Why Can’t I Sleep???
Can’t sleep? You’re not alone. Adults need seven to nine hours of sleep, and according to the National Sleep Foundation, six out of every ten Americans can’t sleep. It’s showing up in our productivity, our waistlines, and our physical and mental health.
Insomnia is considered a sleep-wake disorder and is classified in the DSM-5 as a mental disorder. It has three primary symptoms:
Trouble falling asleep (longer than 20-30 min to fall asleep)
Trouble staying asleep (frequent waking with difficulty getting back to sleep)
Early waking (before 6.5 hours of sleep, with inability to get back to sleep)
The classification also requires that you have adequate opportunity to sleep, you are not under the influence of drugs/alcohol which interfere with sleep, you have no other pre-existing sleep/wake or mental health conditions, and you have struggled with this for at least 3 nights a week for at least 1 month (episodic insomnia) or 3 months (chronic insomnia).
While you may not be able to meet all of the above criteria, the DSM 5 expands its definition to include ‘unspecified insomnia’- for those that fit some but not all of the conditions and feel their lives are disrupted by inadequate sleep; and ‘acute insomnia’ - for those that experience most/all of the symptoms but not for the time duration specified.
Whether you suffer from acute, chronic, or some unspecified type of insomnia, any degree of sleep deprivation can have a significant impact on your health.
Obesity
Weight gain and obesity is associated with inadequate sleep and poor sleep quality for reasons we are still exploring. What we do know is that a lack of sleep can lead to dysregulation of the hypothalamus, resulting in poorly controlled appetite and satiety regulation, and energy expenditure. Children are highly susceptible to this effect.
Also, with inadequate or poor sleep we see increased levels of the hormones ghrelin (increases hunger), cortisol, and insulin (promote fat storage), and decreases in the hormone leptin (signals satiety).
Diabetes
Poor sleep is associated with type two diabetes and increased hemoglobin A1C levels (independently of body weight). Optimizing sleep has been shown to improve blood glucose levels.
Cardiovascular Disease
Poor sleep has been associated with increased risk for hypertension, heart disease, heart attacks, stroke, and cardiac arrhythmias.
Immunity
We all know the feeling of being run down after a few nights of poor sleep. Research confirms that both innate immunity (immunity you are born with), and adaptive immunity (immunity you acquire after exposure to a virus or vaccine), are strengthened while we sleep.
Getting less than 6-7 hours of sleep each night increases our risk of infections such as a cold or the flu. And studies have shown that vaccines are less effective in individuals who regularly sleep less than 7 hours a night, due to a reduced capacity to develop our adaptive immunity.
Inadequate sleep can increase healing time for more serious illnesses and injuries.
Researchers have also found that inadequate sleep can increase the susceptibility of experiencing an allergy attack, and an increased reaction to an allergen.
Other
Chronic poor sleep / insomnia has been found to be a significant risk factor for depression, fibromyalgia, rheumatoid arthritis, asthma, and osteoporosis.
Learning, Memory and Cognition
And…(no surprise here) sleep deprivation affects our cognitive functioning as well.
Sleep is important for memory and learning by affecting all three aspects of learning: acquisition, consolidation, and recall. Acquisition and recall occur while awake. When we are sleep deprived, we are less likely to concentrate, and our mood may be affected. This changes the way in which we perceive information, and reduces the amount of information we are able to process (acquisition). Recall is delayed after a poor night of sleep.
Consolidation, the process we often refer to as ‘committing something to memory’, occurs during sleep. Declarative memory (learning facts), and procedural memory (how to do something- including motor and visual learning) have been found to occur at different sleep stages. Therefore, adequate sleep involves not just the number of hours of sleep, but making sure we go through all of the stages.
These cognitive effects may be largely due to the glymphatic system. The glymphatic system is a complex waste clearance system that works while we sleep to eliminate excess fluid and metabolic waste (including beta-amyloid, which is implicated in Alzheimer’s Disease) from the central nervous system (CNS). It is often referred to as the lymphatic system of the brain. The glymphatic system also delivers nutrients such as glucose, lipids and amino acids, as well as neurotransmitters (chemical messengers) to the brain. The glymphatic system becomes inhibited and ineffective in times of stress and poor sleep. This disruption has been associated with neurodegenerative diseases like Alzheimer’s Disease, Parkinson’s Disease, and ALS, as well as pathological changes in the brain that occur after a brain injury or stroke.
Are you getting enough?
Again, the National Sleep Foundation, the CDC, and most health authorities recommend getting 7-9 hours of sleep a night. Signs of poor sleep quality include not feeling rested even after getting enough sleep, repeatedly waking up during the night, early wakening, and experiencing symptoms of sleep disorders (such as snoring or gasping for air).
If you are experiencing symptoms of poor sleep quality without a known medical reason, there are steps you can take to help improve your nights.
Sleep Stressors
First, it's important to consider what factors may be contributing to poor sleep. Some of the most common denominators to sleep troubles include:
Acute or chronic stress - the inability to wind down when it’s time to rest
Scheduling issues - the inability to sleep at least 7 hours due to work, social, and family obligations
Chemical stimulants - caffeine, herbal stimulants, stimulant medications
Physical stimulants - exercising too close to bedtime
Mental stimulants - emails, social media, TV
Sleep interruptions - children, partner, pets
Physical environment - uncomfortable bed/pillow, temperature issues, etc
Medical - hormonal changes (men and women), pain
Addressing these and other issues that can affect our sleep is part of creating healthy sleep hygiene.
Sleep Hygiene
Sleep Hygiene refers to the behaviors we have around bedtime and sleeping. Improving sleep hygiene can solve many of our sleep problems. Start with these tips:
Try to keep the same bedtime and wake time daily. This helps set and maintain our sleep / wake rhythm
Avoid caffeine in the afternoon. Some of us are slow metabolizers and need to cut it off even earlier. Play with your stop time to see what works best for you.
Exercise regularly. Just not too late. Later evening workouts can create too much stimulation, making it difficult to sleep at night.
Avoid alcohol 3-4 hours before going to bed. While a glass of wine may help you fall asleep, alcohol is a sleep disrupter, causing night waking.
Get as much sunlight as you can during the day, and keep lights low in the evening. This helps regulate your natural melatonin levels- helping you to fall asleep and stay asleep better.
Create a wind-down routine: Start 1-2 hours before you want to fall asleep. Brush your teeth, wash your face, take a shower, stretch, meditate or read, etc.
Avoid getting into bed until 30-50 minutes before you want to go to sleep. This helps to create the association that the bed is for sleeping (not working on your laptop, watching TV, etc)
Avoid stimulating activities 1-2 hours before bedtime (phone use, dramatic / suspenseful television shows, etc). Try reading, listening to relaxing music, etc.
Remove or cover clock faces. This helps eliminate anxiety during night waking.
Take a hot bath or shower. According to the NSF, in the hours before bedtime, our core body temperature naturally cools, while skin temperatures of the hands and feet increase. Researchers believe that exposure to hot water aids this natural temperature regulation process, improving sleep as a result.
Keep your room temperature between 65 and 68 degrees, which is considered the optimal temperature for sleeping.
Keep tech out of the room if possible. Having a phone or device in the room an cause sleep procrastination (ie: a last minute check of email can lead to a 45 min interweb rabbit hole)
Stop eating at least 3 hours before bed. Some researchers suggest that eating close to bedtime interferes with proper sleep function.
If you find it difficult to fall asleep (longer than 20-30 min), get out of bed and go do something somewhere else. Read a book, listen to music, pray, meditate; just not in your bed. Don’t return to your bed until you get sleepy. The goal is to prevent the association of being in the bed with not being able to sleep.
Even if you are sleep deprived, avoid napping during the day. Staying awake is thought to increase ‘sleep pressure’, the strong desire to sleep, which in turn should help you sleep better on subsequent nights.
Don’t get in the habit of using your phone / tech right after you wake in the morning - this can cause anticipatory anxiety at night: We anticipate the flood of anxiety produced by reading emails, checking to-do lists, etc, as we go to bed, which lightens our sleep, decreasing deep sleep. Try to wait until after you’ve been awake, had your coffee, shower, etc.
If you are a light sleeper, consider using white noise or ear plugs to eliminate being woken by the dog, other family members, or outside noises.
Try these tips for at least two weeks.
If you have maximized your sleep hygiene and still have trouble sleeping, you may be tempted to reach for a sleep aid. Read this first…
Concerns with OTC Sleep Aids
Over the counter sleep aids like ZzzQuil and Unisom, as well as antihistamine medications like Benadryl, Nyquil, and Tylenol PM contain diphenhydramine and doxylamine, which block certain chemicals in your brain, helping you to relax. Common side effects include lingering next day sedative effect, dry mouth, blurred vision, urinary retention, and constipation.
When these medications are taken regularly they become less effective. Tolerance to these drugs can lead to users taking doses beyond the recommended limits.
OTC sleep aids containing diphenhydramine (Tylenol PM, Benadryl, Advil PM, Unison, Sominex) are of specific concern because diphenhydramine belongs to a class of drugs called anticholinergics. Anticholinergics block activity of a brain chemical called acetylcholine. Acetylcholine plays a role in muscle activation and also in brain functions like alertness, learning and memory.
Use of anticholinergics has been associated with Alzheimer’s Disease because of this suppression. Diphenhydramine is considered a high potent anticholinergic. One study found that people who took these medications 2-3X/week over a ten year period, have a >50% risk of developing dementia, and the American Geriatrics Society has deemed these ‘generally inappropriate’ for the senior populations.
Concerns with Prescription Sleep Aids
Approximately 8% of Americans turned to prescription sleep aids (PSA) in the past year, a number that has been steadily increasing. PSAs can be chosen depending on whether you have trouble with sleep onset or sleep maintenance.
PSAs come with certain side effects, the most common and notable is next day lingering sedative effect (80% of people). Other side effects include confusion and lack of coordination, and abnormal behavior.
The FDA has added a Black Boxed Warning on certain sedative hypnotic PSAs including Ambian, Lunesta, and Sonata, citing ‘complex sleep behaviors leading to injury and death’. Cases included accidental overdoses, falls, burns, near drowning, exposure to extreme cold temperatures leading to loss of limb, carbon monoxide poisoning, drowning, hypothermia, motor vehicle collisions with the patient driving, and self-injuries such as gunshot wounds and apparent suicide attempts. The underlying mechanism for these reactions is still not totally clear.
There is also an association between sedative hypnotics and an increased risk of cancer (~ 35% increased risk of lymphomas, lung, prostate, colon, breast).
CBT- I
For patients suffering from chronic insomnia, CBT-I (cognitive behavioral therapy for insomnia) is recommended by the American Academy of Sleep Medicine as a first line therapy. From the AASM: “CBT-I combines one or more cognitive therapy strategies with education about sleep regulation plus behavioral strategies such as stimulus control instructions and sleep restriction therapy. Treatment typically involves four to eight sessions.
The AASM recommends that individuals only use PSAs if they are unable to participate in CBT-I or if CBT-I is ineffective.
Other tips:
Nutrition
Good nutrition plays a role in good sleep. Research has identified sleep problems with specific nutrients. Below is a list of different sleep conditions and associated deficiencies or excesses. Increasing or decreasing your daily intake of these nutrients may help you sleep better.
Difficulty falling asleep:
Inadequate selenium: Widely available in foods. Good sources are nuts, fish, eggs, poultry
Inadequate calcium : Best sources are dairy products, also found in edamame, tofu, dark leafy greens, canned salmon or sardines with bones
High saturated fat, specifically hexadecanoic acid- Palmitic acid- often used to improve mouthfeel in processed foods, listed as sodium palmitate in organic foods
Poor restorative sleep:
Inadequate Vitamin C : Citrus fruits, strawberries, potatoes, tomatoes, bell peppers, cruciferous vegetables
Inadequate Calcium : Best sources are dairy products, also found in edamame, tofu, dark leafy greens, canned salmon or sardines with bones
Inadequate water intake
Staying Asleep:
Inadequate Vitamin D : Cod liver oil, salmon, fortified milk, swordfish, tuna, exposure to sunlight, supplements
Shorter sleep duration:
Inadequate Lycopene : Red, pink, or orange fruits and vegetables: tomatoes, grapefruit, apricots, peaches, cranberries, bell peppers
Disrupted sleep:
Excess theobromine: stimulant found in coffee, tea, cocoa
Excess caffeine : coffee, tea, colas, chocolate
Excessive salt intake
There has been a positive association between a Mediterranean Diet and improved sleep latency and quality.
Nutritional and herbal supplements:
The following supplements have been found helpful with sleep, but some come with caution. (Safety information provided is for healthy individuals only. If you have a chronic illness, are pregnant, or take prescriptions medications, talk with your doctor or pharmacist before starting any of these supplements)
Melatonin: Probably the most well known sleep supplement, melatonin is a hormone produced by the pineal gland, relative to light, that sets our circadian rhythm. Melatonin is used widely by individuals, and in the health care setting. Melatonin is suited for short term use only, at doses of .5 mg to 3 mg (vs the 5-10 mg doses often sold at drug stores/grocery).
Unfortunately, the ‘more is better’ mantra doesn’t apply with this medication. Long term use and excess doses can suppress our bodies natural melatonin production, causing disruption to our natural circadian rhythm. And larger doses can have the opposite effect, leaving you awake and restless all night. If you are looking for help sleeping, start by taking 1 mg 2-3 hours before bedtime. Do not take for longer than one week at a time.
Some researchers suggest that we become naturally deficient in melatonin as we age, and recommend taking melatonin regularly after the age of 65, without breaks. Talk with your doctor if this is something you want to explore.
Magnesium : Magnesium has a relaxing effect on the brain and body, and has been shown to help people fall asleep faster and stay asleep - safe doses are 150-250 mg, taken 1-2 hours before bedtime. Larger amounts can cause diarrhea.
Calcium: Calcium is thought to help with sleep due to its role in brain conversion of tryptophan to melatonin, and can help improve REM sleep. Start with 500 mg 1-2 hours before bedtime.
Glycine: 3 g taken before bedtime has been shown to increase sleep latency and quality. This amino acid is often combined with magnesium as a sleep aid.
L theanine: L theanine is another amino acid that is often combined with magnesium. 200 mg has been shown to improve relaxation and sleep.
Tryptophan: The turkey nutrient. Supplements in doses of 1g are shown to improve sleep quality and reduce night waking. Larger doses are not recommended.
Gingko Biloba: may reduce stress and promote relaxation. Try ~240mg, 30-60min before bedtime.
Kava - Kava has been shown to be effective for relaxation and inducing sleep. According to the WHO, liver toxicity is rare, but consider alcohol use, excessive doses and pre-existing liver disease as contraindications to using Kava. Teas made with Kava are a good way to get this herb.
Chamomile - Chamomile is established as safe and effective in improving sleep quality, and anxiety.
Valerian root: Valerian can improve sleep latency and duration. Safe doses are up to 500 mg pills. Teas are also an effective route.
Passion Flower tea: Passion flower has been shown to help sleep latency and quality. It is safe to use in teas.
CBD: CBD is a hot topic right now; for good reason. We are learning about the positive effects of CBD daily. With regard to sleep,the jury is still out. There are not a lot of randomized clinical trials (RCTs - the gold standard) on CBD and sleep, but we do know that it can help with anxiety, and there is a lot of anecdotal evidence it can help with sleep. With the rise in popularity there are companies jumping to get into the game. If you are interested in trying CBD oil, be discerning, and use caution.
Delta 8 and Delta 9 products: These products are legal in some states. Be aware, they may contain active THC, and can create a positive drug test. Some side effects can include hallucinations, disorientation, poor balance and coordination.
Other Helpful Methods for Improving Sleep:
Meditation - A quick search in your phone app store will give you a number of free and paid meditation apps that provide guided meditation specifically for sleep. This low cost, no risk therapy is highly underrated!
Aromatherapy - Another low risk, low cost alternative. A diffuser is often the best way to try aromatherapy, but you can also experiment with scented pillows or preparations designed for topical application. The following essential oils have been shown to help people wind down and sleep better:
Lavender
Ylang Ylang
Chamomile
Marjoram
Vetiver
It’s no wonder we have trouble sleeping these days. Our lives are busy, and often stressful. We neglect our personal needs for our family and work obligations. We’re attached to our tech. We drink too much coffee. We spend all day indoors away from natural light. We eat food that lacks nutrition. We stay up too late. We get up too early. And we think we can keep it up, until we can’t. The good news is that most sleep problems can be solved with more attention to our habits. If you’ve had chronic sleep problems, take some time to work some of these strategies into your routine. And if necessary, talk with your doctor. Your body will thank you!
Resources:
Peter Attia MD Podcast: #221 Understanding Sleep and How To Improve It
Clinical definition of Insomnia
Poor sleep and chronic disease
Poor sleep and chronic disease CDC
Poor sleep and chronic disease Harvard Health
Sleep and the glymphatic system
Risks associated with sleep aids
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3866235/
The 5/10/15
Fuel, Energize, Unwind - on Your time