SLEEP

What can be done about difficulty sleeping (insomnia)?

Sleep is simultaneously boring and fascinating. It is boring because, well, it's sleep. You don't really do much while you are sleeping. In fact, if something is exceptionally boring it is said to "put you to sleep." It's generally an inactive task - the best way to accomplish it is to simply do nothing. It is fascinating because there is much that we still don't understand. For example, a question as basic as "why do we sleep?" is not well known. We do know, with great certainty, that poor sleep is detrimental to one's health -- in fact, lack of sleep can be lethal in extreme cases.

If you want to dive more into the why of sleep, I would recommend this book by Matthew Walker

FIRST, SOME ASSUMPTIONS

For the purposes of this post, I will make several assumptions:

1. Sleep is important
2. More sleep is better
   • In other words, I am assuming that most readers are not getting enough sleep, rather than getting too much sleep.
3. You have not yet tried anything to help your sleep
4. Your habits are typically "American"

OUTLINING THE STEPS TOWARDS BETTER SLEEP

In the following paragraphs, I will walk through the steps I typically take with most patients when they present with a chief concern of insomnia. Certainly every patient is different, and your individual circumstances might not apply. As always, speak with your healthcare professional for any particular concerns.

The process towards better sleep can generally be divided into three steps:

1. Define what "better sleep" means
2. Measure your current sleep patterns and "sleep hygiene"
3. Optimize your sleep hygiene

The first step focuses on defining the issue, so that the desired outcome is clear. The second step focuses on measuring sleep more objectively, so that it is easier to see current patterns and the effect of the interventions (step 3) on sleep. Step 3 focuses specifically on methods to improve sleep, including augmenting the pre-bedtime routine.

STEP 1: DEFINING BETTER SLEEP

I like to define better sleep using both subjective and objective measures. Subjectively, most people can tell whether they've had a good night of sleep simply based on how they feel in the morning. Groggy and foggy? Poor sleep. Energetic and focused? Good sleep. Objectively, for 99% of people, more sleep is better. Therefore, a surrogate marker for sleep quality can be sleep duration (although certainly there are circumstances where duration does not equal quality). If you have a device that measures your sleep (see below), it will typically give you some sort of more objective score or metric for how well you've slept the previous night. These scores, while imperfect, are generally precise enough to interpret as an aggregate. For example: if you notice every Saturday night your sleep score is better than the rest of the week, focus on what you're doing differently on Saturday versus other days. In other words, be careful interpreting data from an individual night, as there is some margin of error.

STEP 2: MEASURING YOUR CURRENT SLEEP PATTERNS AND "SLEEP HYGIENE"

As I alluded to above, objective measures of sleep quality do exist. The most widely used devices measure quality of sleep via sleep actigraphy, which is basically a measure of how restless you are while you sleep, along with other measures such as heart rate. Common devices that use a form of sleep actigraphy to measure sleep include the Apple Watch, Fitbit, and Oura Ring. These various devices that use sleep actigraphy can typically give you a pretty good estimate of how long you've slept (including the estimated time in each of the sleep stages) and the quality of your sleep. This data is useful since, of course, what gets measured gets improved.

Sleep hygiene is an important topic to introduce here. Sleep hygiene is broadly defined as one's patterns of behavior that influence the quality, ease, and duration of sleep. Therefore, sleep hygiene is NOT sleep, but instead involves the waking hours. It is absolutely critical to optimize sleep hygiene in order to improve sleep -- good sleep hygiene is the sine qua non of good sleep.

STEP 3: OPTIMIZE YOUR SLEEP HYGIENE

So, finally, to the core of the issue: what can one do to improve sleep? The following is a non-comprehensive list of the most common ways to improve sleep hygiene and therefore sleep quality. Not every piece of advice may apply to your specific situation, but that is OK - implement changes as appropriate.

• Limit afternoon caffeine. The average half-life of caffeine is about 5 hours. This means that if you drank a cup of coffee at 3pm, you'd still have 25% of that caffeine running around 10 hours later at 1am. This significantly increases risk for insomnia.
• Limit alcohol use. Although alcohol may help you fall asleep, it is known to significantly decrease sleep quality and should absolutely not be used as a sleep aid. It does much more harm than good.
• Limit screen time. This one seems to be the hardest for patients, who are glued to their phone, television, or tablet leading up to bed. The blue light in screens can alter the natural circadian rhythm, and this negatively impacts sleep quality. To be fair, most of the studies in this realm have been done in children/adolescents, but adult studies tend to share similar conclusions.
  • My typical recommendation to patients is that they should avoid screen time 2 hours before they plan on falling asleep. "But what will I do with my time?" patients inevitably ask. My answer: read a book, listen to a podcast, talk with your family/friends, meditate, meal prep for the next day, do laundry, clean the house, work out, etc. Life goes on without the screen!
  • Also: please do not sleep with the television on. Turn it off and enjoy the quiet and darkness.
• Be tired. One of the best ways to get a good sleep is to deserve it - tire yourself out physically and mentally. An early-morning workout is my preferred way to ensure I will sleep better that night, and if I find myself in the "tired-and-wired" phenomenon (where my body is exhausted but my mind is racing), I find that solving an interesting problem/puzzle, and/or meditating for 20 minutes, will ensure I am properly tired and ready for sleep.
• Limit nocturnal interruptions. Wear earplugs if you need to drown out loud neighbors, noisy kids, or snoring spouses.
• Don't chug water before bed. Yes, staying hydrated is important -- but timing matters. Your water drinking should be focused on the first half of the day, not the hour or two before bed. Drinking water (or any other fluid for that matter) before bed will only cause you to wake up in the middle of the night to urinate, which obviously interrupts your sleep.
• Keep the room dark. Light (even if dim) can negatively impact sleep quality, and therefore I recommend sleeping in as dark of an environment as possible.
  • Note: if you are someone who gets up frequently at night and uses a night light, try these motion-activated night lights which will only go on when you need them/move.
• As a last resort, sometimes a little melatonin supplementation can be useful in addition to all of the above interventions. Although there is a wide range of doses of this supplement, I typically recommend a very low dose, 1mg, taken roughly 2 hours before planned bedtime.

Prescription sleep aids are also available, however they can be habit-forming and I do not use these as first-line agents, especially if a patient's sleep hygiene is sub-optimal. For the purposes of this post, I will abstain from intense discussion of these medications, but will offer that trazodone seems to be a good first-line agent since it is non-habit-forming and preserves sleep architecture.

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