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Physiology, Sleep Stages

Aakash K. Patel; John F. Araujo.

Author Information
Last Update: October 27, 2018.

Introduction
During sleep, our body cycles through 4 different stages consisting of both rapid-
eye-movement (REM) and non-rapid eye movement (NREM) sleep. The body
usually cycles through these stages on average 4 to 6 times, averaging 90 minutes
in each stage. As the night progresses, fewer NREM stages occur, and the duration
of REM sleep episodes increase. [1]

Function
Circadian rhythm regulates sleep, which tends to change over the course of
human lives. Newborns spend about 50% of their total sleep in REM sleep, usually
directly entering REM sleep. Newborns also tend to initially sleep in short
intervals, obtaining around 12 to 18 hours of sleep. As children reach 5 to 10
years of age, their sleep demand decreases to 10 hours. The demand further
decreases as teenagers require 8 to 9 hours and adults need 7 to 8 hours. Our
circadian rhythm also controls the nocturnal release of adrenocorticotropic
hormone (ACTH), prolactin, melatonin, and norepinephrine, which are all
essentials hormones for normal body functioning. [2],[3]

Mechanism
Sleep is broken down into 5 phases: wake, N1, N2, N3, and R. Stages N1 to N3 have
considered non-rapid eye movement sleep, each progressively going into deeper
sleep. Sleep is staged in sequential 30-second epochs, and each of these epochs is
assigned a specific sleep stage. The majority of sleep is spent in the N2 stage. [4]

Wake

The first stage is the wake stage or stage W, which further depends on whether
the eyes are open or closed. During eye-open wakefulness, there are alpha and
beta waves present, predominantly beta. As individuals become drowsy, and the
eyes close, the alpha rhythm is the predominant pattern. An epoch is considered
stage W if it contains greater than 50% alpha waves and eye movements
associated with wakefulness. [5]

N1 (Stage 1)

This is the lightest stage of sleep and starts when more than 50% of the alpha
waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There
is muscle tone present in the skeletal muscle and breathing tends to occur at a
regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the
total cycle.

N2 (Stage 2)
This stage represents deeper sleep as your heart rate and body temperate drop. It
is characterized by the presence of sleep spindles, K-complexes or both. These
sleep spindles will activate the superior temporal gyri, anterior cingulate, insular
cortices and the thalamus. The K-complexes show a transition into deeper sleep.
They are single, long delta waves only lasting for a second. As deeper sleep ensues
and the individual moves into N3. All of their waves will be replaced with delta
waves. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens
with each successive cycle, eventually consisting of about 50% of total sleep. 

N3 (Stage 3)

This is considered the deepest stage of sleep and is characterized by a much

slower frequency with high amplitude signals known as delta waves. This stage is
the most difficult to awaken from, and for some people, even loud noises (over
100 decibels) will not awaken them. As people get older, they tend to spend less
time in this slow, delta wave sleep and more time stage N2 sleep. Although this
stage has the greatest arousal threshold, if someone is awoken during this stage,
they will have a transient phase of mental fogginess. This is known as sleep
inertia. Cognitive testing shows that individuals awoken during this stage tend to
have mental performance moderately impaired for 30 minutes to an hour. This is
the stage when the body repairs and regrows its tissues, builds bone and muscle
and strengthens the immune system.

REM Sleep

This is the stage associated with dreaming. Interestingly, the EEG is similar to an
awake individual, but the skeletal muscles are atonic and without movement. The
exception is the eye and diaphragmatic breathing muscles, which remain active.
The breathing rate is altered though, being more erratic and irregular. This stage
usually starts 90 minutes after you fall asleep, and each of your REM cycles gets
longer throughout the night. The first period typically lasts 10 minutes, and the
final one can last up to an hour. [6],[7]

Related Testing
The clinical evaluation of sleep is performed through polysomnogram, which
measures EEG (brain waves), eye movements, muscle movement of chin and legs,
nasal pressure and airflow, chest and thorax movement, and pulse oximetry.
These studies are consolidated to examine and assess each sleep stage for
breathing and movement during sleep. These tests are performed overnight and
usually require a minimum of 6 hours of monitoring.

Pathophysiology
Individuals with sleep-related disorders suffer from sleep fragmentation and
apnea during sleep. As they start to fall into deeper stages of sleep, their upper
airway collapses and interferes with their normal breathing. This interference
forces the body to revert to the lighter sleep stages to continue better respiration.
The deep sleep stages are important in normal functioning to replenish the
immune system, and proper metabolism and growth. People with sleep apnea do
not cycle through the normal stages of the sleep cycle. They have reduced stage
N3 and REM sleep as their airway collapse prevents them from breathing in these
deeper sleep states. This leads to excessive daytime drowsiness as proper,
efficient sleep is not obtained throughout the night. There are two types of sleep
apnea: central and obstructive. Central sleep apnea occurs when the brain fails to
signal respiratory muscles during sleep properly. On the other hand, obstructive
sleep apnea is a mechanical problem in which there is a partial or complete
blockage of the upper airway. [8],[9]

During REM sleep, we normally do not move as our muscles are paralyzed. If the
temporary paralysis (atonia) of REM sleep is disturbed, one can physically act out
dreams. This is called rapid eye movement (REM) sleep disorder. With this
disorder, the normal paralysis is not obtained, and there are episodes of
abnormal movement throughout the night. These episodes coincide with the REM
sleep stage. The cause of this disorder is not completely known but may be
associated with some degenerative neurological conditions such as Parkinson
disease or Lewy body dementia. [10],[11]

Narcolepsy is another sleep cycle abnormality in which individuals usually

present with persistent daytime sleepiness and brief episodes of muscle weakness
known as cataplexy. In narcolepsy, the regulation of sleep is disturbed, and
individuals tend to skip the initial phases of sleep and go directly into REM sleep.
Even during short naps, these individuals can enter the REM phase and have
short dreams. This limits their amount of sleep in the N3 deep-sleep stage and
thus caused an irregular sleep pattern. These individuals also experience sudden
losses of muscle strength as body muscles are atonic and paralyzed in the REM-
sleep phase. These lapses into REM sleep and happen anytime during the day and
usually last from seconds to minutes. [12],[13]

Somnambulism or sleepwalking is a common occurrence in school-aged children.

These individuals tend to make movements that seem purposeful, and it is
important to understand they are not acting out their dreams. Dreams take place
during the rapid eye movement phase of the cycle, in which the body is fully
paralyzed. Sleep walking tends to occur because the sleep cycle is still in the
maturing phase and proper sleep/wake cycles are not yet regulated. Sleepwalking
is comply associated with common behaviors, such as dressing, eating and
urinating. Therefore, sleepwalking takes place in the non-rapid eye movement
phases, usually in N3. [14]

Clinical Significance
Benzodiazepines are a major class of drugs used for the treatment of insomnia as
these tend to increase arousal threshold in stage N3 and REM sleep. These 2
stages are already known to have the highest arousal threshold and
benzodiazepines further increase this threshold. They also tend to decrease the
overall time spent in stage 3 and REM sleep, and thus, can be used for night time
sleepwalking as these occur in the N3 sleep phase.

Questions
To access free multiple choice questions on this topic, click here.

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