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From The Desk Of Clarence Bass

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“More and more evidence is accumulating showing that overall health is very much tied to sleep quality and quantity.” Lawrence J. Epstein, MD, medical director of the Harvard-affiliated Sleep Health Centers, past President of the American Academy of Sleep Medicine, and author (with Steven Mardon) of The Harvard Medical School Guide To A Good Night’s Sleep, (McGraw Hill, 2007)

“If you maintain good health through a regular exercise regimen, eating a balanced diet, and make good sleep habits a priority, you’re likely to experience only minor sleep changes as you age.” Lawrence J. Epstein, MD

The Importance of Sleep--How I Solved My Sleep Problem

I’m always interested in learning more about how the body functions. But there’s a personal reason why I’ve recently focused on sleep: I wake up in the middle of the night and often have trouble going back to sleep. In researching this problem, I learned that it’s normal to wake up several times during the night. “Everyone does so briefly,” Lawrence J. Epstein, MD, writes in A Good Night’s Sleep, “[but it only] becomes an issue when the person stays awake long enough to become aware that he or she is awake.”

As in most things, knowledge is power. “The more you understand about the need for sleep and the mechanics of good sleep, the better able you’ll be to prevent sleep problems from developing, [and] fix problems that do occur,” says Epstein.

Nighttime awakening increases with age, according to Epstein. Sleep experts call the time we spend awake after falling asleep “wake after sleep onset” (WASO). “This WASO time increases from about eighteen minutes at age twenty to forty-four minutes at age 60,” writes Dr. Epstein.

One thing that doesn’t change, however, is the need for sleep. “[People] may have trouble getting [enough sleep] because they wake up more frequently during the night,” says Dr. Epstein, “but total sleep need does not decrease much with age.” (We’ll come back to this problem; I’ll explain my solution.)

Sleep requirements do vary from person to person. About 5% of people, says Epstein, do well on five hours sleep, while another 5% need 10 hours. The vast majority, though, fall somewhere in the middle. Seven and a half hours is a good goal for most people, according to Dr. Epstein. If you feel good when you get up in the morning, and remain alert and productive during the day, you are probably doing fine. If you have difficulty concentrating or get sleepy during the day, you may need more sleep.

We once thought that nothing much happens during sleep, but electroencephalography (EEG), the process of recording brain waves, has taught us that the brain is very active—preparing for the day ahead.

During sleep, the brain cycles up and down through important stages or levels of slumber.

Let’s look at how and why this happens. As usual, I will summarize and simplify the process and leave it to each of you to explore further as you see fit. You’ll find many more details in Dr. Epstein’s book.

Brain Waves and Sleep Levels

In our discussion of naps http://www.cbass.com/Napping.htm, we talked about slow-wave, deep sleep and fast-wave, REM (rapid eye movement) sleep or dream sleep. Those are the two ends of the continuum between relaxed wakefulness and deep sleep. As Dr. Epstein details in A Good Night’s Sleep, important things are happening as the brain cycles between dream sleep and deep sleep.

“The picture of brain activity displayed on an EEG changes constantly from fast, small waves when a person is active or engaged in specific mental activities to large, slow waves when he or she is resting or in deep sleep,” Epstein relates. By studying EEGs, scientists uncovered an orderly fluctuation in brain wave patterns during sleep. Sleep is now divided into two main types: Non-REM, or quiet, sleep and Rapid eye movement (REM), or dreaming, sleep. Non-REM sleep is sub-divided into four stages.

When we close our eyes to go to sleep, we slowly descend through stages of progressively deeper non-REM sleep, and then back up through the stages into REM sleep. We typically cycle through the full range of sleep levels about four times during the course of the night. You’ll remember that it’s normal to wake up a number of times during the night.

As we drift from wakefulness into light sleep, Dr. Epstein says we spend about five minutes in Stage 1. “Body temperature begins to drop, muscles become relaxed, and eyes often move slowly from side to side,” he explains. “We are easily jarred into wakefulness [during this stage],” he adds. People experience this stage in different ways. If awakened, some would recall being relaxed and drowsy, while others would believe they were asleep. 

Stage 2 is the first stage of real sleep. “The first time it occurs it lasts ten to twenty minutes before you progress to another stage of sleep,” Epstein relates. Overall, however, “about half the night is usually spent [cycling back and forth through] Stage 2.”

Stages 3 and 4 take you into deeper sleep or slow-wave sleep. “During deep sleep, your breathing slows and becomes more regular,” says Epstein. “Your brain becomes less responsive to external stimuli, making it difficult to awaken.”

“Deep sleep seems to be a time for your body to renew and repair itself,” Dr. Epstein states. “At the beginning of this stage, the pituitary gland releases a pulse of growth hormone that stimulates tissue growth and muscle repair. Researchers have also detected increased blood levels of substances such as interleukin that activate your immune system, raising the possibility that deep sleep helps the body defend itself against infection.”

This becomes more of an issue as we age, because we spend less time in slow-wave sleep. “Young adults spend about 20 percent of their sleep time in up to half-hour stretches of slow-wave sleep,” Epstein relates, “but slow-wave sleep declines sharply in most people over sixty-five.”

That leaves REM or dream sleep. We don’t know whether dreams have meaning, according to Dr. Epstein. “But we do know that just as deep sleep restores your body, dreaming sleep restores your mind, perhaps in part by helping clear out irrelevant information,” he explains. In the course of three to five cycles, REM sleep makes up about 25 percent of total sleep in young adults.” Again, we typically spend less time in REM sleep as we age.

We still pass through all of the sleep stages as we age, but we spend more time in Stages 1 and 2, and less in deep sleep and REM sleep. “The percentage of time spent in deep sleep falls about 50 percent between ages twenty and sixty, and time spent in REM declines by about 9 percent,” Dr. Epstein reports.

We’ll talk about ways to combat these changes below; I’ll tell you what I’m doing.

First, however, let’s look at some of the macro—and more visible—benefits of sleep, and what happens when we don’t get enough.

Benefits of Sleep

We’ve already established that the need for sleep doesn’t change. Some of us need more sleep than others, but the amount required doesn’t decline with age. It requires more thought and effort, but the benefits—and the penalties—remain about the same.

A good way to appreciate the benefits is to reflect on what happens when we don’t get enough sleep. It depends on whether you deprive yourself of sleep completely or partially, according to Dr. Epstein.  

If you are deprived of sleep completely, you first feel tired and then you feel exhausted. The effects are similar to intoxication. Your hand-eye coordination and reaction time suffer. The longer you stay awake the worse it gets. “Total sleep deprivation can be dangerous and even fatal,” Epstein writes.

Students who stay up all night cramming for a test usually don’t do as well as those who go to bed.

“Partial sleep deprivation is the type that occurs when you get some sleep, but not 100 percent of what you need,” Epstein explains, “what we think of as building up a sleep debt.” You may get by with it for a night, or even two, but make it a habit and you’re likely to pay a steep price.

“Studies have associated long-term sleep deprivation with significant health problems and shorter life,” Epstein warns.

“It’s vital that you think of getting enough sleep as an essential element of maintaining good health—as important as getting regular exercise, eating a healthy diet, and practicing good dental hygiene,” Dr. Epstein emphasizes. “You need to recognize that sleep is not a luxury, but a basic component of good health.”

People who make the effort to get enough sleep on a regular basis will experience major benefits, says Dr. Epstein: You’ll be more alert and perform better. Your memory and concentration will improve, and you’ll be more creative. Your overall health will also be better.

“It comes down to quality of life,” Epstein writes, “whatever your interests and goals, getting enough sleep puts you in a better position to enjoy and achieve them.”

I’m convinced. I hope you are as well. What can we do to get a good night’s sleep?

Have a Good Night

Dr. Epstein recommends a six-step plan for better sleep in A Good Night’s Sleep. I’m going to tell you about three of them. I’ll also tell you how I’ve adapted the recommendation to meet my needs.

1) Recognize the Importance of Sleep: I obviously done that. I hope I’ve made you a believer as well. 

2) Adopt a Healthy Lifestyle: I exercise regularly, eat a healthy balanced diet, and I don’t drink or smoke. So, I’ve also got that one covered.

Regular exercise reduces stress and anxiety, putting you in the frame of mind for sleep. It’s hard going to sleep when you’re stressed out.

Dr. Epstein says exercise also helps lock your body clock into a consistent pattern, “ensuring that you’re ready to fall asleep when bedtime arrives.”

Dr. Epstein describes one benefit of exercise—and eating wisely—that hadn’t occurred to me: Maintaining a healthy body weight helps keep your airway passages open, reducing the likelihood of developing obstructive sleep apnea, a potentially serious health problem.

3) Maintain Good Sleep Habits: I had some room for improvement here. Thanks to Dr. Epstein, I’ve made some important--and successful--adjustments in my sleep habits.

I have long maintained a regular sleep/wake schedule, usually going to bed about 10 PM and getting up about 6 AM. I also take a nap after most workouts and sometimes after lunch; see http://www.cbass.com/Napping.htm

As noted earlier, the quality of my sleep has deteriorated. I wake up during the night and often have trouble going back to sleep.

To compensate, I now try to get in bed around 9 and, when possible, sleep until 7. I still nap after workouts--when you can use a pulse of growth hormone--but I no longer nap on active-rest days.

Dr. Epstein says naps can be beneficial if you are sleep deprived or need a boost in alertness. You have to be careful, however, because “the drive for sleep increases the longer you’ve been awake.” It’s easier to get to sleep—and stay asleep—if you don’t break the time you’re awake during the day. If you have a sleep problem, “you generally want to confine sleep to one long nighttime segment.”

My going to bed earlier involves more than trying to get more sack time. Dr. Epstein recommends developing a presleep routine. He says, “You can’t expect to walk in the door, hop in bed, and fall asleep.”  

The idea is to create a mood for sleep. I take a warm shower—and spend the extra time in bed reading to take my mind off the cares of the day. My favorite magazine for relaxed reading is Sports Illustrated. I also keep several books on my bedside table for the same purpose. I look for books that capture my interest, without stirring me up. I don’t want anything that excites me or makes me anxious. My current favorites are memoirs and novels by Ivan Doig, who many consider the “premier writer of the American West.” (Read one of his books, and you'll want to read more.)

I also read when I wake up during the night. “Bed is for sleeping not frustration,” Epstein counsels. What keeps me awake is usually starting to think about things I can’t do a darn thing about in the middle of the night. The right book breaks that frustrating train of thought and puts me in the mood to go back to sleep. Another series of books that work for me are Vince Flynn's brilliant--and satisfying--novels about CIA super-agent Mitch Rapp. I can always count on Mitchell to carry the day for the good guys, which puts my mind at ease and lulls me back to sleep.

I should warn you that Dr. Epstein says, “Bed is for sleep and sex.” That’s it, nothing else. So he might not be overly enthusiastic about my reading-in-bed strategy. “Don’t spend hours lying in bed, tossing and turning and getting exasperated,” he counsels. If you’re not asleep after twenty or thirty minutes, he says, “get up and do something soothing—such as reading or drinking milk or herbal tea.”

I don’t believe the good doctor would be too unhappy with my approach, however. It may not hue to the letter, but the spirit is true—and it works for me.

Two nights ago as I write this, I woke up four times—the normal number of awakenings—and went back to sleep in minutes the first three times; on number four, when sleep is usually shallow, reading did the trick. Last night, I only remember waking up once—after six and a half hours. I read for a while, and went back to sleep. I didn’t think I had slept--until I noticed that almost two hours had passed. Then I remembered dreaming.

These strategies have helped. But learning that waking up during the night is normal—and manageable—has been equally important in putting my mind at ease.

I have also been reassured by Dr. Epstein's words: “If you maintain good health through a regular exercise regimen, eating a balanced diet, and make good sleep habits a priority, you’re likely to experience only minor sleep changes as you age.”  

Knowledge truly is power. It put me back to sleep.

You’ll find many more good tips on getting a good night’s sleep in Dr. Epstein’s book, including information and advice on medications for treating insomnia. If you have any trouble sleeping—even if you don’t—you should read A Good Night’s Sleep. (In case you’re wondering, the other three steps are: 4) Create the optimal sleep environment; 5) Watch out for sleep saboteurs; and 6) Seek help for persistent sleep problems.)

Take it from Dr. Epstein—and me. Sleep should not be taken for granted, especially at age 60 and beyond.

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