We don’t understand why it is important to try to achieve 8 hours of sleep per night, but we do understand the consequences of not getting proper sleep quantity and quality! Infants need 12-16 hours, preschoolers need 10-14 hours, adolescents need 9-12, teenagers need 8-10 hours and adults should plan for 8 and be happy getting 7 to 8 hours of good sleep most of the time. As we get older, we lose deep (N3 sleep) and dream sleep (REM sleep); there is a difference, dream sleep is not deep sleep. For the “normal” sleeper, we dream about every 90 minutes of the night and our dream periods are longer towards the end of our sleep period. Experts believe dream sleep in infancy helps the brain mature and help adults retain memory better. Deep sleep occurs more in the first few hours of our sleep period, and we believe this sleep helps us feel more refreshed in the morning. Several studies have consistently shown chronically getting less than 6.5 hours of sleep increases our mortality by 70%. Chronic sleep deprivation is now more common than it has ever been in our culture.
It important to understand multiple medications can affect our sleep both quality and quantity. Most over the counter sleep medications that contain Benadryl and Benadryl-like medication decrease both deep and dream sleep so they may help quantity of sleep, but they worsen the quality of our sleep; they also lose effectiveness the longer they are used and require higher doses which only makes the quality of sleep worsen more. If these products are used chronically, they can adversely affect men’s prostate function and lessen both gender’s memory recall and cognition.
Multiple studies continue to prove that Cognitive Behavior Therapy for Insomnia (CBTi) works better than medication, but I believe the two working together works faster for patients who always want an immediate fix. Now over 30 years helping patients with their insomnia, it is quite apparent to me that CBTi is necessary for patients to continue achieving adequate sleep quantity and quality of sleep. Good sleep medications lose their effectiveness if CBTi is not maintained. Maintaining good sleep hygiene and following the rules of CBTi help patients transition off sleep medications sooner and result in better long-term sleep improvement.
CBTi is not commonly covered by insurance companies and usually difficult to find someone who offers this therapy. It can be obtained online through various websites. Over the years I’ve incorporated the multiple modalities of CBTi into my everyday practice working with patients using 5 simple rules. I always guarantee my patients they will be sleeping better over time working with me but the sooner they master my 5 rules, the sooner they will be sleep better with or without medication.
Before discussing my 5 rules of better sleep management, I review the patient’s health history and medications because both can adversely affect their sleep as noted later in this article. Then I ask what 8 hours they want to be in the bedroom preparing for sleep and sleeping in the bed. Typically, it is 10pm to 6am.
Rule #1: Always wake up the same time in the morning and get out of bedroom and start your day no matter how little sleep you have received during the night
Rule #2: No Napping during the day between wake-up time and bedroom time. Napping in the late afternoon is the worst thing a patient can do to get a good night sleep
Rule #3: Only 2 good things in the bed: sleep and intimacy! If not doing either, then get out of the bed but not the bedroom and proceed to Rule #4.
Rule #4: If not doing either of the 2 things mentioned in #3, then leave lights off and get into a comfortable chair in the bedroom and focus on 3 things: music without words, listening prayer, and meditation.
Rule #5: And finally, for the mind racing patients and ones that worry too much, they need a processing time some time before bedroom time. I encourage writing down their “to do list”, what made them angry or upset during the day, and/or simply journaling about the issues on their mind so this is less likely to occur while trying to go to sleep. So many patients do their processing time in bed and wonder why they can’t go to sleep.
We have two receptors in our brain, the GABA and Orexin, acting like the brake and accelerator in our car. If one accelerates the Orexin receptor, while trying the brake the GABA receptor, the car/brain doesn’t work very well. You can use multiple brakes (sleep medications) but if you leave your foot on the accelerator (mind race/worry), the car (brain) will have a difficulty stopping (getting to sleep) and maintaining the brake (sleep) through the night.
Studies have consistently shown worsening health conditions occur when proper sleep quality and quantity are not achieved. Even people who are getting adequate hours of sleep may suffer other medical problems because of unknown sleep apnea, restless legs syndrome/periodic movements of sleep, and other sleep disorders. Here is a list of some medical problems made worse with poor sleep and vice versa:
- Obesity has become epidemic and poor sleep causes an increase secretion in the hunger hormone, ghrelin from the stomach. At the same time there is decrease in the satiety hormone, leptin secreted from the fat cells. One study suggests for every extra hour of sleep towards the daily goal is associated with a 50% reduction in the risk of obesity. Poor sleep also leads to slower metabolism perhaps because of less growth hormone secreted in deep sleep.
- Blood Pressure is affected by poor sleep, elevation is more common in short sleepers getting less than 5 hours of sleep. The lack of physiologic blood pressure drop that normally occurs during the night that is not present in poor sleep can lead to worsening cardiovascular disease. Multiple awakenings during the night from insomnia, sleep apnea, and other sleep disorders increase our adrenaline and is associated with higher blood pressure. Untreated sleep apnea not only elevates blood pressure but is associated with stroke, heart attacks, atrial fibrillation, heart failure, diabetes, lower testosterone, erectile dysfunction, more urination during the night, and more GI reflux at night.
- Diabetes develops from genetic penetration, obesity from poor eating, sleep apnea, and simply from poor sleep. Getting proper sleep quantity and quality improves blood sugar control by enabling your own insulin to work more efficiently. Using CPAP for sleep apnea lowers blood sugar.
- Cholesterol problems particularly elevated triglycerides and low HDL (good cholesterol) can occur from poor sleep.
- Gastrointestinal reflux can cause insomnia and sleep apnea can worsen reflux. Eating too close to bedtime magnifies this problem as well.
- Asthma, uncontrolled, can worsen sleep and untreated sleep apnea can worsen asthma.
- Testosterone production is lowered in poor sleep particularly sleep apnea and replacement of this hormone can worsen sleep apnea.
- Cognitive dysfunction (brain fog) is greatly affected by all types of sleep disorders. Attention Deficit Disorder (ADD) is made worse in poor sleepers and sometimes misdiagnosed when the person may have a sleep disorder.
- Chronic pain, for example fibromyalgia, is worsened by poor sleep and proper sleep management is one of the few consistent modalities that improves this disorder. Chronic muscle pain is helped with proper sleep, particularly REM (dream) sleep because our skeletal muscles are paralyzed during this sleep stage helping our muscles relax.
- Bedwetting and frequent urination at night can be a symptom of sleep apnea and needs to part of the evaluation of these symptoms.
Insomnia is the most common sleep disorder in the United States affecting 30% of our population sometime during their lifetime. Sleep problems should be discussed during the evaluation of multiple medical problems and complaints, some listed above. It is important for patients to volunteer their sleep problems/complaints to their care providers to enable them to obtain the best information to solve their problem.
Michael Ledet, M.D. has practiced Sleep Disorders Medicine and Lipidology in Mobile Alabama for over 30 years. He is Board Certified in these disciplines as well as Family Medicine.