For A Sleep-Sick Society: ‘The Promise of Sleep’

GUEST: Dr. William C. Dement
VTR: 11/3/99

I’m Richard Heffner, your host on The Open Mind. I’m also sleep-deprived like many others in our sleep sick society, so that I’m particularly pleased to have as my guest today, Dr. William C. Dement, a pioneer in sleep medicine, whose quite extraordinary Delacorte Press volume, The Promise of Sleep explores what he describes as “the vital connection between health, happiness and a good night’s sleep”.

Now, whatever my critics may think, I’m not a darned fool. Neither are most of my many skilled, well-educated, highly achieving, but also sleep deprived friends. Yet the basic information that Dr. Dement’s thoroughly readable, The Promise of Sleep conveys so well, has actually been developed by him and other sleep researchers over many, many years now. And we, or at least our physicians, surely must have a good idea by now how much sleep we absolutely have to have, but so often don’t. So that my first question to my guest today must be, just why do so few of us appreciate and do something about what for so many of us is indeed the lost promise of sleep.

Dr. Dement reading your book, I had to ask you that question … why?

DEMENT: Well, I’ll try to answer, but I’m sort of looking very closely to see just how sleep deprived you really are. [Laughter]

HEFFNER: What’s your diagnosis?

DEMENT: Sort of in-between I would say. But I think first of all this knowledge hasn’t penetrated the educational system so that you grow up not getting taught about sleep. There are certain ways that the body functions during the day that create mis-attributions. For example, you can be tired after lunch and then your biological clock alerts the brain and you feel like in some way you get a second wind so you don’t think that that tiredness is in any way permanent. And that mis-attribution is very difficult to deal with. And most people have no idea that lost sleep accumulates. And so they say, “I lost an hour last week … I lost two hours … why am I tired today?” Because they don’t remember that.

HEFFNER: Well you write about “sleep debt”. What do you mean?

DEMENT: Well, I mean that each person needs a certain amount of sleep each day. And if they don’t get it, the sleep they lose piles up as a debt. And the brain sort of keeps track of it like bank. And this is, I think, solid scientific fact now. Because you can say, take someone and have them sleep only four hours a night for a week, and there will be tremendous changes in the way they function and their mood. And now we know there are even some crucial health areas that change. Like … recently a colleague of mine showed changes in glucose tolerance, changes in hormone secretion with, with individuals who were on a schedule of four hours of sleep for six nights, which is, you know, relatively modest sleep deprivation.

HEFFNER: Relatively modest?

DEMENT: Yes, because … say, truck drivers and shift workers, transportation workers will do that for a month. And they get … and then people will fall asleep … you know, it’s just hard to believe, you know that a person could fall asleep at a certain critical moment unless this huge sleep debt … I liken it to a monster waiting to seize your brain …

HEFFNER: Well, you write feelingly, and importantly in the book about young people, in particular, as drivers … and old people, too, and the suddenness with which that attacks us. How does that happen?

DEMENT: Well, I think you’re driving along, the stimulation of moving around and doing other things is not there now, and as you’re quiet, the processes that are driven by a large debt begin to take control of the brain. Then you feel drowsy. There’s a … there’s a moment when it’s an effort. You suddenly realize “my eyes want to close, it’s an effort to keep them open” and at that moment, it’s Russian roulette. And, since people don’t know the strength of this sleep drive, they want to just keep going and they’ll fall asleep and it’s all over. There was a horrible accident in Texas just a couple of weeks ago where a student was driving a pick-up truck, fell asleep, drove up on the sidewalk and killed six students … just like that. Now if he had stopped driving at that moment, it wouldn’t have happened.

HEFFNER: What’s the … what’s the lesson then. For individuals, or for physicians because when you say “we don’t teach our children in our schools”, seemingly we’re not conveying this message adequately to our physicians.

DEMENT: Oh, absolutely, you’re absolutely right. I … we must teach this material. Now, how that’s going to be accomplished is not clear, but I’m certainly working on it. I think the message for everyone though is you must know … have some idea of the amount of sleep you need each day, on the average, not to build up this debt. And then you must have … I hate to say this “get in touch with your feelings”. But the feelings of being sleepy … people don’t seem to be sensitive to that. You know, the word “fatigue” and “I’m tired” and … they don’t connect it with “I’ve been losing sleep”. And then you also need to know when you feel unable to sleep. So that you now can manage your schedule, your life. You can go to bed at the right time. You know stay in bed the right number of hours, and that way be a safer, healthier, more alert, more creative person.

HEFFNER: You make the point that in your own life, at a point where you had to be up late at night, you took advantage of that. How so?

DEMENT: Ah, I’m not sure just what you mean, but I, I did stay up a lot because I’m a sleep researcher and that is … your occupational hazard. I was able to sleep the next day, but I didn’t understand sleep debt in the early days of my research. And I was in medical school, I would fall asleep in class. [Laughter] And some professors really didn’t like that. And I thought well, if I sit in the front row, I won’t fall asleep. But, I mean it was so powerful I would get pretty sleepy, but I wouldn’t fall asleep.

HEFFNER: My sleeping students sit in the back row.

DEMENT: Yeah … no … that’s … but if you snore or make noise or your, you know, book falls on the floor … a lot of small seminars in medical school, though, so it’s hard not to be noticed.

HEFFNER: You know, we said, we must each know our own tolerances … we must each know how much sleep we need. I thought the point was that there is a basic amount of sleep that human beings need. But you’re saying otherwise.

DEMENT: Well, there’s a small variation. I think everyone could start by assuming it’s eight hours. You know, and then, and then if you are actually sleeping eight hours every night and feeling more alert each day, if you kept track of that, then that would be a little more than you needed. Many college students sleeping eight hours a day get sleep deprived. [Laughter] I had … I was talking to a group of students … and as close to me as you are now in this small seminar … and one of the students with me sort of talking right in her face, fell asleep. And I said, “so, you’re very sleep deprived, what have you been doing?”. She said, “Oh, I’ve been sleeping eight hours”. Wasn’t enough. She probably needed nine and she’d been losing an hour a night for quite a while, and it finally was just overpowering.

HEFFNER: I remember having dinner with my landlord and falling asleep … woke up in time for his sentence to be continued and for me to make a good guess as to what he had filled in with before.

DEMENT: Oh.

HEFFNER: But you say we’re so unaware of our sleep, the level of our sleep deprivation … you’ve been, in your researches … been able to identify … I mean, jokingly you said to me before, because I had to make the gag that I’m sleep deprived … and you said, “not, not that much”. What can you tell?

DEMENT: Well, it’s not easy just looking at someone. And it depends a lot on what they’re doing. But … I think I can identify a person who’s probably not sleep-deprived, has a certain energy, a sparkle and someone who’s obviously very sleepy and having trouble controlling it. In between is, is difficult. But we have tests. And we can, we can measure that.

HEFFNER: What kinds of tests?

DEMENT: Well, we measure the speed of falling asleep in a laboratory situation. So that if someone consistently falls asleep during the day and in several tests in less than five minutes, we know they’re seriously sleep deprived. Or have a sleep disorder. If someone would lie down, you right now, in our laboratory on a comfortable bed and you did not fall asleep in twenty minutes and if probably that happened for three tests, I would say you’re optimally alert. And it’s astounding that not falling asleep in the day time in that situation … with wires on your head, is, is very, very rare. Not falling asleep is very rare. Now that is partial documentation of the sleep deprived society.

HEFFNER: And, and for the rest of us? As we are younger or older … that eight hours, does that number still hold?

DEMENT: I think so. I think it’s so kind of the peak of the bell shaped curve that that’s a good place to start. And if you’re sleeping eight hours a night, and you feel wide awake and energetic all day long, you know, you’re on the right path.

HEFFNER: Who is that person, by the way?

DEMENT: There are not many of them. I’ve been working with students and when they lowered their sleep debt and then all of a sudden a miracle happens. They are not sleepy in their one o’clock class … why it’s interesting … they’re not sleepy. Then, they go a little too far, you need a little bit of sleep debt … they’ll suddenly have insomnia. There’ll come a night when they can’t fall asleep. And since it’s the first time in years for many, it’s often a little bit startling. By I say, “you just need enough sleep debt, you know, the power of falling asleep at night, and keeping ;you asleep through the night.

HEFFNER: Of course, I wonder and have to ask you … and it’s not a gag. What about the bankruptcy laws, seriously, to sleep debt? Can you wipe it out without just going …

DEMENT: No. No, you can’t wipe it out. There’s absolutely no way to do that. We, we think that it’s a process in the brain, its molecular, genetic and you know some day we’ll understand it well enough maybe to manipulate it. But it’s there for a purpose we have to assume, and that human beings need this sleep. They may need it to maintain their immune system; they may need it to maintain brain functions. We don’t know very much about that. But, but the protection … there’s a drive to sleep … protects it so that, you know, you have to sleep. You can’t not sleep at some point. It’s a stronger drive than hunger and thirst. Maybe about the same as oxygen where you have to breathe. And, so you have to get your sleep.

HEFFNER: But we all keep hearing so much about manipulation. You say, “perhaps molecular” manipulation. But we all keep hearing about shortcuts by which we fool Mother Nature.

DEMENT: Well, we haven’t … you can fool Mother Nature on this one. We have had little clues that maybe there are certain ways, because there’s a mechanism keeping tract of your wakefulness and your sleep … the amount. It may be a derivation of the same mechanism that biological clock has, it keeps track of the 24 hour day, you know, with a slight variation so that it’s keeping track of the time you’re awake and the time you’re asleep. But we can’t directly manipulate the biological clock yet. And we know a great deal about the genetic molecular mechanisms.

HEFFNER: Yes, but when you write about some one traveling overseas for instance … traveling great distances, going through time zones … you do, in a sense talk about ways to handle our circadian rhythms.

DEMENT: Oh, the clock can be re-set … this 24 hour clock. And that’s what I probably am mostly talking about. Because the clock alerts the brain and it stimulates the brain very intensely at certain periods of the day and you want those periods to stay in the day when you’re in another time zone, so you either make them happen earlier or make them happen latter. And the signal for that, that is the most consistent, is light. And, if in fact your clock has sort of gotten away from the time in which you’re living, then the light signals keep re-adjusting it. So that you’re always … human beings should be awake in the day time and asleep at night.

HEFFNER: Where is that written?

DEMENT: Well … good question … I think what we do know Is that human being and primates are so depend on vision, I’m talking now about “primitive” conditions. And that to be out at night is … you’re helpless. Virtually helpless. And therefore not only does this ensure that you get the amount of sleep you need. But it also assures that you are asleep at night and safe and awake in the day time when your visions can fit your pattern of the world.

HEFFNER: Many years ago, a long time a go, when I was still, nevertheless, not a young man; I began commuting between New York and California. Not daily, obviously, but very often. And at that time there was talk about chemical means of re-setting circadian rhythms … the clock … what progress has been made there?

DEMENT: Ah. The hormone melatonin is, is a clock re-setter, and it … it is secreted by the pineal gland at night. And it … if you would have bright light come on to a person at night, then the suppression would be … I mean it really would be suppressed. So that it seems to be there to tell the biological clock that it’s night. And so if you take melatonin in the day time, the clock thinks that “uh, oh, something’s wrong I’ve got to move toward that period of time”. So you can take melatonin in the morning or late in the day and shift your clock. It is … it is probably not as effective as light, as bright light. But it, it works.

HEFFNER: What about the damage, if any, that we do to ourselves by monkeying with this nature given phenomenon?

DEMENT: Well, we aren’t clear what the damage … I think we feel there is damage but, but sleep is so well protected, you see. Before you get to some danger level, I think you’re so sleepy, you sleep. Now, in terms of …

HEFFNER: Whether driving or not.

DEMENT: Well, that’s … yeah … no driving is … I’m thinking that’s a product of civilization in a way. I mean the worse damage, of course, is, is the inappropriate sleep episode. I mean the tragedies and the catastrophes … I think the other thing that I should mention is all the many things that are wrong that you didn’t do deliberately. And these are the sleep disorders that afflict millions and millions of people. And here, again, the symptoms are pretty much the same. Sleep deprivation … you’re tired. Several of the very serious sleep disorders … the main symptom is being tired. And again, tiredness doesn’t sound any bells for physicians or people.

HEFFNER: That’s so strange to me. I know that’s the point that you make, and that’s why I began the program by saying I would assume that medical schools are teaching this. And I would assume that our doctors know this.

DEMENT: It’s hard to believe. All I can say is that I have more direct proof probably than any other human being on earth … because my group has been going to primary care clinics, on-site, in the trenches, talking to patients, talking to doctors, going through all the records and sleep disorders are just not there. There maybe little islands of knowledge in this vast sea of ignorance, but you know, I haven’t found any yet.

HEFFNER: And in the medical school curricula?

DEMENT: A little progress is being made today. It’s still not really there in a sense that in the family practices that we have studied, more than half the patients have a sleep disorder that is diagnosable, it has a name and criteria, and so forth. And none of them are recognized. And this recently … I’m doing this at Stanford University Medical Center. Now thank goodness the primary care faculty are welcoming me into their “home”, but they aren’t there either. I … I think I’ve given up trying to explain why this hasn’t happened and I’m just going to devote all my energies to making it happen.

HEFFNER: Was there a time, ever, when we were more aware in the history of mankind of the need for sleep? And of the relationship between sufficient sleep and a healthy life, a healthy existence?

DEMENT: I guess I would doubt it. I would only assume that, you know, a million years ago, if man was sleepy, he slept and thought nothing of it. And when he couldn’t sleep, he didn’t sleep.

HEFFNER: I just wondered whether our way of life, as we go into the …

DEMENT: Ahhh …

HEFFNER: … twenty-first century …

DEMENT: Oh, yes.

HEFFNER: … has changed things radically.

DEMENT: Oh, absolutely, and it’s the most alarming, sort of new things … usually pre-pubertal children are very alert all day long. They can get enough sleep at night. And in a most recent national poll of the National Sleep Foundation, which was presented in … last March … children are starting to fall asleep in class. Eight year olds, seven year olds. That’s to me, shocking, because generally once children get to the point where they … you know, they accept going to bed … and so on, they get plenty of sleep and they’re just bundles of energy all day long. It’s delightful. But, but, it’s changing. And it has to be cable television, the Internet, parents not really knowing … but a child shouldn’t fall asleep in class. That to me is a tragedy.

HEFFNER: Listen, I belong to an age in which my brother and I at six o’clock would eat our dinner and at 6:30 listen to Uncle Don and at 7:00 o’clock be asleep.

DEMENT: Yeah.

HEFFNER: And that wasn’t when we were just two and three, but for quite some time.

DEMENT: Yeah.

HEFFNER: That’s what I meant about the change. And parental attitudes toward sleep.

DEMENT: Well, there is this phenomenon that we call clock dependent alerting and that opposes the sleep-debt during the day. It has two major periods … one in the morning and then a stronger one in the evening for young people at least. And so you may be very sleepy after lunch, and as I said earlier, this strong “alerting” effect comes on and I think that creates the notion, in the minds of most people that the time of most energy is in the evening, and it may continue until pass bedtime. And so, if someone isn’t’ sleepy, it’s hard for parents to say, “well, you have to go to bed”. And the kid says, “I can’t, I’m wide awake”. This is mainly for the teenagers. But parents have no real knowledge about this. So that the … there’s … I think difficulty in being authoritative … and say, “No, no, I know”. Because if your child, your teenage child is wide awake, you know, and you can tell they’re wide awake … it’s just very difficult. But the other side of the coin is then getting up early to go to school. And it has become travesty … whereas you may go to sleep at one and have to get up at five … as a teenager. I mean this is why the young man fell asleep while driving the pick-up. It just becomes so huge that it’s irresistible, even when you know that falling asleep is, you know, deadly.

HEFFNER: And you mention disease. What are the diseases that bring about …

DEMENT: Well, the one that’s the most serious and certainly one of the most common is called “obstructive sleep apnea”. And what that means is that you can’t breathe when you’re asleep and as you attempt to inhale as a patient, or the victim, the negative pressure closes the throat so it’s … ugggh … and air doesn’t go in. And usually there’s some loud snoring. You have to wake up to breathe … tone will not come back to these muscles that have collapsed unless you wake up. So you wake up, you breathe, you fall asleep again, air doesn’t pass, you wake up again and over years this gets worse. The huge number of wakings make you very sleepy in the day time, so you’re tired and fatigued … and the doctor, “oh, it’s fatigue”. And finally it has an impact and negative impact on the heart and blood vessels, so that there’s a very, very high prevalence of high blood pressure, heart attack and stroke in this illness as it progresses.

HEFFNER: Is this a function of aging, by and large?

DEMENT: Well, it tends to be more prevalent the older you get, but you see it in children, you see it in teenagers, and younger people. Being overweight makes it worse. But it, it … small airway, small jaw is a risk factor. But in the practices … the primary care practices we were studying, we found about a third of the males had this problem, and maybe 20% of the females. Again, unrecognized. And then sometimes you see, honest, miracles you would hardly believe when these people are identified and treated.

HEFFNER: What is the treatment?

DEMENT: The treatment is to keep the airway open when you’re asleep. And the most widely used treatment for doing that is to create air pressure through a mask over the nose and that splints the airway and holds it open. So you breath in and out normally. Now, probably 10%, 20% of patients who need this treatment desperately, still can’t tolerate it. Then there are surgical treatments that enlarge the airway. If you have big tonsils, you know, take them out. There a new radio frequency treatment that is bloodless and nearly painless that can shrink tissues. But you need, at that point, an expert, a sleep expert or a surgeon who’s had a lot of experience treating this particular problem.

HEFFNER: But generally, and I didn’t want to take us off this notion with the question of disease … generally you think about this as a public health problem, right?

DEMENT: I would say so, Yes. I was Chairman of the Congressional Commission, we had a chance to gauge the national problem. And I said I think it’s the biggest health problem in America. [Laughter] I said, “Well, at least it’s the biggest invisible problem”. And I believe that with all my heart. The mechanisms to gauge the cost are sort of not there. You know, that most accidents that are do to falling asleep aren’t labeled that way. Many people have heart attacks, probably have this obstructive sleep apnea, but no body knows it. And, I think until we have better data, we won’t know for sure. But I think we know enough now for me to make that statement.

HEFFNER: Well, is that a “Catch-22”. You won’t get the better data, unless there is more attention. That “attention must be paid”.

DEMENT: No, it has definitely been a “Catch-22”. But I’m hopeful … I hate to say the “new millennium” … but I’m hopeful … we’re reaching a kind of critical mass … I was attending a meeting recently of the Federal Bar Association. And the issue was transportation … fatigue and transportation, some of the liability issues when people fall asleep and have accidents. And I was amazed that some of the industries … Union Pacific Railroad, for example, is now addressing the problem. Actually screening employees for obstructive sleep apnea and trying to deal with fatigue as sleep deprivation. So there’s one place. There are some medical schools now. And here I am talking to you.

HEFFNER: Right. Well, here is this very wonderful book that I still think the title is great, The Promise of Sleep. A pioneer in sleep medicine explores that connection between health, happiness and a good night’s sleep. That’s not what we generally think of. But I do want to thank you so much for joining me today, Dr. Dement.

DEMENT: I thank you also, from the bottom of my heart, I really mean it.

HEFFNER: Okay. And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.