoms of a sleep disorder by completing Part 2 of the activity. Then take a look at the various behavior change strategies in the next section of the chapter and make any appropriate improvements. Of course, the most basic recommendation is to make sure you are getting enough hours of sleep every night. If you still experience a sleep problem after following these recommendations, you may want to consult your physician. If the problem is serious enough, your physician may refer you to a sleep clinic or lab or a sleep disorder specialist. If you are referred to a sleep clinic or lab, you may be asked to monitor your sleeping habits at home by keeping a sleep diary for a week or more. You will record the times you go to bed, awaken during the night, and wake up in the morning, as well as what and when you eat in the evening, any alcohol, tobacco, or drugs you consume, and so on. Alternatively, you may be evaluated at the lab. You may take a Multiple Sleep Latency Test, in which you lie down in a dark room and are told not to resist sleep. This test, repeated five times during the day, measures sleep latency as an index of daytime sleepiness. n.12
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Chapter 5. Sleep
Getting a Good Night's Sleep
What is the best way to ensure healthy sleep patterns over the course of the lifespan? In this section we provide several strategies and tips that will help you get a good night's sleep. ESTABLISHING GOOD SLEEP HABITS
Several habits and behaviors concerning when and where you sleep and what you do before you sleep can help you sleep better and solve sleep problems (see the box “Cole: A Case of Insomnia”). Maintain a Regular Sleep Schedule
Try to get about 8 hours of sleep every night, 7 days a week. With a regular sleep schedule, you fall asleep faster and awaken more easily, because you are psychologically and physiologically conditioned for sleep and waking. Most students have an irregular sleep schedule.2,5 As noted earlier, such a schedule throws off your internal biological clock and disrupts the structure of sleep. Page 97
Cole: A Case of Insomnia
Cole is a 19-year-old sophomore majoring in psychology. During his freshman year, he had grant money to cover his tuition, but this year he is on his own. So when school started 3 months ago, he got a job working the evening shift at an upscale restaurant. On paper, it seemed like a logical setup: work till 11 p.m., study till 1 a.m., and wake up at 8 a.m. for a 9 o'clock class. But a month into the school year, Cole began having trouble falling and staying asleep. Sometimes he'd lie in bed for hours, staring at the ceiling, trying to think himself to sleep. Eventually he decided to just spend time on the computer playing games and messaging his friends on Facebook until he finally felt sleepy, usually between 3 and 4 a.m. He only averaged about 5 hours of sleep on weekdays, but he was grateful for the weekends, when he could sleep in and try to catch up on sleep. At first, Cole felt okay during the day with the help of some caffeine. He stopped by Starbucks on the way to class in the morning to pick up a Venti coffee. Whenever he started feeling tired during the day or during his study time at night, he'd grab a Red Bull or a RockStar or take a caffeine pill like Vivarin. But eventually the caffeine stopped having any effect. Midterms were coming up in a few weeks and Cole felt stressed. He was in a fog during the day and couldn't fall asleep at night. He bought some Adderall from a classmate to help him stay awake and focus on studying. He also tried Tylenol PM for a few days to help him sleep, but it didn't work. The breaking point came when Cole could not fall asleep for two days straight and felt like he was going a little crazy. He knew his strategies were not working, so he made an appointment at the student health clinic to get help. Create a Sleep-Friendly Environment
Your bedroom should be a comfortable, secure, quiet, cool, and dark place for inducing sleep. Your mattress should be hard enough to allow you to get into a comfortable sleep position. If it is too hard, however, it may not provide an adequate cushion to prevent painful pressure on your body.5 Noise can reduce restful sleep. Research on people who live near airports has found that excessive noise may jog individuals out of deep sleep and into a lighter sleep. Street noises have a similar effect.33 Noise levels above 40 decibels (about as loud as birds singing) can disturb sleep. College residence halls and apartment complexes often have noise levels that exceed 40 decibels. Earplugs and earphones can reduce noise levels by as much as 90 percent. If it isn't possible to eliminate noise, try creating white noise, a monotonous and unchanging sound such as that of an air conditioner or a fan. Noise generators that create soothing sounds such as falling rain, wind, and surf have been proven effective in protecting sleep.7,34 If you can't find an inexpensive noise generator, start with a fan.34 Temperature is important too. You sleep best when the temperature is within your specific comfort zone. A temperature below or above that zone often causes fragmented sleep or wakefulness. The ideal is usually 62° F to 65° F. Generally, temperatures above 75° F and below 54° F cause people to awaken.5 Finally, don't expect to get a good night's sleep if you cannot lie down. Research has shown that people sleeping in an upright position have poorer quality sleep than those sleeping in a horizontal position. The amount of slow-wave sleep a person experiences in a sitting position is almost zero. If you fall asleep while standing up, your body begins to sway so that you quickly awaken. Perhaps the brain operates in a similar fashion when you are sleeping in a seated position. With your body mainly upright, your brain may interpret this position as not sufficiently safe to allow deep sleep.5
■ One key to getting a good night's sleep is creating a pleasant environment and establishing a relaxing bedtime routine. Avoid Caffeine, Nicotine, and Alcohol
Caffeine, a stimulant, disrupts sleep, whether it comes in coffee, tea, chocolate, or soda. Caffeine enters your bloodstream quickly, reaches a peak in about 30 to 60 minutes, and it may take up to 4 to 6 hours for half of caffeine intake to clear the blood system of a young adult. A single cup of coffee may double the amount of time it takes an average adult to fall asleep. It may also reduce the amount of slow-wave or deep sleep by half and quadruple the number of nighttime awakenings.12 Avoiding caffeine intake 6 to 8 hours before going to bed may improve sleep quality. Page 98
Like caffeine, nicotine is a stimulant that can disrupt sleep. People who smoke a pack of cigarettes a day have been shown to have sleep problems. Brain wave pattern analysis indicates that they do not sleep as deeply as nonsmokers. Smoking also affects the respiratory system by causing congestion in the nose and swelling of the mucous membranes lining the throat and upper airway passages. These physiological factors increase the likelihood of snoring and aggravate the symptoms of sleep apnea. They also decrease oxygen uptake, which leads to more frequent awakenings.5, 34, 35, 37 Alcohol induces sleepiness and reduces the amount of time it takes to fall asleep, but it causes poorer sleep and restlessness later in the night. Even if consumed 6 hours before bedtime, alcohol can increase wakefulness in the second half of the night, probably through its effect on serotonin and norepinephrine, neurotransmitters that regulate sleep. Because alcohol is a depressant, it prevents REM sleep from occurring until most of the alcohol has been absorbed. After absorption, vivid dreams are more likely. Sleep experts call this an alcohol rebound effect, in which the body seems to be trying to recover REM sleep that was lost earlier. Additionally, alcohol can aggravate sleep disorders such as obstructive sleep apnea and trigger episodes of sleepwalking, sleep-related eating disorders, and other disorders. The impact of alcohol on sleep apnea is of particular concern; it can even be deadly. Alcohol consumption makes throat muscles even more relaxed than during normal sleep; it also interferes with the ability to awaken.36 Get Regular Exercise but Not Close to Bedtime
Regular exercise during the day or early evening hours may be beneficial for sleep. Exercising within 3 hours of going to bed, however, is not recommended, because exercise stimulates the release of adrenaline and elevates core body temperature. It takes 5 to 6 hours for body temperature to drop enough after vigorous exercise for drowsiness to occur and deeper sleep to take place.5,34 Manage Stress and Establish Relaxing Bedtime Rituals
Stress increases physiological arousal and can adversely affect sleep patterns. Stress management and reduction techniques, such as those described in Chapter 3, can be used to help induce sleepiness. For example, keep a worry book by your bedside and record bothersome thoughts and problems in it that keep you awake at night. Once you've written them down, tell yourself you'll work on them during daylight hours, and then let go of them. Use your notes to focus energy and attention on these problems over the course of the next few days. It can also be helpful to develop a bedtime ritual, such as reading, listening to soothing music, or taking a warm (but not too hot) bath; your mind and body will come to associate bedtime with relaxation and peacefulness. Avoid stressful or stimulating activities before bedtime, such as working or paying bills, and dim the lights to let your internal clock know that drowsiness is appropriate. Experiment until you find a method of calming down and relaxing at bedtime that works for you. If you do have a hard time falling asleep, don't stay in bed longer than 30 minutes. Get up, leave the room, and listen to soothing music or read until you feel sleepy. Avoid Eating Too Close to Bedtime
Try not to eat heavy meals within 3 hours of bedtime, particularly meals with high fat content. When you are lying down, the force of gravity cannot assist the movement of food from the stomach into the small intestine to complete digestion, and you may experience acid indigestion, or heartburn. Also avoid caffeinated beverages, citrus fruits and juices, and tomato-based products such as pasta sauce, because these foods can temporarily weaken the esophageal sphincter. When weakened, this sphincter allows stomach contents to move back into the esophagus, a condition known as acid reflux. If you have acid reflux, try raising the head of your bed 6 to 8 inches, which will allow gravity to help empty stomach contents into the small intestine. Tilting the bed is more effective than elevating the upper body with pillows. For those who are overweight, moderate weight loss may reduce discomfort, because excessive stomach fat can cause abdominal pressure that contributes to heartburn.5,7 Be Smart About Napping
The typical North American adult takes one or two naps a week, and about a third of adults nap more than four times a week. About a fourth never take a nap. If you are a napper, sleep experts recommend naps of only 15 to 45 minutes, which can be refreshing and restorative. If you nap longer than 45 minutes, your body can enter stage 4 deep sleep. It is more difficult to awaken from this stage, and you are likely to feel groggy.5,7 If you know you will be going to bed later than usual, you may want to take a “preventive nap” of 2 to 3 hours. Research suggests that people who take preventive naps increase their alertness by about 30 percent over that of people who do not nap. Napping 15 minutes every 4 hours until you attain 2 hours of preventive napping is also recommended. This short nap strategy has been effectively used by physicians and law enforcement officers, who must perform in emergency situations for long hour.38 Page 99
Highlight on Health
Critters in Your Bed and Bedroom
Dust mites are extremely common bedroom pests. A typical used mattress may have as many as 100,000 to 10 million microscopic dust mites inside, and 10 percent of the weight of a 2-year-old pillow may be made up of dust mites and their droppings. If not controlled, dust mites can spread throughout the house. To control dust mites, follow these precautions: * Replace pillows frequently.
* Use synthetic rather than down pillows.
* Vacuum your mattress thoroughly, or cover it with a plastic case that can be wiped with a damp cloth. * Wash your bed linens weekly in hot water (at least 130° F). * Vacuum the bedroom carpet frequently.
* Choose hardwood floors over carpet.
Bed bugs are another bedroom pest. For unknown reasons, many cities have recently experienced an upsurge in bed bug infestations. Bed bugs are small, brownish, flattened insects that feed on the blood of animals. Adults are about ¼ inch long. They are active primarily at night and during the day prefer to hide in the tiny crevices provided by the mattress, box spring, bed frame, or headboard. Their bites, usually on the arms or legs, cause welts and itching that are often mistaken for mosquito bites. Professional pest control may be needed to control a bed bug problem. Another bedroom pest is the brown recluse spider, found primarily in the central midwestern states southward to the Gulf of Mexico. This spider is about ⅜ inch long and is sometimes referred to as a fiddleback or violin spider because of the faint violin-shaped marking on its back. The brown recluse is not an aggressive spider; people are usually bitten when they accidentally crush, handle, or disturb it, as can happen if it has crawled into bedding. Most bites leave only a small reddish mark, but in some cases the bite can cause a deep, painful wound that can blister, enlarge, and cause a general systemic reaction that includes agitation, itching, fever, chills, nausea, vomiting, or shock. Children, older adults, and people with immune suppression disorders are more vulnerable to systemic reactions. To prevent bites by the brown recluse or any other spider, follow these precautions: * Inspect bedding and towels before use.
* Move your bed away from the wall.
* Shake out clothing and shoes before getting dressed.
* Dust and vacuum regularly.
* Eliminate clutter in closets.
* Seal and caulk crevices where spiders can enter your home. * Wear gloves when handling cardboard boxes, firewood, or rocks. Many commercial pesticide products are effective for spider control, but if the problem is widespread, you may need to use a pest management company.
Dust mites (left) are microscopic. Bed bugs (center) are about ¼ inch in length. The brown recluse spider (right) has a body about ⅜ inch in length. Get Rid of Dust Mites and Other Bedroom Pests
Dust mites are microscopic insects that feed on dead skin cells. They live primarily in pillows and mattresses. Dust mite droppings become airborne and are inhaled while people are sleeping, causing allergic reactions and asthma in sensitive individuals. If you experience itchy or watery eyes, sneezing, wheezing, congestion, or difficulty breathing in your bedroom, the culprit may be dust mites. For guidelines on preventing and controlling dust mites, and for information on other bedroom pests, see the box “Critters in Your Bed and Bedroom.” Page 100
Consider Your Bed Partner
Snoring is a major disrupter of partners' sleep, and body movement during sleep can also be a problem for partners. Avoiding alcohol before bedtime, using nasal sprays, sleeping on your side, and using a humidifier may help reduce snoring. Men tend to thrash around in bed more than women do, and older couples tend to move in less compatible ways than do younger couples. A mattress with low motion transfer may help prevent sleep disruption caused by a partner's movement. Sleep can also be disrupted if a partner has a different sleep schedule or has a sleep disorder. If your partner's sleep habits create a problem for you, encourage your partner to improve his or her sleep habits or to see a sleep disorder specialist. As a last resort, you or your partner may have to sleep in a different bed or room. USING SLEEP AIDS
Because sleep is so influential in your daily functioning, and because sleep problems are so common, it should not be surprising that many people resort to sleep aids of one kind or another to help them get a good night's sleep. About 15 percent of adults use a prescription sleep medication and/or an over-the-counter sleep aid to help them sleep a few nights a week.34 Prescription Medications
Safe and effective sleep medications are those that can be taken at higher doses, are not addictive, do not produce serious side effects, and wear off quickly so that you are not drowsy the next day. Sleep experts disagree about whether today's sleep medications meet these criteria.5 No sleep medication should be used for longer than two weeks without physician consultation. The most frequently prescribed, longer acting sleep medications are the benzodiazepines Restoril, Dalmon, and Doral. These drugs induce sleep but suppress both deep sleep and REM sleep. Their effects can last from 3 to 24 hours, and daytime side effects include decreased memory and intellectual functioning. People quickly build tolerance to long-lasting benzodiazepines, which are addictive and lose their effectiveness after 30 nights of consecutive use. There are some shorter acting benzodiazepines on the market that do not suppress deep sleep and REM sleep.34 A new category of sleep medications is the imidazopyridines. The National Sleep Foundation considers these drugs the best prescription sleeping aids.34 One drug in this category, zolpidem, sold under the trade name Ambien, has become the best-selling prescription sleep aid in the United States, but it has been associated with some disturbing side effects (see the box “Sleep Aids and Bizarre Behaviors”). Over-the-Counter Medications
Nonprescription, or over-the-counter, medications can be useful for treating transient or short-term insomnia, such as may occur under conditions of great stress or trauma. They should be discontinued once the cause of the problem has been eliminated, ideally within 2 weeks. The recommended maximum use is 4 weeks. Many over-the-counter sleep products contain anti histamine, a type of drug developed to treat allergies. The effects of antihistamines are general throughout the body; besides drowsiness, they cause dehydration, agitation, and constipation. Additionally, you can quickly develop tolerance to antihistamines, and when you stop taking them, you may experience rebound insomnia—insomnia that is worse than what you experienced before you started taking the medication.34 Rebound insomnia can be avoided by gradually reducing the dose. Over-the-counter products like Tylenol PM that contain acetaminophen should also be used with caution. Large doses of acetaminophen are toxic to the liver and can cause severe liver damage.
■ Ambien belongs to a class of drugs considered the best prescription sleep aids, but use of this medication is associated with unusual side effects, including eating, driving, and having sex while asleep. Complementary and Alternative Products and Approaches
Complementary and alternative products and approaches to sleep problems include herbal products, dietary supplements, and aromatherapy. The herbal product most commonly used for insomnia is valerian, which has a tranquilizing or sedative effect. Hops is another product currently receiving attention as a possible sleep aid. Both are widely available in health food stores. Herbal products can interact with other medications and drugs, including caffeine and alcohol; it is strongly recommended that you consult with your physician before trying any herbal remedies.39 Melatonin is a dietary supplement that has been marketed as a sleep aid, but health experts are divided on its effectiveness. As noted earlier in this chapter, melatonin is a hormone naturally secreted by the pineal gland in response to darkness. It lowers body temperature and causes drowsiness. Most experts agree that the 3-milligram dose of synthetically produced melatonin available in health food stores is too high and that a dose of 0.1 milligram is as effective as a higher dose.34,39 Potential side effects, interactions with drugs, and long-term health effects of melatonin supplements have not been studied extensively. Caution is advised, because some studies have reported increased risk of heart attack, infertility, fatigue, and depression with melatonin use. Page 101
Sleep Aids and Bizarre Behaviors
Sleep medications commonly have such side effects as next-day drowsiness, dizziness, headaches, confusion, agitation, and even hallucinations. More bizarre reactions are said by drug manufacturers to be “remote,” defined as fewer than 1 episode per 1,000 users. But in recent years, there have been reports of people eating, cooking, and driving in their sleep after taking Ambien, a sleep aid. A study by the Minnesota Regional Sleep Center found that thousands of Ambien users have experienced sleep-eating and sleep-driving behaviors. Sexsomnia—engaging in sexual behavior while asleep—is also associated with Ambien. Scientists believe that sleep-aid medications may suppress the brain's arousal system and cause these and other bizarre behaviors. Another condition associated with sleep medications is “traveler's amnesia.” Sleep aids typically cause temporary amnesia, lasting for a few hours after the drug is taken. Temporary memory loss is usually not a problem, because the user is asleep. But when a sleep medication is taken by someone who is traveling, the person may have to wake up before the drug has worn off. Many people in this situation have found they have amnesia for the hours when the drug was still active. The side effects of sleep medications can vary, depending on the person's general health, drug tolerance, and other medications. Most of these sleep medications, however, have not been tested for long-term use, and the U.S. Food and Drug Administration has requested that manufacturers use stronger language on their labels warning of potential risks. Some physicians question the value of these drugs, since users fall asleep faster than nonusers by only about 15 to 20 minutes. If you use sleep aids, consult with your physician or pharmacist about proper dosage and possible side effects. Sleep medications should not be crushed or chewed, and alcohol should not be used in combination with sleep aids. Sources: A Good Night's Sleep, by L. J. Epstein, 2007, New York: McGraw-Hill; “Ambien Linked to ‘Sleep Eating,’” by D. DeNoon, retrieved from www.webmd.com/content/Article/120/113595.htm?pagenumber=3. In aromatherapy, certain essential oils, such as jasmine and lavender, are used to induce relaxation and sleepiness. Aromatherapists believe these oils relieve insomnia by reducing stress, enhancing moods, and easing respiratory or muscular problems, but no strong scientific evidence supports these claims.39 Aromatherapy oils may be applied to the skin by full body massage, or a drop may be placed on the wrist or at the base of the throat so the scent is inhaled during sleep. Scented sprays can be used on bed linens, but aromatherapy candles should not be used when you are sleeping. Aromatherapy products are generally available in health food stores. If you are interested in trying this approach, however, it is recommended that you consult a trained aromatherapist before making any purchases. * * *
As noted, it is not surprising that people go to great lengths to get enough high-quality sleep. Nothing is as refreshing and restorative as a good night's sleep, giving us a fresh perspective and renewed energy for facing the demands of the day. Shakespeare called sleep the “balm of hurt minds, chief nourisher in life's feast.” Sleep, he wrote, “knits up the ravell'd sleeve of care.” Conversely, almost nothing is as distressing as being unable to avail ourselves of the respite provided by sleep. Chronic sleep deprivation can interfere with physical, emotional, and cognitive functioning and leave us fatigued, depressed, and more susceptible to illness and disease. As with so many other facets of lifestyle, good sleep habits and practices, established early in life, can help you maintain wellness in both younger and older adulthood. Page 102
You Make the Call
Should Drowsy Drivers Be Criminally Liable for Crashes They Cause? Maggie McDonnell, a 20-year-old college student from Washington Township, New Jersey, was killed in July 1997 when the car she was driving was hit head-on by a van that had crossed three lanes of traffic. The driver of the van told police he had not slept in 30 hours and had smoked crack cocaine a few hours before the crash. He was charged with vehicular homicide. At the time, conviction for vehicular homicide under New Jersey law required driver recklessness. A person who drove while knowingly fatigued and caused a fatal crash could be charged only with careless driving. The jury was not allowed to consider driver fatigue as a factor in this case. The first trial ended in a deadlock on the charge of vehicular homicide, and the second trial ended in acquittal. The driver was fined $200 and received two points on his driving record. In 2003, New Jersey passed the first statute to specifically cite driver fatigue as a factor that could be considered under the charge of vehicular homicide. New Jersey's Drowsy Driving Act, called Maggie's Law, explicitly allows a jury to find a driver reckless if he or she was awake for 24 hours prior to causing a fatal crash. Maggie's Law prevents the defense from using an inadequate law as a tool to defend the guilty. A motorist violating the law can be charged with vehicular homicide, punishable by up to 10 years in prison and a fine of $150,000. Since Maggie's death, the number of criminal prosecutions and civil suits involving driver-fatigue crashes has increased. A Virginia man who killed two people when he fell asleep at the wheel received a 5-year jail sentence. This sentence exceeded state sentencing guidelines. McDonald's Corporation paid $400,000 to the family of a victim killed by a teenage McDonald's employee in Oregon who had only 7 hours of sleep in the previous 48 hours due to his work and school schedule. The accident occurred when the employee was driving home from work. The Los Angeles City Council approved a $16 million settlement to the family of a woman permanently disabled by a city maintenance truck when the driver fell asleep at the wheel. In 2002, a bill named Maggie's Law: National Drowsy Driving Act of 2002 was introduced in the U.S. House of Representatives. Although it never became law, the bill would have encouraged states and communities to develop traffic safety programs to reduce crashes related to driver fatigue and sleep deprivation, to create a driver's education curriculum, to standardize reporting of fatigue-related crashes on police report forms, and to implement countermeasures such as continuous shoulder rumble strips and rest areas. Many states besides New Jersey have passed laws making driver drowsiness a form of recklessness under the vehicular homicide charge. Proponents of these measures claim that stringent laws with severe consequences are needed to get sleep-deprived drivers off the roads, but opponents argue that the measures are unnecessary, ineffective, and difficult to enforce. What do you think? PROS
* Almost 55 percent of adults who drive say they have driven their vehicles while feeling drowsy, and 28 percent of adults report falling asleep while driving. An estimated 60 million Americans are operating vehicles each day without adequate sleep. These people need to be held responsible for the outcomes of their choices. Page 103
* Driving fatigue has been underestimated as a factor in driving performance. The National Highway Traffic Safety Administration conservatively estimates that 100,000 police-reported crashes are the direct result of driver fatigue each year, resulting in 1,550 deaths and 71,000 injuries. * Investigation of driver fatigue can be improved with new technology. States may mandate that cars come equipped with eyelid-measuring devices. Post-crash investigators could use this information to determine if a driver involved in a crash was significantly impaired by drowsiness. CONS
* Most police officers are not trained to properly investigate driver drowsiness accidents. This lack of training makes it difficult to collect sufficient evidence for prosecution and wastes taxpayers' money on cases that can't be won. * The point of New Jersey's Drowsy Driving Act was to make driver drowsiness akin to driving while intoxicated. Research suggests similarities between these two conditions, but it is much more difficult for a police officer to detect driver fatigue than to detect intoxication. A driver involved in a crash or pulled over for erratic driving may experience an adrenaline rush that masks fatigue symptoms. * It is easy for people to lie about how many hours they have been awake in order to avoid prosecution. * Under this law, people with diagnosed sleep disorders that can cause daytime drowsiness, such as sleep apnea or narcolepsy, could be punished for having conditions they can't help and could be held liable for outcomes for which they are not really responsible. Sources: “Testimony of the Impact of Driver Fatigue. Report Before the Subcommittee on Highways and Transit, Committee on Transportation and Infrastructure,” June 27, 2002, retrieved from www.drowsydriving.org; “A Place to Crash: The Dangers of Driving While Drowsy,” by A. Dalton, retrieved June 1, 2008, from www.legalaffairs.org/printerfriendly.msp?id=843; “Sleep in America” Poll, National Sleep Foundation, 2009, Washington DC: National Sleep Foundation. -------------------------------------------------
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Chapter 5. Sleep
How does sleep impact your health?
Quantity and quality of sleep are strongly associated with overall health and quality of life. Adequate sleep gives the body time for repair, recovery, and renewal. Sleep deprivation is associated with a wide range of health problems, ranging from cardiovascular disease to depression to overweight and obesity. What makes you sleep?
Sleep is induced by the activity of a specific set of structures in the brain, in combination with environmental cues such as darkness. Humans have a circadian rhythm slightly longer than 24 hours; every morning the body resets this biological clock to adjust to the next 24-hour cycle. What is the structure of sleep?
Every night, people cycle through several stages of sleep, characterized by different brain waves, different states of muscle relaxation, and different nervous system activity. NREM sleep includes stages of deep sleep, whereas REM sleep includes dreaming and brain activity related to the consolidation of learning and memory. What are sleep disorders?
Problems associated with falling or staying asleep are classified as dyssomnias; they include insomnia, sleep apnea, narcolepsy, and restless legs syndrome. Problems associated with behavior during sleep are classified as parasomnias; examples are sleepwalking, nocturnal eating disorder, and a disorder sometimes associated with sleep medications, sexsomnia. How can you enhance the quality of your sleep?
The key to a good night's sleep is establishing good sleep habits, such as maintaining a regular sleep schedule, creating a sleep-friendly environment, and avoiding stimulants late in the day. Sleep aids, whether prescription, over the counter, or herbal, can help with situational sleep problems but shouldn't be used over the long term. Page 104
* American Academy of Sleep Medicine: This professional organization focuses on the advancement of sleep medicine and sleep research. Its Web site offers links to several sleep journals and other sleep organizations. www.aasmnet.org
* American Sleep Apnea Association: This organization focuses on increased understanding of sleep apnea disorders. It is dedicated to reducing injury, disability, and death from sleep apnea and to enhancing the well-being of those affected by this common disorder. www.sleepapnea.org/
* National Sleep Foundation: From the basics of getting a good night's sleep to understanding sleep problems and disorders, this site offers helpful information. It features interactive sleep quizzes, brochures, and a variety of tools for better sleep. www.sleepfoundation.org
* SleepNet: If you want to locate a sleep lab, take a sleep test, understand sleep terms, and learn about sleep disorders, this site is the place to visit. It highlights various sleep problems, offering clear explanations, and features related readings. www.sleepnet.com
* Sleep Research Society: This organization is dedicated to scientific investigation of all aspects of sleep and sleep disorders. It promotes the exchange of knowledge pertaining to sleep. www.sleepresearchsociety.org