Sleep is full of unknowns, and science is striving to understand them amid rising public concern about the effects of sleep deprivation. But as Dr. Daniel Barone makes clear, there is plenty we can do now to improve our slumber.The veil of sleep hides a swarm of activity. While we slumber, the brain is tuning itself up to keep thoughts and memories flowing smoothly while also clearing out debris that could sow the seeds of disease. The brain tends to the rest of the body too, cueing a state of relaxation—shallow breathing, low blood pressure, slow heart rate—that helps restore us and prepare us for the day ahead.
Describing all this nighttime cleanup and repair work, Dr. Daniel Barone makes one thing clear: There’s a lot we still don’t know about slumber and the disorders that impede it.
But he makes other things clear too: Better sleep is attainable for those who seek it. And, in our sleep-deprived society, more people need to do that, he says, citing dangers ranging from disease to traffic accidents to everyday fogginess.
“I have a lot of patients come to me and say, ‘You know what, I’m just not as sharp as I used to be,’” he tells an audience at Webster Library on Manhattan’s Upper East Side during a presentation in July. “‘I’m not as quick as I used to be. I go into a room, I can’t remember why I’m there,’ that kind of stuff.
“There’s other reasons for that, possibly, but one of them is sleep,” says Barone, assistant professor of neurology at Weill Cornell Medicine and associate medical director of the Center for Sleep Medicine at New York-Presbyterian/Weill Cornell Medical Center.
Barone, a 2001 graduate of Fordham College at Rose Hill, serves as an increasingly public expert on sleep, appearing in media outlets and giving talks around New York. He’s finding receptive audiences and many opportunities to speak, given the growing concern about sleep deprivation, labeled a “public health epidemic” by the U.S. Centers for Disease Control and Prevention because of its links to depression, anxiety, hypertension, obesity, and cancer.
If sleep is essential, however, it’s also frustratingly hard to attain for many, one reason Barone recently authored Let’s Talk About Sleep: A Guide to Understanding and Improving Your Slumber (Rowman & Littlefield, 2018).
Written with Lawrence A. Armour, it tells the stories of patients who found their way to better slumber through considerable patience, persistence, and trial and error. Despite all the recent scientific and technological advances in the field of sleep, there are no quick fixes or standard solutions. As Barone describes it, the quest for better sleep involves not only science, medicine, and proven practices, but also a certain amount of faith.
Discovering Sleep Science
Barone grew up on Long Island, in Franklin Square, studied biology on a premed track at Fordham, and earned his medical degree from New York Medical College in Valhalla, New York. He first learned about sleep medicine when he was in residency at Saint Vincent’s Catholic Medical Center in New York City. A visiting lecturer spoke about it, and Barone was fascinated.
He went on to complete a one-year fellowship in sleep medicine at Stony Brook University and earned board certifications in neurology and sleep medicine from the American Board of Psychiatry and Neurology.
In a way, sleep medicine is still a “great frontier” because of all its unknowns, he says. Some aspects are well established: When light dims, nerve cells in the eye signal the brain’s pineal gland to release melatonin, which readies the body for sleep. While we slumber, long-term memories are solidified as the brain pares back some nerve connections and strengthens others, Barone says. And because it is a powerful antioxidant, melatonin also cleans up free radicals, metabolic byproducts that could damage cells and pave the way for heart disease or cancer.
Other functions of sleep have only recently come to light. In 2012, researchers at the University of Rochester Medical Center discovered the glymphatic system, a kind of “shadow plumbing system” in the brain, according to a university statement. It fires up only during slumber, flushing out toxins that build up during the day, including those linked to Alzheimer’s and Parkinson’s diseases. Some brain cells actually shrink to accommodate this outflow, Barone says.
But many aspects of slumber are still poorly understood, like the tipping point between our waking and sleeping states, as shown by the fact that “we never remember the exact moment at which sleep onset occurs,” Barone writes in the book.
Sleep disorders offer up plenty of unknowns as well. Barone’s research focus is REM behavior disorder, in which people act out their dreams during the rapid-eye-movement stage of sleep. Other scientists are studying restless legs syndrome, one condition that impedes the slumber of Barone’s patients. “We know so much about the brain, but there’s still a lot we don’t understand about restless legs syndrome,” he says.
A Concern for All Ages
Some sleep disruptors are better understood, like blue light from computer screens, which keeps nerve cells in the eye from triggering the release of melatonin. One of the most common disorders is sleep apnea, in which the tongue repeatedly falls back to block the airway, interrupting sleep and causing daytime drowsiness. It afflicts as many as one-quarter of middle-aged men and 9 percent of women, according to Barone, although its severity varies.
His patients have often been sleep deprived and exhausted for years. They may struggle to fall asleep, wake up too early, or wake up tired after a full night’s slumber. Some only learn about their disorders after spending a night in the Weill Cornell sleep clinic, hooked up to monitoring equipment.
Let’s Talk About Sleep includes a variety of stories from patients (identified only by first names) who volunteered to be interviewed for the book. They tend to be middle-aged or older, as sleep tends to degrade with age because of weight gain, hormonal changes, prostate issues, or other things, he says.
But young people are hardly immune to sleep troubles. As Barone describes in his book, one patient’s sleep disorder—narcolepsy—emerged in high school, causing her to fall asleep in class. And sleep needs to be a big priority for college students, no matter how overstuffed their schedules are, Barone says, noting that sleep loss is linked to anxiety and depression, and can also get in the way of one’s studies.
Barone has some experience with this. After studying all night for tests as an undergraduate at Fordham, he found that he didn’t remember much of anything unless he found time to sleep. In fact, a quick nap was enough. “I remember thinking, ‘That’s pretty amazing—just a little bit of sleep actually helps you to retain the information.’ Without it, it was almost impossible.”
Treating Sleep Loss
Treatments vary from patient to patient. Medication is just one, often short-term, option. Behavior changes, like avoiding electronic screens before bed, are also important. For insomnia, one of Barone’s preferred techniques is mindfulness meditation, which activates the relaxing parasympathetic nervous system, improving not only sleep but also one’s general mindset, he says.
Technology also plays a role. Sleep apnea patients, for instance, may use a continuous positive airway pressure, or CPAP, mask that feeds pressurized air into their airways overnight, allowing them to sleep uninterrupted. Their other options include a dental device that pulls the jaw forward, keeping the tongue away from the back of the throat, or positioning devices to ensure they sleep on their side. One new option is a device implanted in the chest that electrically stimulates the hypoglossal nerve to keep the tongue from collapsing backward.
Whatever the sleep issue, the patient’s attitude is key, Barone says. Another patient mentioned in Let’s Talk About Sleep, a 61-year-old married mother of two, was waking up at midnight or 1 a.m. and tossing and turning for the rest of the night. This problem had persisted for 15 or 20 years. Then she heard an expert speak about the ill effects of sleep loss. The presentation hit home; she realized that she was in fact noticing some of the effects, like rising blood pressure, so she changed her “tough it out” attitude and sought help.
In consultation with Barone, she devised a regimen including progressive muscle relaxation, regular bedtimes, and the use of an alarm clock. Over time, her sleep improved. “It has made an incredible difference in my life,” she says in the book.
One of the most important changes she made was psychological. She developed what she called “an overall appreciation for the importance of sleep.” This appreciation doesn’t always take hold easily in the U.S., where the ability to do without sleep is viewed “almost like a badge of honor,” Barone says. “I’ve been guilty of that myself.”
Slighting the Sandman
Adults generally need seven to nine hours of sleep per night on average, according to the National Sleep Foundation. But, as stated in the book, more than a third of Americans are regularly getting inadequate shuteye. And some 50 to 70 million Americans suffer from chronic sleep disorders and periodic sleep problems, according to the National Institutes of Health.
People can be blind to the impact of sleep loss. Barone noted that one 2003 study by researchers at Harvard and the University of Pennsylvania found that people limited to six hours of sleep or less for several nights were just as impaired in a simple attention test as those who had missed as much as two whole nights of sleep.
All the same, the participants thought their bodies and minds were adjusting to the sleep loss, and that they were “doing OK” on the attention test. “In reality, they were not doing OK,” Barone says. “They were making a lot of mistakes,” and “this is just a small scale. You can imagine what’s happening when sleep deprivation is much more chronic,” he adds, naming motorists’ impaired reaction times in particular.
Such concerns are one reason why the U.S. Centers for Disease Control and Prevention has described sleep deprivation as a public health epidemic, and why Barone has accepted so many invitations to speak publicly. He hopes that it will eventually be recognized that “lack of quality sleep for a long period of time is as bad for us as smoking,” he says.
Dreaming of Better Sleep
One of sleep’s greatest mysteries is dreaming, a particular interest of Barone’s. He and other researchers are in the midst of a privately funded three-year study of REM behavior disorder, caused by a failure of the sleep paralysis that usually keeps people from acting out their dreams. Someone dreaming about being in a fight, for instance, might thrash about in bed, Barone says. While this kind of thing is alarming, the real concern—and the focus of the study—is the link between this disorder and Parkinson’s disease, he says.
The possible benefits of dreams are the biggest question mark of all. “There must be a good reason” for them, given the amount of brainpower they require, Barone writes; the sleeping brain not only generates the content of dreams but also the slumbering mind’s experience of them, a level of activity that indicates that dreaming “is not some random thing,” he writes.
Theories abound: Dreaming may prepare us for the stresses and threats of waking life by providing a kind of dry run during sleep. They may provide a “theater of the mind” in which we work through problems, or allow us to test out emotional reactions to various situations. “There’s probably 10 different theories as to why we dream. Nobody knows for sure,” Barone says. “The brain is beyond complex,” with 100 billion neurons interacting in uncounted trillions of ways.
In Let’s Talk About Sleep, he conveys respect for sleep and the need to give it its due. Rather than serve as a medical text, the book is meant to stimulate interest in sleep, Barone writes; he urges readers to talk to a doctor about their particular sleep troubles and medical concerns. In his July presentation, he offered some tips for getting better sleep generally, like exercising and setting regular bedtimes. And he made it clear that being patient and putting one’s expectations on the shelf were also important. “None of these things are going to change your sleep overnight—pun intended,” he said.
His patients may work for weeks, months, or longer, trying different approaches and laying the groundwork for better sleep, which he describes as something to be encouraged, coaxed, cajoled. Or won over, perhaps.
“I always say, sleep is kind of like love,” Barone says. You can do all the right things and put yourself in a position to make it happen, he says, but ultimately it follows its own timetable. “I always tell patients, ‘Let me worry about your sleep. You just concentrate on doing the right things, and eventually sleep will happen.’”