Dr. Poceta: Well, maybe the easiest answer is because that’s how we feel our best. We get restored. We’re more productive, and it just feels good. And of course you need that much sleep for long-term health benefits as well.
Dr. Poceta: Some wake ups in the night are really normal, especially as we get older. You’re going to wake up more. Very few people sleep solidly for seven, eight hours straight. So a couple of wake ups here and there, bathroom breaks, are not unexpected, and that’s fine.
Dr. Poceta: Some people view insomnia, difficulty sleeping, as maybe not really a sleep disease or disorder, but just a feature of lifestyle and the human condition and worrying and thinking about things. But it is important that you’re giving yourself the opportunity to sleep and rest for seven to nine hours.
When insomnia becomes chronic and perpetual, and the person has done everything they can do and they’re still sleeping maybe only five hours a night, despite adequate opportunity to sleep, then we would say that is a sleep disorder. We would call that insomnia.
Other disorders that cause wakefulness in the night are restless leg syndromes and sleep apnea.
Dr. Poceta: Restless legs is a specific condition where people experience an unpleasant feeling in their legs that makes them want to move around. And that is what’s keeping them awake. A lot of times it’s just a bad feeling, a little trembling, a little tingling, but certainly a restlessness that makes you move. The leg might jerk on its own.
Dr. Poceta: Sleep apnea is difficulty breathing through the throat at night. People snore heavily and that snoring interrupts their sleep and wakes them up.
Dr. Poceta: The first is feeling tired the next day and or sleepy. That can lead to car accidents and poor performance. But also in the long run, it increases the chances of high blood pressure and certain other conditions. To some extent, cancer is more common among shift workers for example.
We don’t really know the underlying reason that we sleep, right? It certainly is to restore our brains and restore our bodies. So there is a certain restorative part of sleep and when that’s disrupted, there are long-term, negative consequences for health.
Obesity is linked to people that often are not giving themselves adequate opportunity to sleep. Think of the person that is up till midnight and has to get to up then at 6 am. That person is at increased risk of gaining weight.
Certainly, anxiety goes with insomnia and difficulty sleeping. It’s important to distinguish: Are we talking about risk from a sleep disorder like sleep apnea? Or risk from anxiety of being awake at night? Or risk from only being in bed for five hours?
Dementia is more and more linked to inadequate sleep, be it from sleep apnea or decreased sleep length. In fact, probably the leading theory as to why we sleep is to clear metabolic byproducts from the brain, so that it’s only during sleep that the brain can kind of clear itself out of some of these products. In theory, at least right now, inadequate amount of sleep leads to a build up of some of these negative byproducts.
Dr. Poceta: Sleep apnea is treated by keeping the upper airway open with a CPAP oral appliance. A CPAP is a little device placed under the nose and connected to a small machine. It blows air in the nose to keep the throat open so the person breathes better, sleeps better and feels better.
Dr. Loewy: It’s a combination of things. Certainly, lifestyle plays a role. If you think about technology these days, our unlimited access to our devices, our phones, our tablets and computers, et cetera, there is a lot more opportunity to be engaged with this technology at what might be considered inappropriate hours, for example, when it’s too close to bed time, or in the middle of the night if you can’t sleep. This can have two negative impacts on sleep. One is light emanating from these devices has the potential to suppress your natural melatonin, which is the sleep hormone you need to fall asleep and maintain sleep. Your brain interprets the light signal from these devices basically as being that the sun is up and it’s time to wake up. The other potential risk of these devices is that the content of what you’re looking at can keep you awake. If you’re engaged in watching your favorite Netflix show, or you’re checking the news, or doing work email, that’s keeping you mentally stimulated and it’s probably preventing you from relaxing into a sound sleep.
Caffeine has a rather long half-life, of about six hours. That’s the time it takes for half of it to be eliminated. Caffeine late in the day for some people who are sensitive to it can make it hard to fall asleep. My rule of thumb is keep your caffeine to before lunch time to be safe.
Alcohol can have two different effects. It can help you fall asleep more effectively because it’s a central nervous system depressant. However, it gets metabolized pretty quickly and people are prone to waking up in the middle of the night and having a restless sleep from that point forward. So a couple of glasses of wine in the evening with dinner shouldn’t be a problem. But too much consumption too close to bed time may have a disruptive effect.
I think we all know that exercise as a general rule is a good thing for health and well-being. With respect to sleep, it is probably not a bad idea to wind down any vigorous exercise at least three hours before your plan to go to sleep. Probably the best time to exercise, if you have the time, it’s best to do it first thing in the morning. We often recommend going for a morning walk or going for a morning workout in association with a lot of bright light. Those two events, physical activity and light in the morning are a great signal to your internal sleep clock that this marks the beginning of the waking part of your cycle and that will have an impact on when you fall asleep that night.
Dr. Poceta: Speaking broadly, the over-the-counter sleeping aids, Benadryl and some other antihistamines, we generally recommend avoiding them. They’re linking with long-term health consequences as well, and they don’t really work that well for most people. The antihistamine and anticholinergic medicines have recently been associated with risk of dementia. But most people figure that out, that they feel spacey and tired in the morning if they take Benadryl at bed time or one of the so-called PM medicines.
But there are a number of supplements that we generally think are safe and can be effective. Melatonin at the right time of day and in the right dose can help. Gaba is recommended. Valerian is one of the over-the-counter products. Magnesium is pretty popular right now as a sleep aid. There are a number of supplements that we think are safe, and might be effective for people.
Prescription sleeping pills are considered a last resort now. Most of them are habit-forming. Most of them don’t work as well over time, but there are some people that do benefit from prescription sleeping pills. And there is sort of a middle-ground. There are a few sedatives approved by the FDA that are not habit-forming. They’re not in that Valium, Ambien family. And those can be safely prescribed and used by people. Silenor, doxepin, mirtazapine, trazodone, amitriptyline, those are medicines that we believe are safe and reasonably effective for long-term use.
You need to have a conversation with your doctor, about the risks of taking a sleeping pill, versus the benefits and also to be sure that people are doing all the other things right in their lifestyle. It’s not a good idea to use a sleeping pill just to make you sleep at a certain time if you’re also ingesting caffeine too late and drinking too late and keeping an irregular schedule.
Dr. Loewy: My practice at Scripps involves something called cognitive behavioral therapy for insomnia or CBTI. This is a pretty well-established method for helping people sleep better, non-pharmacologically.
Within the context of our group at Scripps, we try to steer people away from sleeping pills when possible. More often than not though, people come in to see me in the insomnia clinic who are already taking something. I would say 90 percent of the people who are on something would rather not, but they need to sleep. They’re in this risk benefit analysis where they are asking themselves: “Should I take the pill? I’d rather not, but I have to sleep to function during the day.” They’re kind of trapped.
What CBTI allows is an opportunity to bring to bear knowledge and wisdom about how human beings sleep in such a way that we can augment or enhance their natural sleep ability, which would then allow them to gradually wean off the medication.
What happens is many times they’ll experiment themselves, by going off their medication for a night or two to test how they can sleep. And if they’ve been on these things for a long time, guess what happens? It doesn’t work. Those first couple of nights are horrible. And that reinforces their belief that they can’t sleep without the drug. That is both true and false. Certainly true those first couple of nights. But in the long-term, false. Their natural sleep system is still there. It still resides within them but it’s been weakened over time because the medication is doing the work. It’s like a muscle you want to exercise. It doesn’t go away, but in a moment’s notice, if there’s no pill, it can’t step up and save the night. CBTI strengthens that natural sleep muscle through sleep scheduling, light therapy, managing cognitive arousal, anxiety at night, so that their sleep muscle is working again. Once we see evidence of that, then we turn our attention to the medication and introduce a tapering program. It’s a very successful approach.
The length of time for therapy depends on the person, depends on how many meds they’re taking, the dosages, how anxious they are, how compliant they are with the recommendations. We do ask them to do a few things that are outside their comfort zone. But if they’re motivated for the change, they’re usually pretty adherent. I would say probably we would get people off their medication in four to eight weeks.
Dr. Poceta: I often say sleep is natural. If you stay up long enough or if you’re a child, you will fall asleep naturally and easily. But over time, sleep is also a learned behavior. We learn that the blanket or the pacifier the lullaby, this means go to sleep.
Unfortunately, many people develop problems in life, stresses in life. Maybe they’ve got a baby. Maybe it’s a good stress. They have to be up at night. But now they start to worry about how am I going to perform the next day? And then the brain learns that when I want to fall asleep, I can’t. We call it a conditioned response. We think a lot of insomnia now is a conditioned response. The brain is in the habit of not sleeping when it otherwise would sleep. And that overrides the natural sleep tendency.
Yes. I think any woman would say so. Having perimenopausal symptoms and then being in a postmenopausal-decreased estrogen state absolutely worsens sleep. They really need an approach to help them sleep that does not involve medicines. Sometimes an approach might involve medicines. The combination is what is most effective.
Dr. Poceta: Sleep is very adaptable. Sleep does allow us to be stressed out and still function the next day. Sleep does allow us to rummage around to find food and stay awake to fight the bad guys. The sleep system can deal with it. So occasionally, getting up at 3 am is okay. Some people adapt a lot better than others, but there is no easy answer to how to deal with shift work, very difficult.
Dr. Loewy: There is a tendency for insomnia to be familial. Patients who’ve had insomnia problems since early childhood, and have a family history of something similar, we think that there is a genetic component.
But I think most insomnias are kind of learned inadvertently as a function of life to stress. The different things we go through can derail our sleep. We can often develop a conditioned, association with arousal at bed time. How many times have I heard the patient say, “I feel sleepy watching TV in the living room, but as soon as I go in that bedroom, I’m wide awake.” It’s mystifying to them because they were the same sleep-deprived person five minutes ago in that room, but now they’re awake in this room. And we talk about that in terms of conditioning.
Your bedroom is where you’ve had all your suffering with your insomnia. That’s where your fight or flight system is getting triggered, when you go into that room. In the living room, nothing bad has happened to you there. And you’re relaxing at the end of a long day. Sleep comes to find you. You go to bed. Now it’s showtime. And there’s a pressure, an internal pressure to sleep and perform and it goes sideways.
You can take your cell phone into the bedroom if you want, but don’t look at it. The other thing that’s even more insidious than the phone is having the alarm clock staring you in the face when you can’t sleep all night. Recommend don’t be a clock-checker at night. Clock is not helpful.
Dr. Poceta: We have a lot of practitioners, doctors, nurse practitioners and psychologists. We really have a comprehensive sleep center. We evaluate and treat all kinds of sleep disorders.
One kind of sleep disorder that runs in families is the tendency to be a morning person or a night owl. It’s another common aspect that we have to assess. If the person, for example, can’t fall asleep till 2 am, but they sleep till noon on weekends, well that’s a timing issue. We have a couple of doctors, Dr. Loewy is one, who specifically deal with circadian rhythm disorders. We treat everything from circadian rhythm disorders to narcolepsy, restless legs and sleep apnea.
Dr. Poceta: Narcolepsy is a brain chemical abnormality that comes on in the 20s usually. This is a condition where people are excessively sleepy all day and they really cannot stay awake even though they did sleep all night. Narcolepsy is a brain condition.
Dr. Poceta: We always have them see one of the doctors first, to see if a sleep test is necessary. Sometimes it is. Sometimes it’s not. We can do sleep testing at home or sleep testing in the sleep center with wires and monitors on. We have a device that is sort of like a Fitbit that can give us information. So the testing is whatever is necessary for that individual person. We see if there are breathing problems. We see if there are leg movement problems. We see if their awareness and ideas of their sleep, matches what we can see on the brainwaves.
Dr. Loewy: One thing that’s very important is to maintain a consistent morning wake up time and compliment that with getting light. Bright sunlight in the morning, combined with a consistent wake up, is the anchor point for your internal sleep rhythm. I usually give people a bit of a break on the weekend with that. I’ll give them an extra hour in bed because I don’t want to be cruel. But it shouldn’t be a wide discrepancy.
On the bed time side, patients always say, “I'm told to keep a regular bed time.” Well you can’t predict when you’re going to fall asleep, so sometimes that can be a little tricky. My recommendation for bed time is go to bed when you feel sleepy, not tired, bored or fatigued, but sleepy. That’s when your body is knocking on the door saying, “Okay, it’s time to go to bed.” Don’t artificially put yourself to bed prematurely. You’re just going to set yourself up for long-time waiting, and that creates more conditioned arousal and frustration. So sleepy bed time, regular morning wake up. And no clock checking at night.
Don’t suffer your insomnia in bed. Give yourself a chance to fall asleep. Or if you wake up, give yourself a chance to fall back to sleep. But if it starts to prolong, and you’re getting restless, agitated, angry, leave. Go somewhere else. Do something distracting and relaxing. Read a book. When you feel more centered, come back and try again. But don’t suffer your insomnia in bed because those negative feelings will start getting automatically associated with that room. I’ve had people tell me they dread their bed. They hate bed time. They hate night time.That’s a deep hole to come out of and to prevent that, you don’t want to suffer in bed.
I usually tell people to turn off their screens about an hour before their intended bed time because it’s usually about an hour before you fall asleep where your melatonin is starting to get secreted. The reality of the situation is you can tell people to turn off their devices in the evening, but they’re not going to do it. Similarly, students who have to do homework on computers, they have to do what they have to do. So you try to create like a buffer, maybe no electronics for an hour before bed. And that’s a good time to read or do something that’s non-technology based.
Dr. Poceta: Blue light is more arousing. Blue light suppresses melatonin better. So most of the phones or devices have apps to minimize the blue and enhance the yellow. That is less stimulating to the body.
Dr. Loewy: You can find that in your device settings for display. Just look for the blue filter setting and you can tell it when to turn off and turn on. And that will help protect the melatonin.
Don’t drink alcohol after dinner time, or three our four hours before bed.
If the only time to work out is after work, so be it. Just don’t do an intensive workout too close to bed time. Give yourself a couple of hours.
Make sure your room is quiet and cool. Quiet bedrooms usually make for the best sleep, but that is not always achievable. There are pets. There are noisy neighbors. There are snoring bed partners, which is a huge one. So we try to sift through as much of that as we can.
Dr. Poceta: Studies show the bed partner of a sleep apnea patient sleeps worse. Of course, our brain adapts so that we don’t hear the rain every time after a while, but things in the bedroom that are loud can be a real problem.
Meditation, breathing exercises, relaxation exercises are important as an add on to the overall sleep program. In and of itself, it won’t put you to sleep, but meditating can reduce stress, reduce heart rate, relax you and enhance the ability of your sleep to come out.
Dr. Loewy: It also helps to have a routine, something sort of consistent in the way we sleep train our young children. The evening routine before bed is consistent and so part of them is actually anticipating the onset of sleep. Adults respond to the same kinds of cues. And so an evening ritual that includes relaxation without technology, and that is consistent, can be very helpful.
Dr. Poceta: Sleep is kind of Zen-like. It comes passively to you. You want to do what you can to help it, but you can’t worry about it and freak out about it because then you’re in a negative cycle. So there’s a lot we still don’t understand about sleep and how to sleep better but all the things that we’ve said are really solid and should be able to help people.