When Sleep is Elusive
Simple changes can eliminate restless nights.
by Susan Weiner
Among her friends, Ann Muldoon is likely to be voted most drowsy. A former university research scientist, Muldoon is a full-time mom to 11-year-old twins, works two part-time jobs when the girls are at school, and helps run the family homestead, a self-built log cabin on 56 acres in Hector, New York. Overrun with daily responsibilities, Muldoon wrestles with menopausal symptoms and her husband’s degenerative disc disease, which often keeps him sidelined. As a result, these days she tends to feel frustrated, forgetful and sleepy.
“It was supposed to be a hobby farm but neither one of us has the energy to farm,” says Muldoon, 49, who gets the kids to the bus stop by 6:30 a.m., then feeds and cleans up after 10 goats, 11 cats, 2 dogs, more than 20 chickens and 2 ducks before heading off to work. While the challenging schedule never concerned Muldoon in the past, recent stressors have affected her ability to sleep through the night.
“When I lie down at night, I think about what happens tomorrow, what happened today,” explains Muldoon. “I have nervous sleep interruptions. My stomach cramps up and I get intestinal distress. I usually go to the bathroom once or twice and then try to work through things in my head.”
Like Muldoon, most people will experience insomnia at some point. Simply defined, insomnia is the inability to get high-quality sleep. The inability to fall or stay asleep, in addition to waking up early and awakening throughout the night, are all forms of insomnia. It can last a day, a week, a month or even years.
Only one-third of adults say they are getting enough sleep every night, reports the Centers for Disease Control and Prevention in a 2008 study. An estimated 50 to 70 million Americans suffer from chronic sleep and wakefulness disorders, with sleep loss tied to mental distress, depression, anxiety, obesity, high blood pressure, diabetes, high cholesterol and risky behaviors such as cigarette smoking, physical inactivity and heavy drinking. One in 10 adults reported not getting enough sleep every day for the past month, and women were more likely than men to report not getting sufficient sleep.
Prompted by natural cycles of activity in the brain, sleep is composed of two basic states: REM, or rapid eye movement, and NREM, or non-rapid eye movement. The body cycles between non-REM and REM sleep, with dreams occurring during the REM stage.
NREM sleep is made up of stages 1 to 4. A person can be awakened easily from Stage 1 and may feel as though he or she hasn’t slept. During Stage 2, a period of light sleep, the heart rate slows and body temperature decreases. Stages 3 and 4 are deep sleep stages, known as slow-wave or delta sleep, and are the stages when the immune system strengthens and the body repairs and regenerates tissue.
“Without proper deep sleep, the body doesn’t have the opportunity to restore itself,” says Linda Klein, MD, of Oregon City Family Practice Clinic in Oregon. “So all functions could break down, including immune response, cognitive function and motor coordination. Sleep is the body’s way of recharging. If you don’t plug in your cell phone, the battery is going to die.”
With sleep increasingly losing out to late-night television and Internet surfing, scientific evidence suggests that sleep deprivation is taking its toll on America’s health. The Harvard-run Nurses’ Health Study links insufficient or irregular sleep to greater risk for heart disease, diabetes, colon cancer and breast cancer, since sleep disruption affects hormones and proteins that play a role in these diseases. Moreover, sleep-deprived people often develop problems regulating their blood sugar, increasing the risk for diabetes.
When treating her patients, Klein first tries to rule out underlying psychiatric and metabolic disorders, including conditions such as sleep apnea and restless legs syndrome. She then reviews the medications and emotional status of her sleepless patients. “What I most commonly hear is, ‘I get into bed and I’m thinking about the stressors in my life,’” says Klein. “They’re running a list in their mind and, when they get to the bottom of the list, they start again at the top.” Before going into the bedroom to sleep, Klein asks patients to write down their thoughts. “Journaling the list is a way of purging it out of their brain. It seems to really help.”
The primary reason Americans are tired is because they want to be. That’s the view of Michael Breus, PhD, a specialist in clinical sleep disorders and author of Good Night: The Sleep Doctor’s 4 Week Program to Better Sleep and Better Health (Penguin). “Sleep as a main concern really seems to move down the priority list rapidly,” says Breus, who practices in Scottsdale, Arizona. “People say, ‘I don’t have enough time to sleep,’ or ‘I’ll sleep when I’m dead.’ You never hear people say, ‘I’ll eat when I’m dead.’”
Along with the usual suspects—caffeine, nicotine, alcohol, exercise and certain medications too close to bedtime—stress is a primary sleeplessness trigger, Breus reports. “Probably 75% of my patients who come through the door with some form of insomnia usually have either depression or anxiety as a major factor in their ability to fall asleep and stay asleep,” he says.
Even a patient who sleeps through the night may still feel rundown and exhausted. “If you sleep eight hours, but it’s a restless sleep, it could be the equivalent of three,” explains Breus. “There’s the physical act of sleeping and there’s the perception of sleep. One person’s six hours may be great for one person and a nightmare for someone else. There’s no scale for sleep. You can’t go in the bedroom and step on a scale to see how well you sleep.”
Alongside a greater likelihood of depression, fatigued individuals are more likely to pack on the pounds, since even mild sleep deficits disrupt levels of the appetite-regulating hormones ghrelin and leptin. Researchers found that over a 16-year period, women sleeping five or fewer hours per night were 32% more likely to experience a significant weight gain of 33 pounds or more, with another 12% increasingly prone to becoming obese, according to a study presented at the American Thoracic Society 2006 International Conference.
Women face another challenge: About 61% of menopausal women lie awake at night, according to the National Sleep Foundation. “Hot flashes, anxiety and depression can interfere with sleep,” says Breus. “A lot of these have to do with hormone fluctuations happening on a regular basis and disrupting sleep.” To help ease menopause symptoms, Breus suggests banishing heat-holding memory foam mattress toppers, increasing soy intake, wearing pajamas made from dry-weave material and trading in down for a cool-feeling wool comforter.
Sleep Hygiene Helpers
Anyone can engage in healthy practices and behaviors that can improve sleep. Many commonsense points include avoiding big meals, exercise and stimulants such as nicotine, alcohol and caffeine before turning in. Habits such as sleeping odd hours, napping during the day, sleeping with pets, eating junk food, paying bills in bed, using the Internet and even watching television in the bedroom can also lead to tossing and turning late into the night.
“When thinking about sleep, you should think about all five senses,” says Breus, who suggests creating your own unique sleep sanctuary that incorporates darkness, peaceful quiet or soothing sounds, aromatherapy and a comfortable, quality bed. By avoiding spicy foods and stimulants, you can also avoid any unpleasant aftertastes or heartburn that may affect you during the night.
“Consider your environment,” adds Klein. “Lights should be off, air should be comfortable and soft music might be helpful. Reading a novel in bed, if it makes you sleepy, is okay, but not studying or working. If you’re taking medications for other conditions, you may want to take them in the morning instead of before going to bed. And you want to incorporate healthy foods into your diet.”
Keep your sleeping sanctuary dark, since exposure to light at night reduces levels of melatonin, a protective hormone believed to shield against cancer by affecting levels of other hormones, including estrogen, according to a series of sleep laboratory studies conducted at Harvard Medical School. Proper doses of a melatonin supplement may enhance sleep while reducing the risk of developing breast and prostate cancer.
At any age, sleeping well is essential to your physical and emotional well-being. Faced with the stresses of daily living and the physical and hormonal changes of aging, however, bouts of insomnia may be inevitable. How we approach those sleepless nights makes all the difference. By creating a comfortable environment and making healthy changes, trying to get to sleep doesn’t have to be a nightmarish experience.
Don’t Snore Through Sleep Apnea
The standard snoring joke involves an upset spouse and banishment to the couch, but sawing wood is no laughing matter. Heavy snoring can be a sign of obstructive sleep apnea (“without breath” in Greek), in which blocked airflow can cause breathing disruptions that shatter sleep and result in low blood oxygen levels. The American Sleep Apnea Association (ASAA) says that more than 12 million Americans suffer from sleep apnea; an estimated additional 10 million sufferers have not yet been diagnosed.
When soft tissue at the back of the throat collapses, the upper airway becomes blocked. As a result, breathing can temporarily become either reduced (hypopnea) or stop entirely (apnea). This causes oxygen levels to fall, which in turn leads the brain to rouse the body from sleep. The person may not actually wake up during these episodes. But they disrupt slumber all the same, leading to excessive daytime sleepiness.
One way to measure apnea’s effects is the apnea-hypopnea index (AHI), which measures the number of apneas and hypopneas that occur during an hour of sleep. According to the American Academy of Sleep Medicine (www.aasmnet.org), an AHI between 5 and 15 indicates mild apnea, marked by sleepiness during activities such as watching TV; an AHI between 15 and 30 indicates moderate apnea, often marked by sleepiness during meetings or presentations; and an AHI of more than 30 indicates severe apnea, marked by sleepiness during activities such as driving. Excessive drowsiness isn’t apnea’s only effect: This disorder has been linked to cardiovascular problems (including a higher stroke risk), mood changes, poor concentration and problems with blood sugar control.
Sleep apnea becomes more common as people move into middle age and beyond. Other risk factors include smoking, alcohol usage, persistent nasal congestion, family history and endocrine disorders such as hypothyroidism. It is also more common among people with large necks (17” or more in men, 16” or more in women) and those with head and neck abnormalities.
While not everyone with sleep apnea is overweight, excessive weight is a risk factor for disordered nighttime breathing. Researchers have found a link between sleep apnea and metabolic syndrome, a collection of health problems that includes abdominal obesity and excessive blood sugar, pressure and cholesterol levels (European Journal of Internal Medicine 6/10). In another study, sleep apnea was associated with reduced physical activity and an unhealthy diet (Journal of Clinical Sleep Medicine 10/15/08).
Weight loss has been shown to ease sleep apnea, especially mild cases. “However, it may be hard to lose weight when you have untreated sleep apnea,” cautions the ASAA. “You may be too tired to exercise and you may eat to stay awake.” Sleeping on one’s side reduces the tendency of the throat to collapse during sleep, as does avoiding alcohol. Other sleep apnea treatments include surgery, dentist-fitted oral appliances designed to maintain an open airway and continuous positive airway pressure (CPAP), devices that send gently pressurized air through the nose to keep the throat open.
To learn more about sleep apnea, visit the ASAA at (www.sleepapnea.org).