3 February, 2022

In ancient Greek mythology, Sleep was the twin brother of Death, children of the personified gods of Darkness and Night. It seems there has always been an association between sleep and death. When people die in their sleep, it seems like a peaceful and almost idealized way to pass.

We spend one-third of our lives asleep, so it should be no surprise that a lot of people die in their sleep. There is an important difference between dying healthy and dying when unconscious in the latter stages of a fatal disease. Older people and those who are sick draw less scrutiny than the young. Depending on the setting of the death (home versus hospital versus assisted care facility), the death may be commented on by a physician. Rarely would an autopsy be performed unless there are unusual circumstances. This evaluation may be more likely in younger adults or children who die suddenly without known illness. Even an autopsy may be unrevealing. The cause of death may not be clear. The death certificate may note non-specific reasons: “cardiorespiratory failure,” “died of natural causes,” or even “old age. “Family and friends may wonder what really happened.

In some cases, death occurs due to some sort of external factor, either directly from the environment or another outside agent, for example, an earthquake, Carbon monoxide poisoning from faulty ventilation, overdose of certain medications or alcohol intoxication.

There is considerable evidence that cardiac function may be stressed during sleep. Rapid eye movement (REM) sleep, in particular, may redline the system with increasing risk in morning. There also seems to be a circadian pattern of cardiac dysfunction, with problems often occurring late in the night and near the time of waking. It is recognized that in the electrical storm that makes the heart’s main pumping chambers suddenly begin to beat erratically in a way that stops the flow of blood to the brain and body termed ventricular fibrillation, the condition causes Sudden Cardiac Death (SCD), in which the victim instantly becomes unconscious and dies unless CPR or a defibrillator is available to shock the heart back into its steady beat. Sudden cardiac death (SCD) due to this electrical instability causes an estimated 325,000 deaths annually in the United States alone. One of the deepest mysteries about SCD has been its timing. Health experts have known for more than 30 years that the erratic heartbeat responsible for SCD strikes most often at certain times of the day. The peak risk hours range from 6 a.m. to 10 a.m., with a smaller peak in the late afternoon. Scientists long suspected a link between SCD and the 24-hour body clock, located in the brain. It governs 24-hour cycles of sleep and wakefulness called circadian rhythms that coordinate a range of body functions with the outside environment.

Specific SUD called sudden unexplained nocturnal death syndrome (SUNDS) has different academic terms but similar definitions in different countries, such as bangungut in Philippines, Lai Tai in Thailand, Pokkuri Death Syndrome (PDS) in Japan, and SUNDS in the United States and China. Despite these multiple terms, the common characteristics (modalities) of these victims are sudden death of young healthy individuals (the vast majority are males) during nocturnal sleep and postmortem routine autopsy that cannot explain their deaths. The pathogenesis of SUNDS has been extensively explored, mainly focusing on physiological abnormalities associated with electrical instability, respiratory problems, sleeping disorders, and metabolic and endocrine disturbance. Many surveys have been conducted to explore arrhythmia- associated environmental risk factors, such as potassium deficiency and excessive carbohydrate eating habit. Night terrors are a sleep disorder that is characterized by vocalization, clonic movements, an unarousable state, and severe autonomic discharge. These manifestations can also be observed in SUNDS cases before their deaths. The hypothesized mechanism is that night terrors cause sympathetic discharge, resulting in increased cardiac vulnerability to VA in patients with cardiac conduction defects.

If you struggle to get up in the morning you’re at risk of early death. A six-year study of nearly half a million people in the UK has found that people who were “night owls” were 10 per cent more likely to die during that time period. It is reported in literature that people who stayed up late had higher rates of diabetes, mental health disorders, and neurological conditions. They were also more likely to experience psychological stress, drug abuse or alcohol, and not get enough exercise or sleep. The problem may be that people who are night owls have a body clock that fails to match their external environment.

But why most death occurs between 3 am to 4 am in early morning. There is no certain time for death and that can come at any time. Yet, some reports say most death occurs during night while the time span between 3 am to 4 am is the most vulnerable. According to a research most hospital deaths occur between 3am to 4am. This is the time in a day when the body tries to prepare for the activities of the next day while the brain tries to dispose some information to give space to the future happenings of the next day. At this time, adrenaline and anti-inflammatory hormones are at their lowest which causes airways to narrow. Spasm triggering compounds are also at the highest at this time and a person is more likely to die at this time according to Harvard medical research. On the other hand there is a religious answer that says that the difference between spiritual world and earth is very thin at this hour and thus it is easy for one to transfer to the other world easily. Probably, that is the reason that the darkest of rituals are always done at around 3am to 4am.

The take home message from this article is “Light meals at night; timely and adequate sleep; No screen time before sleep; take your medications especially Beta blockers or antiarrhythmic drugs in time as prescribed.”

“Don’t be a night owl.”

Dr. A.K. Dewan
Director – Surgical Oncology

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