Last month, another health issue was recognized with a weeklong campaign highlighting the problem, its effects, and prevention strategies. I found it interesting—nearly ironic—that as I saw the poster glaring at me from across the room, I had just finished yawning! I had attended several conferences over the past few years that addressed this common predicament, and I found the data interesting. But it was only after reading the poster that I realized how inured many of us are to this condition: sleep deprivation.
So many of us suffer from inadequate sleep that we tend to minimize the effects. But as far back as the 1930s, researchers documented a link between the speed and accuracy of cognitive functioning and sleep patterns.1 Nathaniel Kleitman, the father of sleep research, found that even in well-rested individuals, performance decreased in the early morning and late at night.
Situations that require concentration and the ability to make critical decisions can be disastrous when people suffer from sleep deprivation. For example, sleep deprivation has been implicated in the Exxon Valdez and the Challenger incidents and the nuclear accidents at Three Mile Island and Chernobyl.2 Even everyday activities are more challenging when we are sleep deprived.
The Institute of Medicine (IOM) Committee on Sleep Medicine and Research concluded that awareness among the general public and health care professionals regarding sleep disorders and the impact of sleep deprivation is minimal compared to the magnitude of the problem.3 Inadequate sleep has been associated with long-term health consequences, including chronic medical conditions such as diabetes, hypertension, and heart disease. In addition, mood disorders have been associated with chronic sleeplessness. And sleep deprivation has been identified as a factor in medical errors.
The impact of sleep deprivation on medical errors was first documented by Friedman, Bigger, and Kornfeld in 1971.4 In that study, the researchers found that interns made twice as many errors reading ECGs after working for more than 24 hours than they did after a night of sleep. In a landmark study by the Harvard Work Hours, Health and Safety Group,5 researchers found that interns made 35.9% more serious medical errors during the traditional schedule (extended shifts and on-call duties) than during a modified schedule (fewer hours, no extended shifts). In the same study, Landrigan and his colleagues noted a 22% higher rate of serious errors in critical care units when interns worked extended shifts.
And it isn’t only those in the health care field for whom sleep deprivation has an adverse impact on their work. In a study by Williamson and Feyer6, 30 employees from the transport industry and nine from the army were studied. In one part of the study, the subjects were deprived of sleep for 28 hours; in the other, they consumed doses of alcohol to reach a blood alcohol level of about 0.1%. The researchers found that common levels of sleep deprivation diminished performance to a level similar to that of alcohol intoxication (a blood alcohol level of at least 0.05%).
Similarly, the National Highway Traffic Safety Administration presents the conservative estimate of 100,000 police-reported crashes each year that are the direct result of driver fatigue.7 In the National Sleep Foundation’s 2009 Sleep in America Poll™, 54% of adults—about 110 million licensed drivers—reported having driven while drowsy at least once in the past year. Nearly one-third of drivers polled (28%) said that they had nodded off or fallen asleep while driving a vehicle.8
Our memory and learning are also impaired by inadequate sleep. Our ability to concentrate and focus on information presented is considerably reduced when we are sleep deprived. We also have difficulty remembering things we have known in the past. This is scary, especially when you consider how busy our lives are and how many times we have “burned the candle” at both ends.
Our lives are consumed by work, family activities, and household chores. All of those activities have caused us to lose sleep and be a drowsy driver at some time, I am sure. I know that I have been guilty of that—and have had to pull over or into a rest stop for a bit. And I have had the occasion when my memory of driving someplace was vague.
The list of anticipatory guidance for our patients gets longer every year, but we should add maintaining healthy sleep habits to it. Recommendations from sleep specialists9 include:
• Maintain a regular sleep-wake schedule.
• Avoid caffeine, alcohol, nicotine, and other chemicals that interfere with sleep.
• Make your bedroom a comfortable sleep environment.
• Establish a calming pre-sleep routine.
• Go to sleep when you’re truly tired.
• Do not watch the clock at night.
• Use light to your advantage: Expose yourself to light during the day, and limit light exposure in the evening.
• Do not nap too close to your regular bedtime.
• Get enough food and fluids, but not too much or too soon before bedtime.
• Exercise regularly—but not too close to bedtime.
Years ago, I saw a quip with the question: How much sleep does the average adult need? The answer was: Five more minutes. But that is not enough. We need to get back to a pattern that provides us with sufficient rest to recover our minds and our bodies. We need to follow those steps the sleep experts recommend so that we can properly attend to the responsibilities of our day and make the right decisions.
1. Nathaniel Kleitman, PhD, 1895-1999 [obituary]. University of Chicago Medical Center press release (1999). www.uchospitals.edu/news/ 1999/19990816-kleitman.html. Accessed November 11, 2009.
2. Harvard Medical School Division of Sleep Medicine. Sleep, performance, and public safety. healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-performance-and-public-safety. Accessed November 11, 2009.
3. Institute of Medicine Committee on Sleep Medicine and Research. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem (2006). www.iom.edu/en/Reports/2006/Sleep-Disorders-and-Sleep-Deprivation-An-Unmet-Public-Health-Problem.aspx. Accessed November 11, 2009.
4. Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285(4):201-203.
5. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-1848.
6. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57(10): 649–655.
7. Knipling RR, Wang JS. Revised estimates of the US drowsy driver crash problem size based on general estimates system case reviews. Presented at: 39th Annual Proceedings of the Association for the Advancement of Automotive Medicine; October 16-18,1995; Chicago, IL.
8. National Sleep Foundation. 2009 Sleep in America Poll™: Summary of Findings. www.sleep foundation.org/sites/default/files/2009%20Sleep%20in%20America%20SOF%20EMBAR GOED.pdf. Accessed November 11, 2009.
9. Epstein L, Mardon S. The Harvard Medical School Guide to a Good Night’s Sleep. New York, NY: McGraw-Hill; 2007.