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RESIDENT AND FELLOW PAGE

Residency Training

Cognitive benefits of sleep and their


loss due to sleep deprivation
Jeffrey M. Ellenbogen, MD

W
hen Nobel laureate Otto ioral performance. For example, in would be entirely attributed to the
Loewi discovered the a prospective, randomized study detriments from sleep loss. The
chemical basis of neuro- looking at the effects of sleep depri- missed benefits would go unnoticed.
transmission in 1921, he attributed vation in residency training, in- By analogy, if you do not deposit
his experimental design to an in- terns working a traditional money in a bank, and it is subse-
sight he made during sleep.1 In re- schedule made 36% more serious quently stolen, your losses may be
cent years, scientific discoveries medical errors compared with in- calculated as the amount of money
have begun to empirically validate terns under an intervention sched- stolen. However, the real amount of
the hypothetical role of sleep in cog- ule that included more sleep.2 money lost is the quantity stolen,
nitive processes such as insight for- Another study demonstrated that plus that which would have been
mation and memory consolidation. traditional-schedule interns had added had it been in the bank earn-
Yet these new and important scien- more than twice the rate of atten- ing interest prior to being stolen.
tific findingsthat sleep benefits tional failures when compared with
cognition have gained little atten- the intervention-schedule interns.3 Evidence supporting
tion in the debates over regulating Taken together, these studies dem- cognitive benefits of sleep
resident work hours. onstrate that sleep-deprived house Evidence for a beneficial role of
In this article, I aim to achieve staff make a significant amount of sleep in cognition is rapidly emerg-
three goals: First, I will show that serious medial errors, largely the ing in the cognitive and neuro-
sleep deprivation causes two inde- consequence of attentional failures science literature.4-8 These studies
pendent negative consequences to from sleepiness. These excellent isolate sleeps benefit by comparing
cognition: a detriment and a loss of studies provide empirical evidence a sleep period with a non-sleep-
benefit; I will explain this distinc- for the cognitive detriments of sleep deprived wake period. The para-
tion. Second, I will briefly review loss. digm is as simple as it is insightful:
evidence supporting sleeps benefits Recently published studies (see control participants train on a cog-
for cognition. Finally, I will argue below) looking at the benefits of nitive task in the morning and are
that these benefits of sleep for cog- sleep take a different, but comple- tested 12 hours later; they are com-
nition provide novel reasons why mentary, approach. They seek to pared with a group that trains at
depriving residents of sleep is in- understand the benefits of sleep, night, sleeps, and is tested 12 hours
consistent with our ethical stan- rather then the detriments of sleep later.
dards and educational goals for loss. This is a subtle but important Walker et al.4 performed a
medical training. In this final sec- distinction. Instead of studying the study that illustrates the paradigm
tion, I will also argue against the negative consequences of sleep loss, (figure). There are two groups of
assertion that residents should use these studies seek to understand participants: the wake-control
performance-enhancing medica- the positive gains produced by group and the sleep-experimental
tions to overcome the effects of sleep. If these cognitive benefits of group. The wake-control partici-
sleep deprivation. sleep exist, then missing sleep pants engage in a motor-learning
would hypothetically deprive a per- task at 10 AM, where they practice a
Sleep loss: Distinguishing son of them. particular set of sequences on a
detriments from loss of Were one not aware of this loss keyboard. The last few trials of the
benefits of benefit, poor performance during training session are taken as a
Sleep loss causes profound im- cognitive testing on the morning marker of their best performance
pairments in cognitive and behav- following a night of missed sleep (speed and accuracy). Next, they

From the Department of Neurology, University of Pennsylvania, Philadelphia.


Address correspondence and reprint requests to Dr. J.M. Ellenbogen, Department of Neurology, University of Pennsylvania, 3 West Gates Bldg., 3400 Spruce
Street, Philadelphia, PA 19104-4283; e-mail: jeffreye@mail.med.upenn.edu

Copyright 2005 by AAN Enterprises, Inc. E25


Figure. Exemplary study showing the benefit of sleep for motor learning (adapted from Walker et al.4). (A) Method. Wake
(control) group was trained on a motor-memory task in the morning, and then tested again after 12 hours of wakefulness.
Sleep (experimental) group was trained in the evening; then this group was tested in the morning following a nights
sleep. (B) Results. Testing after a 12-hour period which contained sleep resulted in a statistically significant improvement
in performance when compared to a 12-hour period of wakefulness. Train performance during the last (and therefore
best) trials of training; test performance on testing 12-hours later, either after a waking day (wake group) pr after a
night which included sleep (sleep group).

are tested on the same task at 10 this hypothetical model asserts medication, in order to adequately
PM (12 hours later). The sleep- that, in wakefulness, information is perform their job, exposes them to
experimental participants learn the encoded in the hippocampus. Dur- these agents potentially serious
task at 10 PM, sleep overnight, and ing the subsequent slow wave risks (known or unknown) or
are tested at 10 AM on the following sleep, the encoded memory trace is merely unpleasant side effects or
morning. The sleep group shows replayed by the hippocampus; the both. Second, there are serious eth-
significantly greater improvement movement of information between ical concerns raised by employing
in performance, from training to the neocortex and hippocampus medications for performance en-
testing, when compared with the then repeats over each sleep cycle. hancement,11 and the medical com-
wake controls. This experimental This reiterative process is thought munity is not exempt from such
paradigm has been successfully em- to facilitate consolidation of memory considerations.
ployed to show the benefit of sleep traces. Evidence for the hippocam- Finally (and most relevant for
for several forms of neural process- palneocortical dialogue already ex- this article), taking medication
ing, including insight formation,5 ists in animals,10 and translational willin principlenot recover the
novel-language perception,6 visual research looking at declarative benefit sleep has to offer cognition.
discrimination,7 and motor skills.8 (hippocampal-dependent) memory in Even if we hypothetically could
There is not universal agree- humans is currently under way. safely and completely restore sleep-
ment that sleep benefits cognition.9 deprived arousal and attention
However, many recently published Performance-enhancing impairments by administering
studies employ improvements in medication for residents medication, a memory trace that
methodology, including avoiding Some physicians advocate that was not consolidated during a night
the use of sleep deprivation, and sleep-deprived residents be re- of lost sleep could not be recovered
they no longer focus exclusively on quired to take medication such as thereafter.
REM sleep. These studies provide modafinil or more traditional stim-
strong evidence for sleep-dependent ulants (including caffeine) to over- Conclusion
cognitive processing. come the cognitive and behavioral If the demands of residency
In addition to the behavioral detriments resulting from sleep training result in sleep-depriving
data, there is also a biologically loss. There are several serious prob- house staff, this will impair resi-
plausible mechanism for sleep ben- lems with this proposal: First, no dents cognitive processing for two
efiting memory: the hippocampal- medication is free of side effects. independent reasons: detriments
neocortical dialogue. Simplified, Compelling house staff to consume and loss of benefits. The detriments
E26 NEUROLOGY 64 April (1 of 2) 2005
resulting from sleep loss include in the loss of sleeps benefits for makes perfect: sleep-dependent motor skill
learning. Neuron 2002;35:205211.
impaired cognitive and behavioral cognitive processes such as memory 5. Wagner U, Gais S, Haider H, Verleger R,
performance, partly from dimin- and insight formation: the building Born J. Sleep inspires insight. Nature 2004;
427:352355.
ished attention and arousal. The blocks of learning, creativity, and 6. Fenn KM, Nusbaum HC, Margoliash D.
loss of benefits due to the lack of scientific discovery. These losses Consolidation during sleep of perceptual
sleep includes missing sleep- are also ethically problematic, in- learning of spoken language. Nature 2003;
425:614 616.
dependent cognitive processing compatible with our health- 7. Stickgold R, James L, Hobson JA. Visual
such as memory consolidation and providing goals, and inconsistent discrimination learning requires sleep after
training. Nat Neurosci 2000;3:12371238.
insight formation. with the educational aspirations of 8. Walker MP, Brakefield T, Hobson JA, Stick-
Detriments due to sleep loss residency training. gold R. Dissociable stages of human memory
consolidation and reconsolidation. Nature
compromise the health and well- 2003;425:616 620.
being of residents (including plac- 9. Siegel JM. The REM sleep-memory consoli-
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N Engl J Med 2004;351:1829 1837. tended work shifts and the risk of motor
medical practices and policies. 4. Walker MP, Brakefield T, Morgan A, Hob- vehicle crashes among interns. N Engl
Sleep deprivation also results son JA, Stickgold R. Practice with sleep J Med 2005;352:125134.

April (1 of 2) 2005 NEUROLOGY 64 E27


Cognitive benefits of sleep and their loss due to sleep deprivation
Jeffrey M. Ellenbogen
Neurology 2005;64;E25-E27
DOI 10.1212/01.wnl.0000164850.68115.81

This information is current as of April 11, 2005

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