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PART 2

Why Should You Sleep?

CHAPTER 6

Your Mother and Shakespeare Knew

The Benefits of Sleep for the Brain

AMAZING BREAKTHROUGH!

Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory and makes you more creative. It makes you look more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu. It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed, and less anxious. Are you interested?

While it may sound hyperbolic, nothing about this fictitious advertisement would be inaccurate. If it were for a new drug, many people would be disbelieving. Those who were convinced would pay large sums of money for even the smallest dose. Should clinical trials back up the claims, share prices of the pharmaceutical company that invented the drug would skyrocket.

Of course, the ad is not describing some miracle new tincture or a cure-all wonder drug, but rather the proven benefits of a full night of sleep. The evidence supporting these claims has been documented in more than 17,000 well-scrutinized scientific reports to date. As for the prescription cost, well, there isn’t one. It’s free. Yet all too often, we shun the nightly invitation to receive our full dose of this all-natural remedy—with terrible consequences.

Failed by the lack of public education, most of us do not realize how remarkable a panacea sleep truly is. The following three chapters are designed to help rectify our ignorance born of this largely absent public health message. We will come to learn that sleep is the universal health care provider: whatever the physical or mental ailment, sleep has a prescription it can dispense. Upon completion of these chapters, I hope even the most ardent of short-sleepers will be swayed, having a reformed deference.

Earlier, I described the component stages of sleep. Here, I reveal the attendant virtues of each. Ironically, most all of the “new,” twenty-first-century discoveries regarding sleep were delightfully summarized in 1611 in Macbeth, act two, scene two, where Shakespeare prophetically states that sleep is “the chief nourisher in life’s feast.”I Perhaps, with less highfalutin language, your mother offered similar advice, extolling the benefits of sleep in healing emotional wounds, helping you learn and remember, gifting you with solutions to challenging problems, and preventing sickness and infection. Science, it seems, has simply been evidential, providing proof of everything your mother, and apparently Shakespeare, knew about the wonders of sleep.

SLEEP FOR THE BRAIN

Sleep is not the absence of wakefulness. It is far more than that. Described earlier, our nighttime sleep is an exquisitely complex, metabolically active, and deliberately ordered series of unique stages.

Numerous functions of the brain are restored by, and depend upon, sleep. No one type of sleep accomplishes all. Each stage of sleep—light NREM sleep, deep NREM sleep, and REM sleep—offer different brain benefits at different times of night. Thus, no one type of sleep is more essential than another. Losing out on any one of these types of sleep will cause brain impairment.

Of the many advantages conferred by sleep on the brain, that of memory is especially impressive, and particularly well understood. Sleep has proven itself time and again as a memory aid: both before learning, to prepare your brain for initially making new memories, and after learning, to cement those memories and prevent forgetting.

SLEEP-THE-NIGHT-BEFORE LEARNING

Sleep before learning refreshes our ability to initially make new memories. It does so each and every night. While we are awake, the brain is constantly acquiring and absorbing novel information (intentionally or otherwise). Passing memory opportunities are captured by specific parts of the brain. For fact-based information—or what most of us think of as textbook-type learning, such as memorizing someone’s name, a new phone number, or where you parked your car—a region of the brain called the hippocampus helps apprehend these passing experiences and binds their details together. A long, finger-shaped structure tucked deep on either side of your brain, the hippocampus offers a short-term reservoir, or temporary information store, for accumulating new memories. Unfortunately, the hippocampus has a limited storage capacity, almost like a camera roll or, to use a more modern-day analogy, a USB memory stick. Exceed its capacity and you run the risk of not being able to add more information or, equally bad, overwriting one memory with another: a mishap called interference forgetting.

How, then, does the brain deal with this memory capacity challenge? Some years ago, my research team wondered if sleep helped solve this storage problem by way of a file-transfer mechanism. We examined whether sleep shifted recently acquired memories to a more permanent, long-term storage location in the brain, thereby freeing up our short-term memory stores so that we awake with a refreshed ability for new learning.

We began testing this theory using daytime naps. We recruited a group of healthy young adults and randomly divided them into a nap group and a no-nap group. At noon, all the participants underwent a rigorous session of learning (one hundred face-name pairs) intended to tax the hippocampus, their short-term memory storage site. As expected, both groups performed at comparable levels. Soon after, the nap group took a ninety-minute siesta in the sleep laboratory with electrodes placed on their heads to measure sleep. The no-nap group stayed awake in the laboratory and performed menial activities, such as browsing the Internet or playing board games. Later that day, at six p.m., all participants performed another round of intensive learning where they tried to cram yet another set of new facts into their short-term storage reservoirs (another one hundred face-name pairs). Our question was simple: Does the learning capacity of the human brain decline with continued time awake across the day and, if so, can sleep reverse this saturation effect and thus restore learning ability?

Those who were awake throughout the day became progressively worse at learning, even though their ability to concentrate remained stable (determined by separate attention and response time tests). In contrast, those who napped did markedly better, and actually improved in their capacity to memorize facts. The difference between the two groups at six p.m. was not small: a 20 percent learning advantage for those who slept.

Having observed that sleep restores the brain’s capacity for learning, making room for new memories, we went in search of exactly what it was about sleep that transacted the restoration benefit. Analyzing the electrical brainwaves of those in the nap group brought our answer. The memory refreshment was related to lighter, stage 2 NREM sleep, and specifically the short, powerful bursts of electrical activity called sleep spindles, noted in chapter 3. The more sleep spindles an individual obtained during the nap, the greater the restoration of their learning when they woke up. Importantly, sleep spindles did not predict someone’s innate learning aptitude. That would be a less interesting result, as it would imply that inherent learning ability and spindles simply go hand in hand. Instead, it was specifically the change in learning from before relative to after sleep, which is to say the replenishment of learning ability, that spindles predicted.

Perhaps more remarkable, as we analyzed the sleep-spindle bursts of activity, we observed a strikingly reliable loop of electrical current pulsing throughout the brain that repeated every 100 to 200 milliseconds. The pulses kept weaving a path back and forth between the hippocampus, with its short-term, limited storage space, and the far larger, long-term storage site of the cortex (analogous to a large-memory hard drive).II In that moment, we had just become privy to an electrical transaction occurring in the quiet secrecy of sleep: one that was shifting fact-based memories from the temporary storage depot (the hippocampus) to a long-term secure vault (the cortex). In doing so, sleep had delightfully cleared out the hippocampus, replenishing this short-term information repository with plentiful free space. Participants awoke with a refreshed capacity to absorb new information within the hippocampus, having relocated yesterday’s imprinted experiences to a more permanent safe hold. The learning of new facts could begin again, anew, the following day.

We and other research groups have since repeated this study across a full night of sleep and replicated the same finding: the more sleep spindles an individual has at night, the greater the restoration of overnight learning ability come the next morning.

Our recent work on this topic has returned to the question of aging. We have found that seniors (aged sixty to eighty years old) are unable to generate sleep spindles to the same degree as young, healthy adults, suffering a 40 percent deficit. This led to a prediction: the fewer sleep spindles an older adult has on a particular night, the harder it should be for them to cram new facts into their hippocampus the next day, since they have not received as much overnight refreshment of short-term memory capacity. We conducted the study, and that is precisely what we found: the fewer the number of spindles an elderly brain produced on a particular night, the lower the learning capacity of that older individual the next day, making it more difficult for them to memorize the list of facts we presented. This sleep and learning link is yet one more reason for medicine to take more seriously the sleep complaints of the elderly, further compelling researchers such as myself to find new, non-pharmacological methods for improving sleep in aging populations worldwide.

Of broader societal relevance, the concentration of NREM-sleep spindles is especially rich in the late-morning hours, sandwiched between long periods of REM sleep. Sleep six hours or less and you are shortchanging the brain of a learning restoration benefit that is normally performed by sleep spindles. I will return to the broader educational ramifications of these findings in a later chapter, addressing the question of whether early school start times, which throttle precisely this spindle-rich phase of sleep, are optimal for the teaching of young minds.

SLEEP-THE-NIGHT-AFTER LEARNING

The second benefit of sleep for memory comes after learning, one that effectively clicks the “save” button on those newly created files. In doing so, sleep protects newly acquired information, affording immunity against forgetting: an operation called consolidation. That sleep sets in motion the process of memory consolidation was recognized long ago, and may be one of the oldest proposed functions of sleep. The first such claim in the written human record appears to be by the prophetic Roman rhetorician Quintilian (AD 35–100), who stated:

It is a curious fact, of which the reason is not obvious, that the interval of a single night will greatly increase the strength of the memory. . . . Whatever the cause, things which could not be recalled on the spot are easily coordinated the next day, and time itself, which is generally accounted one of the causes of forgetfulness, actually serves to strengthen the memory.III

It was not until 1924 when two German researchers, John Jenkins and Karl Dallenbach, pitted sleep and wake against each other to see which one won out for a memory-savings benefit—a memory researchers’ version of the classic Coke vs. Pepsi challenge. Their study participants first learned a list of verbal facts. Thereafter, the researchers tracked how quickly the participants forgot those memories over an eight-hour time interval, either spent awake or across a night of sleep. Time spent asleep helped cement the newly learned chunks of information, preventing them from fading away. In contrast, an equivalent time spent awake was deeply hazardous to recently acquired memories, resulting in an accelerated trajectory of forgetting.IV

The experimental results of Jenkins and Dallenbach have now been replicated time and again, with a memory retention benefit of between 20 and 40 percent being offered by sleep, compared to the same amount of time awake. This is not a trivial concept when you consider the potential advantages in the context of studying for an exam, for instance, or evolutionarily, in remembering survival-relevant information such as the sources of food and water and locations of mates and predators.

It was not until the 1950s, with the discovery of NREM and REM sleep, that we began to understand more about how, rather than simply if, sleep helps to solidify new memories. Initial efforts focused on deciphering what stage(s) of sleep made immemorial that which we had imprinted onto the brain during the day, be it facts in the classroom, medical knowledge in a residency training program, or a business plan from a seminar.

You will recall from chapter 3 that we obtain most of our deep NREM sleep early in the night, and much of our REM sleep (and lighter NREM sleep) late in the night. After having learned lists of facts, researchers allowed participants the opportunity to sleep only for the first half of the night or only for the second half of the night. In this way, both experimental groups obtained the same total amount of sleep (albeit short), yet the former group’s sleep was rich in deep NREM, and the latter was dominated instead by REM. The stage was set for a battle royal between the two types of sleep. The question: Which sleep period would confer a greater memory savings benefit—that filled with deep NREM, or that packed with abundant REM sleep? For fact-based, textbook-like memory, the result was clear. It was early-night sleep, rich in deep NREM, that won out in terms of providing superior memory retention savings relative to late-night, REM-rich sleep.

Investigations in the early 2000s arrived at a similar conclusion using a slightly different approach. Having learned a list of facts before bed, participants were allowed to sleep a full eight hours, recorded with electrodes placed on the head. The next morning, participants performed a memory test. When researchers correlated the intervening sleep stages with the number of facts retained the following morning, deep NREM sleep carried the vote: the more deep NREM sleep, the more information an individual remembered the next day. Indeed, if you were a participant in such a study, and the only information I had was the amount of deep NREM sleep you had obtained that night, I could predict with high accuracy how much you would remember in the upcoming memory test upon awakening, even before you took it. That’s how deterministic the link between sleep and memory consolidation can be.

Using MRI scans, we have since looked deep into the brains of participants to see where those memories are being retrieved from before sleep relative to after sleep. It turns out that those information packets were being recalled from very different geographical locations within the brain at the two different times. Before having slept, participants were fetching memories from the short-term storage site of the hippocampus—that temporary warehouse, which is a vulnerable place to live for any long duration of time if you are a new memory. But things looked very different by the next morning. The memories had moved. After the full night of sleep, participants were now retrieving that same information from the neocortex, which sits at the top of the brain—a region that serves as the long-term storage site for fact-based memories, where they can now live safely, perhaps in perpetuity.

We had observed a real-estate transaction that takes place each night when we sleep. Fitting the notion of a long-wave radio signal that carries information across large geographical distances, the slow brainwaves of deep NREM had served as a courier service, transporting memory packets from a temporary storage hold (hippocampus) to a more secure, permanent home (the cortex). In doing so, sleep had helped future-proof those memories.

Put these findings together with those I described earlier regarding initial memorization, and you realize that the anatomical dialogue established during NREM sleep (using sleep spindles and slow waves) between the hippocampus and cortex is elegantly synergistic. By transferring memories of yesterday from the short-term repository of the hippocampus to the long-term home within the cortex, you awake with both yesterday’s experiences safely filed away and having regained your short-term storage capacity for new learning throughout that following day. The cycle repeats each day and night, clearing out the cache of short-term memory for the new imprinting of facts, while accumulating an ever-updated catalog of past memories. Sleep is constantly modifying the information architecture of the brain at night. Even daytime naps as short as twenty minutes can offer a memory consolidation advantage, so long as they contain enough NREM sleep.V

Study infants, young kids, or adolescents and you see the very same overnight memory benefit of NREM sleep, sometimes even more powerfully so. For those in midlife, forty- to sixty-year-olds, deep NREM sleep continues to help the brain retain new information in this way, with the decline in deep NREM sleep and the deterioration in the ability to learn and retain memories in old age having already been discussed.

At every stage of human life, the relationship between NREM sleep and memory solidification is therefore observed. It’s not just humans, either. Studies in chimpanzees, bonobos, and orangutans have demonstrated that all three groups are better able to remember where food items have been placed in their environments by experimenters after they sleep.VI Descend down the phylogenetic chain to cats, rats, and even insects, and the memory-maintaining benefit of NREM sleep remains on powerful display.

Though I still marvel at Quintilian’s foresight and straightforward description of what scientists would, thousands of years later, prove true about sleep’s benefit to memory, I prefer the words of two equally accomplished philosophers of their time, Paul Simon and Art Garfunkel. In February of 1964, they penned a now famous set of lyrics that encapsulate the same nocturnal event in the song “The Sound of Silence.” Perhaps you know the song and lyrics. Simon and Garfunkel describe greeting their old friend, darkness (sleep). They speak of relaying the day’s waking events to the sleeping brain at night in the form of a vision, softly creeping—a gentle information upload, if you will. Insightfully, they illustrate how those fragile seeds of waking experience, sown during the day, have now been embedded (“planted”) in the brain during sleep. As a result of that process, those experiences now remain upon awakening the next morning. Sleep’s future-proofing of memories, all packaged for us in perfect song lyrics.

A slight, but important, modification to Simon and Garfunkel’s lyrics is warranted, based on very recent evidence. Not only does sleep maintain those memories you have successfully learned before bed (“the vision that was planted in my brain / Still remains”), but it will even salvage those that appeared to have been lost soon after learning. In other words, following a night of sleep you regain access to memories that you could not retrieve before sleep. Like a computer hard drive where some files have become corrupted and inaccessible, sleep offers a recovery service at night. Having repaired those memory items, rescuing them from the clutches of forgetting, you awake the next morning able to locate and retrieve those once unavailable memory files with ease and precision. The “ah yes, now I remember” sensation that you may have experienced after a good night of sleep.

Having narrowed in on the type of sleep—NREM sleep—responsible for making fact-based memories permanent, and further recovering those that were in jeopardy of being lost, we have begun exploring ways to experimentally boost the memory benefits of sleep. Success has come in two forms: sleep stimulation, and targeted memory reactivation. The clinical ramifications of both will become clear when considered in the context of psychiatric illness and neurological disorders, including dementia.

Since sleep is expressed in patterns of electrical brainwave activity, sleep stimulation approaches began by trading in the same currency: electricity. In 2006, a research team in Germany recruited a group of healthy young adults for a pioneering study in which they applied electrode pads onto the head, front and back. Rather than recording the electrical brainwaves being emitted from the brain during sleep, the scientists did the opposite: inserted small amounts of electrical voltage. They patiently waited until each participant had entered into the deepest stages of NREM sleep and, at that point, switched on the brain stimulator, pulsing in rhythmic time with the slow waves. The electrical pulsations were so small that participants did not feel them, nor did they wake up.VII But they had a measurable impact on sleep.

Both the size of the slow brainwaves and the number of sleep spindles riding on top of the deep brainwaves were increased by the stimulation, relative to a control group of subjects who did not receive stimulation during sleep. Before being put to bed, all the participants had learned a list of new facts. They were tested the next morning after sleep. By boosting the electrical quality of deep-sleep brainwave activity, the researchers almost doubled the number of facts that individuals were able to recall the following day, relative to those participants who received no stimulation. Applying stimulation during REM sleep, or during wakefulness across the day, did not offer similar memory advantages. Only stimulation during NREM sleep, in synchronous time with the brain’s own slow mantra rhythm, leveraged a memory improvement.

Other methods for amplifying the brainwaves of sleep are fast being developed. One technology involves quiet auditory tones being played over speakers next to the sleeper. Like a metronome in rhythmic stride with the individual slow waves, the tick-tock tones are precisely synchronized with the individual’s sleeping brainwaves to help entrain their rhythm and produce even deeper sleep. Relative to a control group that slept but had no synchronous auditory chimes at night, the auditory stimulation increased the power of the slow brainwaves and returned an impressive 40 percent memory enhancement the next morning.

Before you drop this book and start installing speakers above your bed, or go shopping for an electrical brain stimulator, let me dissuade you. For both methods, the wisdom of “do not try this at home” applies. Some individuals have made their own brain-stimulating devices, or bought such devices online, which are not covered by safety regulations. Skin burns and temporary losses of vision have been reported by mistakes in construction or voltage application. Playing loud tick-tock acoustic tones on repeat next to your bed sounds like a safer option, but you may be doing more harm than good. When researchers in the above studies timed the auditory tones to strike just off the natural peak of each slow brainwave, rather than in perfect time with each brainwave, they disrupted, rather than enhanced, sleep quality.

If brain stimulation or auditory tones were not bizarre enough, a Swiss research team recently suspended a bedframe on ropes from the ceiling of a sleep laboratory (stick with me here). Affixed to one side of the suspended bed was a rotating pulley. It allowed the researchers to sway the bed from side to side at controlled speeds. Volunteers then took a nap in the bed as the researchers recorded their sleeping brainwaves. In half of the participants, the researchers gently rocked the bed once they entered NREM sleep. In the other half of the subjects, the bed remained static, offering a control condition. Slow rocking increased the depth of deep sleep, boosted the quality of slow brainwaves, and more than doubled the number of sleep spindles. It is not yet known whether these sway-induced sleep changes enhance memory, since the researchers did not perform any such tests with their participants. Nevertheless, the findings offer a scientific explanation for the ancient practice of rocking a child back and forth in one’s arms, or in a crib, inducing a deep sleep.

Sleep stimulation methods are promising, but they do have a potential limitation: the memory benefit they provide is indiscriminate. That is, all things learned before sleep are generally enhanced the next day. Similar to a prix fixe menu at a restaurant in which there are no options, you are going to get served all dishes listed, like it or not. Most people do not enjoy this type of food service, which is why most restaurants offer you a large menu from which you can pick and choose, selecting only those items you would like to receive.

What if a similar opportunity was possible with sleep and memory? Before going to bed, you would review the learning experiences of the day, selecting only those memories from the menu list that you would like improved. You place your order, then go to sleep, knowing that your order will be served to you overnight. When you wake up in the morning, your brain will have been nourished only by the specific items you ordered from the autobiographical carte du jour. You have, as a consequence, selectively enhanced only those individual memories that you want to keep. It all sounds like the stuff of science fiction, but it is now science fact: the method is called targeted memory reactivation. And as is so often the case, the true story turns out to be far more fascinating than the fictional one.

Before going to sleep, we show participants individual pictures of objects at different spatial locations on a computer screen, such as a cat in the lower right side, or a bell in the upper center, or a kettle near the top right of the screen. As a participant, you have to remember not only the individual items you have been shown, but also their spatial location on the screen. You will be shown a hundred of these items. After sleep, picture objects will again appear on the screen, now in the center, some of which you have seen before, some you have not. You have to decide if you remember the picture object or not, and if you do, you must move that picture object to the spatial location on the screen where it originally appeared, using a mouse. In this way, we can assess whether you remember the object, and also how accurately you can remember its location.

But here is the intriguing twist. As you were originally learning the images before sleep, each time an object was presented on the screen, a corresponding sound was played. For example, you would hear “meow” when the cat picture was shown, or “ding-a-ling” when the bell was shown. All picture objects are paired, or “auditory-tagged,” with a semantically matching sound. When you are asleep, and in NREM sleep specifically, an experimenter will replay half of the previously tagged sounds (fifty of the total hundred) to your sleeping brain at low volume using speakers on either side of the bed. As if helping guide the brain in a targeted search-and-retrieve effort, we can trigger the selective reactivation of corresponding individual memories, prioritizing them for sleep-strengthening, relative to those that were not reactivated during NREM sleep.

When you are tested the following morning, you will have a quite remarkable bias in your recollection, remembering far more of the items that we reactivated during sleep using the sound cues than those not reactivated. Note that all one hundred of the original memory items passed through sleep. However, using sound cuing, we avoid indiscriminate enhancement of all that you learned. Analogous to looping your favorite songs in a repeating playlist at night, we cherry-pick specific slices of your autobiographical past, and preferentially strengthen them by using the individualized sound cues during sleep.VIII

I’m sure you can imagine innumerable uses for such a method. That said, you may also feel ethically uncomfortable about the prospect, considering that you would have the power to write and rewrite your own remembered life narrative or, more concerning, that of someone else. This moral dilemma is somewhat far in the future, but should such methods continue to be refined, it is one we may face.

SLEEP TO FORGET?

Up to this point, we have discussed the power of sleep after learning to enhance remembering and avoid forgetting. However, the capacity to forget can, in certain contexts, be as important as the need for remembering, both in day-to-day life (e.g., forgetting last week’s parking spot in preference for today’s) and clinically (e.g., in excising painful, disabling memories, or in extinguishing craving in addiction disorders). Moreover, forgetting is not just beneficial to delete stored information we no longer need. It also lowers the brain resources required for retrieving those memories we want to retain, similar to the ease of finding important documents on a neatly organized, clutter-free desk. In this way, sleep helps you retain everything you need and nothing that you don’t, improving the ease of memory recollection. Said another way, forgetting is the price we pay for remembering.

In 1983, the Nobel Laureate Francis Crick, who discovered the helical structure of DNA, decided to turn his theoretical mind toward the topic of sleep. He suggested that the function of REM-sleep dreaming was to remove unwanted or overlapping copies of information in the brain: what he termed “parasitic memories.” It was a fascinating idea, but it remained just that—an idea—for almost thirty years, receiving no formal examination. In 2009, a young graduate student and I put the hypothesis to the test. The results brought more than a few surprises.

We designed an experiment that again used daytime naps. At midday, our research subjects studied a long list of words presented one at a time on a computer screen. After each word had been presented on the screen, however, a large green “R” or a large red “F” was displayed, indicating to the participant that they should remember the prior word (R) or forget the prior word (F). It is not dissimilar to being in a class and, after having been told a fact, the teacher impresses upon you that it is especially important to remember that information for the exam, or instead that they made an error and the fact was incorrect, or the fact will not be tested on the exam, so you don’t need to worry about remembering it for the test. We were effectively doing the same thing for each word right after learning, tagging it with the label “to be remembered” or “to be forgotten.”

Half of the participants were then allowed a ninety-minute afternoon nap, while the other half remained awake. At six p.m. we tested everyone’s memory for all of the words. We told participants that regardless of the tag previously associated with a word—to be remembered or to be forgotten—they should try to recall as many words as possible. Our question was this: Does sleep improve the retention of all words equally, or does sleep obey the waking command only to remember some items while forgetting others, based on the tags we had connected to each?

The results were clear. Sleep powerfully, yet very selectively, boosted the retention of those words previously tagged for “remembering,” yet actively avoided the strengthening of those memories tagged for “forgetting.” Participants who did not sleep showed no such impressive parsing and differential saving of the memories.IX

We had learned a subtle, but important, lesson: sleep was far more intelligent than we had once imagined. Counter to earlier assumptions in the twentieth and twenty-first centuries, sleep does not offer a general, nonspecific (and hence verbose) preservation of all the information you learn during the day. Instead, sleep is able to offer a far more discerning hand in memory improvement: one that preferentially picks and chooses what information is, and is not, ultimately strengthened. Sleep accomplishes this by using meaningful tags that have been hung onto those memories during initial learning, or potentially identified during sleep itself. Numerous studies have shown a similarly intelligent form of sleep-dependent memory selection across both daytime naps and a full night of sleep.

When we analyzed the sleep records of those individuals who napped, we gained another insight. Contrary to Francis Crick’s prediction, it was not REM sleep that was sifting through the list of prior words, separating out those that should be retained and those that should be removed. Rather, it was NREM sleep, and especially the very quickest of the sleep spindles that helped bend apart the curves of remembering and forgetting. The more of those spindles a participant had during a nap, the greater the efficiency with which they strengthened items tagged for remembering and actively eliminated those designated for forgetting.

Exactly how sleep spindles accomplish this clever memory trick remains unclear. What we have at least discovered is a rather telling pattern of looping activity in the brain that coincides with these speedy sleep spindles. The activity circles between the memory storage site (the hippocampus) and those regions that program the decision of intentionality (in the frontal lobe), such as “This is important” or “This is irrelevant.” The recursive cycle of activity between these two areas (memory and intentionality), which happens ten to fifteen times per second during the spindles, may help explain NREM sleep’s discerning memory influence. Much like selecting intentional filters on an Internet search or a shopping app, spindles offer a refining benefit to memory by allowing the storage site of your hippocampus to check in with the intentional filters carried in your astute frontal lobes, allowing selection only of that which you need to save, while discarding that which you do not.

We are now exploring ways of harnessing this remarkably intelligent service of selective remembering and forgetting with painful or problematic memories. The idea may invoke the premise of the Oscar-winning movie Eternal Sunshine of the Spotless Mind, in which individuals can have unwanted memories deleted by a special brain-scanning machine. In contrast, my real-world hope is to develop accurate methods for selectively weakening or erasing certain memories from an individual’s memory library when there is a confirmed clinical need, such as in trauma, drug addiction, or substance abuse.

SLEEP FOR OTHER TYPES OF MEMORY

All of the studies I have described so far deal with one type of memory—that for facts, which we associate with textbooks or remembering someone’s name. There are, however, many other types of memory within the brain, including skill memory. Take riding a bike, for example. As a child, your parents did not give you a textbook called How to Ride a Bike, ask you to study it, and then expect you to immediately begin riding your bike with skilled aplomb. Nobody can tell you how to ride a bike. Well, they can try, but it will do them—and more importantly you—no good. You can only learn how to ride a bike by doing rather than reading. Which is to say by practicing. The same is true for all motor skills, whether you are learning a musical instrument, an athletic sport, a surgical procedure, or how to fly a plane.

The term “muscle memory” is a misnomer. Muscles themselves have no such memory: a muscle that is not connected to a brain cannot perform any skilled actions, nor does a muscle store skilled routines. Muscle memory is, in fact, brain memory. Training and strengthening muscles can help you better execute a skilled memory routine. But the routine itself—the memory program—resides firmly and exclusively within the brain.

Years before I explored the effects of sleep on fact-based, textbook-like learning, I examined motor skill memory. Two experiences shaped my decision to perform these studies. The first was given to me as a young student at the Queen’s Medical Center—a large teaching hospital in Nottingham, England. Here, I performed research on the topic of movement disorders, specifically spinal-cord injury. I was trying to discover ways of reconnecting spinal cords that had been severed, with the ultimate goal of reuniting the brain with the body. Sadly, my research was a failure. But during that time, I learned about patients with varied forms of motor disorders, including stroke. What struck me about so many of these patients was an iterative, step-by-step recovery of their motor function after the stroke, be it legs, arms, fingers, or speech. Rarely was the recovery complete, but day by day, month by month, they all showed some improvement.

The second transformative experience happened some years later while I was obtaining my PhD. It was 2000, and the scientific community had proclaimed that the next ten years would be “The Decade of the Brain,” forecasting (accurately, as it turned out) what would be remarkable progress within the neurosciences. I had been asked to give a public lecture on the topic of sleep at a celebratory event. At the time, we still knew relatively little about the effects of sleep on memory, though I made brief mention of the embryonic findings that were available.

After my lecture, a distinguished-looking gentleman with a kindly affect, dressed in a tweed suit jacket with a subtle yellow-green hue that I still vividly recall to this day, approached me. It was a brief conversation, but one of the most scientifically important of my life. He thanked me for the presentation, and told me that he was a pianist. He said he was intrigued by my description of sleep as an active brain state, one in which we may review and even strengthen those things we have previously learned. Then came a comment that would leave me reeling, and trigger a major focus of my research for years to come. “As a pianist,” he said, “I have an experience that seems far too frequent to be chance. I will be practicing a particular piece, even late into the evening, and I cannot seem to master it. Often, I make the same mistake at the same place in a particular movement. I go to bed frustrated. But when I wake up the next morning and sit back down at the piano, I can just play, perfectly.”

“I can just play.” The words reverberated in my mind as I tried to compose a response. I told the gentleman that it was a fascinating idea, and it was certainly possible that sleep assisted musicianship and led to error-free performance, but that I knew of no scientific evidence to support the claim. He smiled, seeming unfazed by the absence of empirical affirmation, thanked me again for my lecture, and walked toward the reception hall. I, on the other hand, remained in the auditorium, realizing that this gentleman had just told me something that violated the most repeated and entrusted teaching edict: practice makes perfect. Not so, it seemed. Perhaps it was practice, with sleep, that makes perfect?

After three years of subsequent research, I published a paper with a similar title, and in the studies that followed gathered evidence that ultimately confirmed all of the pianist’s wonderful intuitions about sleep. The findings also shed light on how the brain, after injury or damage by a stroke, gradually regains some ability to guide skill movements day by day—or should I say, night by night.

By that time, I had taken a position at Harvard Medical School, and with Robert Stickgold, a mentor and now a longtime collaborator and friend, we set about trying to determine if and how the brain continues to learn in the absence of any further practice. Time was clearly doing something. But it seemed that there were, in fact, three distinct possibilities to discriminate among. Was it (1) time, (2) time awake, or (3) time asleep that incubated skilled memory perfection?

I took a large group of right-handed individuals and had them learn to type a number sequence on a keyboard with their left hand, such as 4-1-3-2-4, as quickly and as accurately as possible. Like learning a piano scale, subjects practiced the motor skill sequence over and over again, for a total of twelve minutes, taking short breaks throughout. Unsurprisingly, the participants improved in their performance across the training session; practice, after all, is supposed to make perfect. We then tested the participants twelve hours later. Half of the participants had learned the sequence in the morning and were tested later that evening after remaining awake across the day. The other half of the subjects learned the sequence in the evening and we retested them the next morning after a similar twelve-hour delay, but one that contained a full eight-hour night of sleep.

Those who remained awake across the day showed no evidence of a significant improvement in performance. However, fitting with the pianist’s original description, those who were tested after the very same time delay of twelve hours, but that spanned a night of sleep, showed a striking 20 percent jump in performance speed and a near 35 percent improvement in accuracy. Importantly, those participants who learned the motor skill in the morning—and who showed no improvement that evening—did go on to show an identical bump up in performance when retested after a further twelve hours, now after they, too, had had a full night’s sleep.

In other words, your brain will continue to improve skill memories in the absence of any further practice. It is really quite magical. Yet, that delayed, “offline” learning occurs exclusively across a period of sleep, and not across equivalent time periods spent awake, regardless of whether the time awake or time asleep comes first. Practice does not make perfect. It is practice, followed by a night of sleep, that leads to perfection. We went on to show that these memory-boosting benefits occur no matter whether you learn a short or a very long motor sequence (e.g., 4-3-1-2 versus 4-2-3-4-2-3-1-4-3-4-1-4), or when using one hand (unimanual) or both (bimanual, similar to a pianist).

Analyzing the individual elements of the motor sequence, such as 4-1-3-2-4, allowed me to discover how, precisely, sleep was perfecting skill. Even after a long period of initial training, participants would consistently struggle with particular transitions within the sequence. These problem points stuck out like a sore thumb when I looked at the speed of the keystrokes. There would be a far longer pause, or consistent error, at specific transitions. For example, rather than seamlessly typing 4-1-3-2-4, 4-1-3-2-4, a participant would instead type: 4-1-3 [pause] 2-4, 4-1-3 [pause] 2-4. They were chunking the motor routine into pieces, as if attempting the sequences all in one go was just too much. Different people had different pause problems at different points in the routine, but almost all people had one or two of these difficulties. I assessed so many participants that I could actually tell where their unique difficulties in the motor routine were just by listening to their typing during training.

When I tested participants after a night of sleep, however, my ears heard something very different. I knew what was happening even before I analyzed the data: mastery. Their typing, post-sleep, was now fluid and unbroken. Gone was the staccato performance, replaced by seamless automaticity, which is the ultimate goal of motor learning: 4-1-3-2-4, 4-1-3-2-4, 4-1-3-2-4, rapid and nearly perfect. Sleep had systematically identified where the difficult transitions were in the motor memory and smoothed them out. This finding rekindled the words of the pianist I’d met: “but when I wake up the next morning and sit back down at the piano, I can just play, perfectly.”

I went on to test participants inside a brain scanner after they had slept, and could see how this delightful skill benefit had been achieved. Sleep had again transferred the memories, but the results were different from that for textbook-like memory. Rather than a transfer from short- to long-term memory required for saving facts, the motor memories had been shifted over to brain circuits that operate below the level of consciousness. As a result, those skill actions were now instinctual habits. They flowed out of the body with ease, rather than feeling effortful and deliberate. Which is to say that sleep helped the brain automate the movement routines, making them second nature—effortless—precisely the goal of many an Olympic coach when perfecting the skills of their elite athletes.

My final discovery, in what spanned almost a decade of research, identified the type of sleep responsible for the overnight motor-skill enhancement, carrying with it societal and medical lessons. The increases in speed and accuracy, underpinned by efficient automaticity, were directly related to the amount of stage 2 NREM, especially in the last two hours of an eight-hour night of sleep (e.g., from five to seven a.m., should you have fallen asleep at eleven p.m.). Indeed, it was the number of those wonderful sleep spindles in the last two hours of the late morning—the time of night with the richest spindle bursts of brainwave activity—that were linked with the offline memory boost.

More striking was the fact that the increase of these spindles after learning was detected only in regions of the scalp that sit above the motor cortex (just in front of the crown of your head), and not in other areas. The greater the local increase in sleep spindles over the part of the brain we had forced to learn the motor skill exhaustively, the better the performance upon awakening. Many other groups have found a similar “local-sleep”-and-learning effect. When it comes to motor-skill memories, the brainwaves of sleep were acting like a good masseuse—you still get a full body massage, but they will place special focus on areas of the body that need the most help. In the same way, sleep spindles bathe all parts of the brain, but a disproportionate emphasis will be placed on those parts of the brain that have been worked hardest with learning during the day.

Perhaps more relevant to the modern world is the time-of-night effect we discovered. Those last two hours of sleep are precisely the window that many of us feel it is okay to cut short to get a jump start on the day. As a result, we miss out on this feast of late-morning sleep spindles. It also brings to mind the prototypical Olympic coach who stoically has her athletes practicing late into the day, only to have them wake in the early hours of the morning and return to practice. In doing so, coaches may be innocently but effectively denying an important phase of motor memory development within the brain—one that fine-tunes skilled athletic performance. When you consider that very small performance differences often separate winning a gold medal from a last-place finish in professional athletics, then any competitive advantage you can gain, such as that naturally offered by sleep, can help determine whether or not you will hear your national anthem echo around the stadium. Not without putting too fine a point on it, if you don’t snooze, you lose.

The 100-meter sprint superstar Usain Bolt has, on many occasions, taken naps in the hours before breaking the world record, and before Olympic finals in which he won gold. Our own studies support his wisdom: daytime naps that contain sufficient numbers of sleep spindles also offer significant motor skill memory improvement, together with a restoring benefit on perceived energy and reduced muscle fatigue.

In the years since our discovery, numerous studies have shown that sleep improves the motor skills of junior, amateur, and elite athletes across sports as diverse as tennis, basketball, football, soccer, and rowing. So much so that, in 2015, the International Olympic Committee published a consensus statement highlighting the critical importance of, and essential need for, sleep in athletic development across all sports for men and women.X

Professional sports teams are taking note, and for good reason. I have recently given presentations to a number of national basketball and football teams in the United States, and for the latter, the United Kingdom. Standing in front of the manager, staff, and players, I tell them about one of the most sophisticated, potent, and powerful—not to mention legal—performance enhancers that has real game-winning potential: sleep.

I back up these claims with examples from the more than 750 scientific studies that have investigated the relationship between sleep and human performance, many of which have studied professional and elite athletes specifically. Obtain anything less than eight hours of sleep a night, and especially less than six hours a night, and the following happens: time to physical exhaustion drops by 10 to 30 percent, and aerobic output is significantly reduced. Similar impairments are observed in limb extension force and vertical jump height, together with decreases in peak and sustained muscle strength. Add to this marked impairments in cardiovascular, metabolic, and respiratory capabilities that hamper an underslept body, including faster rates of lactic acid buildup, reductions in blood oxygen saturation, and converse increases in blood carbon dioxide, due in part to a reduction in the amount of air that the lungs can expire. Even the ability of the body to cool itself during physical exertion through sweating—a critical part of peak performance—is impaired by sleep loss.

And then there is injury risk. It is the greatest fear of all competitive athletes and their coaches. Concern also comes from the general managers of professional teams, who consider their players as prized financial investments. In the context of injury, there is no better risk-mitigating insurance policy for these investments than sleep. Described in a research study of competitive young athletes in 2014,XI you can see that a chronic lack of sleep across the season predicted a massively higher risk of injury (figure 10).

Figure 10: Sleep Loss and Sports Injury

Sports teams pay millions of dollars to hugely expensive players, lavishing all manner of medical and nutritional care on their human commodities to augment their talent. Yet the professional advantage is diluted several-fold by the one ingredient few teams fail to prioritize: their players’ sleep.

Even teams that are aware of sleep’s importance before a game are surprised by my declaration of the equally, if not more, essential need for sleep in the days after a game. Post-performance sleep accelerates physical recovery from common inflammation, stimulates muscle repair, and helps restock cellular energy in the form of glucose and glycogen.

Prior to giving these teams a structured set of sleep recommendations that they can put in practice to help capitalize on the full potential of their athletes, I provide proof-of-concept data from the National Basketball Association (NBA), using the measured sleep of Andre Iguodala, currently of my local team, the Golden State Warriors. Based on sleep-tracker data, figure 11 is the difference in Iguodala’s performance when he’s been sleeping more than eight hours a night, relative to less than eight hours a night:XII

Figure 11: NBA Player Performance

More than Eight Hours Sleep vs. Less than Eight Hours Sleep

Of course, most of us do not play for professional sports teams. But many of us are physically active throughout life and constantly acquiring new skills. Motor learning and general physicality remain part of our lives, from the banal (learning to type on a slightly new laptop or text on a different-size smartphone) to the essential, such as experienced surgeons learning a new endoscopic procedure or pilots learning to fly different or new aircraft. And so, therefore, we continue to need and rely upon our NREM sleep for refining and maintaining those motor movements. Of interest to parents, the most dramatic time of skilled motor learning in any human’s life occurs in the first years after birth, as we start to stand and walk. It is of little surprise that we see a spike in stage 2 NREM sleep, including sleep spindles, right around the infant’s time of transition from crawling to walking.

Returning full circle to that which I had learned years ago at the Queen’s Medical Center regarding brain damage, we have now discovered that the slow, day-by-day return of motor function in stroke patients is due, in part, to the hard night-by-night work of sleep. Following a stroke, the brain begins to reconfigure those neural connections that remain, and sprout new connections around the damaged zone. This plastic reorganization and the genesis of new connections underlie the return of some degree of motor function. We now have preliminary evidence that sleep is one critical ingredient assisting in this neural recovery effort. Ongoing sleep quality predicts the gradual return of motor function, and further determines the relearning of numerous movement skills.XIII Should more such findings emerge, then a more concerted effort to prioritize sleep as a therapeutic aid in patients who have suffered brain damage may be warranted, or even the implementation of sleep-stimulation methods like those described earlier. There is much that sleep can do that we in medicine currently cannot. So long as the scientific evidence justifies it, we should make use of the powerful health tool that sleep represents in making our patients well.

SLEEP FOR CREATIVITY

A final benefit of sleep for memory is arguably the most remarkable of all: creativity. Sleep provides a nighttime theater in which your brain tests out and builds connections between vast stores of information. This task is accomplished using a bizarre algorithm that is biased toward seeking out the most distant, nonobvious associations, rather like a backward Google search. In ways your waking brain would never attempt, the sleeping brain fuses together disparate sets of knowledge that foster impressive problem-solving abilities. If you ponder the type of conscious experience such outlandish memory blending would produce, you may not be surprised to learn that it happens during the dreaming state—REM sleep. We will fully explore all of the advantages of REM sleep in the later chapter on dreaming. For now, I will simply tell you that such informational alchemy conjured by REM-sleep dreaming has led to some of the greatest feats of transformative thinking in the history of the human race.

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