By David Spero, RN | July 24, 2006 12:00 am
Sleep that knits up the ravell’d sleeve of care,
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
— William Shakespeare, Macbeth
You don’t need to be a great poet to describe the healing value of sleep. Nearly everyone knows the dragged-out feeling that comes with a sleepless night and how much better we feel after a restful one. What many people may not realize, however, is that sleep is not just “pleasant” or “refreshing” but necessary for good health.
Sleep gives the body time to relax and repair and is now also understood to play a role in learning. Insomnia, however, is one of the most common complaints in America, and it also has a link to diabetes: Sleep deprivation can make diabetes worse, and diabetes symptoms can make it harder to sleep.
The good news is that sleep problems are nearly always treatable. Usually, you don’t need any medicines or surgery to get to sleep, just some simple behavior changes. This article gives the basic concepts that sleep specialists use to help people get to sleep, stay asleep, and wake up rested. You will also learn what sleep conditions benefit from a doctor’s care.
Insomnia isn’t just an occasional rough night or sleeping less than you think you should. The key question to determine if you have insomnia is “how rested do I feel?” If you have all the energy and alertness you want, you don’t have insomnia, no matter how little sleep you get. On the other hand, if you’re tired and drowsy all day, you may have insomnia, even if you’re in bed 12 hours a night. The quality of sleep is as important as the quantity. For example, if you’re struggling for breath all night or your body can’t relax because of stress and tension, you may not feel rested no matter how much you sleep.
There are at least three kinds of insomnia: problems getting to sleep, problems staying asleep, and waking up too early and not being able to go back to sleep. Problems getting to sleep (sleep-onset insomnia) are often due to stress, too much activity or anxiety at bedtime, or bad sleep habits.
Problems staying asleep (sleep-maintenance insomnia) are often due to medical problems described later in this article such as sleep apnea or an enlarged prostate. We all wake up 12–15 times a night, but we usually get right back to sleep without ever realizing or remembering we’ve been awake. It’s insomnia if you can’t get back to sleep easily.
Problems with waking up too early are often a sign of depression, or they may be caused by noise and light in the bedroom.
Our fast-paced society takes its toll on sleep. The average American sleeps about 7 hours a night. A century ago, the average was 9 hours. Francis Buda, MD, cofounder of the Atlanta Center for Sleep Disorders, says, “The American population as a whole is chronically sleep deprived.”
Until recently, though, it was thought that lack of sleep had few long-term health effects. The main concern has been accidents and mistakes due to poor concentration and fatigue. But recent studies at institutions such as the University of Chicago and Pennsylvania State University have shown that sleep deprivation (getting at least two hours less than you want) leads to insulin resistance, increases in appetite, and higher levels of stress hormones in the blood — conditions that can contribute to the development of diabetes. Some researchers believe there may also be a connection between sleep disorders and heart disease.
While sleeplessness can promote diabetes, symptoms associated with high blood glucose, low blood glucose (hypoglycemia), and some diabetes complications can also interfere with sleep. If your blood glucose level is high, you may be in the bathroom urinating every few hours during the night. Hypoglycemia can cause nightmares, night sweats, or headache; hunger that wakes you up to get food; or symptoms associated with daytime hypoglycemia such as rapid heartbeat, dizziness, or shaking. Tracy Kuo, PhD, insomnia specialist and clinical psychologist at Sleep Disorders and Behavioral Medicine Services, says that a vicious circle can occur with diabetes and insomnia because “diabetic neuropathy can cause restless legs and pain. Fatigue from a poor night’s sleep may keep some people with diabetes from getting enough daytime activity, which in turn makes it harder to sleep the following night.”
As many as 36% of Americans have some type of sleep disorder. That’s a huge number. Why is sleeping so difficult? Sleep specialists have identified the following reasons, among others.
Substances. The late sleep specialist Peter Hauri, PhD, formerly Co-Director of the Mayo Clinic Sleep Disorders Center, says, “There are three things that have an excellent chance of helping you sleep, no matter what other factors are involved. These things are reducing caffeine, limiting alcohol, and stopping smoking.”
Although coffee and soft drinks are the most commonly recognized sources of caffeine, chocolate, some teas, and some medicines also contain caffeine. Even one cup of tea or a chocolate bar in the afternoon can keep some people up after midnight. Dr. Hauri suggests cutting all caffeine out of your diet. Once you get some normal sleep going, you can try slowly adding the caffeine back. If you smoke, nicotine cravings don’t stop at night, and they can wake you up. The only way out of this trap is to stop smoking completely. Of course, smoking and diabetes are a horrible combination anyway, so if getting a good night’s sleep encourages you to quit, it’s a win–win proposition.
People used to think an alcoholic drink was a good sleep aid, hence the term “nightcap.” But Dr. Hauri says, “Drinking alcohol late in the evening produces troubled and fragmented sleep. The person does not sleep soundly but wakes up several times and does not get back to sleep promptly. By morning, there invariably is less sleep than without alcohol.” Some foods, especially spicy foods, also cause insomnia in some people.
Sleeping pills. Almost all sleep specialists now try to avoid prescribing sleeping pills for people with chronic sleep problems. Although they can be useful for treating some short-term sleep disturbances, hypnotics (sleeping pills) are not usually given to people with chronic insomnia because they can become habit-forming, and people may even experience a rebound effect of more pronounced insomnia when the drugs are stopped. People also rapidly build up a tolerance to many sleep medicines, needing more and more over time to get to sleep. In addition, with some drugs, you can wake up in the morning feeling as tired as if you hadn’t slept at all. You’re also in danger of falling if you wake up in the night to go to the bathroom with sedatives in your system. This is a major cause of broken hips and other injuries for older people, especially people in nursing homes. Over-the-counter sleep medicines are just as bad, according to Dr. Buda.
Depression. Both insomnia and “hypersomnia” (sleeping too much) are classic symptoms of depression. If you lie in bed having thoughts of hopelessness or worthlessness, especially in the early morning, you may be depressed. Because depression is a risk factor for other problems and because it is treatable, you should seek professional help.
Sleep apnea. A number of medical conditions interfere with sleep. One is sleep apnea, where the person experiences interruptions of breathing during the night. Sleep apnea normally happens to heavy snorers, who are usually, but not always, overweight. Sleep apnea is typically observed when loud snoring is interrupted by about 10 seconds or more of silence as breathing stops and then starts again — often with a loud snort or gasp — which may wake you. (Some people think they woke to go to the bathroom, when actually it was sleep apnea.) This pattern may repeat many times an hour throughout the night. If you have a bed partner, he or she would probably notice the signs of sleep apnea first. You could also spend a night in a sleep lab for an official diagnosis. It’s worth checking out, because sleep apnea is associated with serious health problems, including diabetes and heart disease.
Other medical conditions. Gastroesophageal reflux disease (GERD) is commonly known as heartburn. When people with GERD lie down, acid from the stomach can leak back into the esophagus, causing pain and, sometimes, severe damage. Other people have periodic limb movements or restless legs syndrome, in which jumping of the legs makes sleep difficult. (Sometimes it’s even more difficult for the bed partner!) Older men may develop a benign enlargement of the prostate, which can cause more frequent urges to urinate, waking them several times a night. These conditions are treatable and should be checked out by a physician.
Many other diseases, including heart, kidney, liver, nerve, and thyroid problems, can cause insomnia. Many prescription and over-the-counter drugs can cause insomnia in some people. Check the labels on the drugs you take or ask your pharmacist if you suspect a drug may be causing or contributing to your sleep difficulties.
Pain, whether from neuropathy, headache, arthritis, or some other source, can make it hard to get to sleep.
Stress and anxiety. What’s happening in your life — money problems, job hassles, family stress, worrying about the world situation, or whatever — can leave you too worked up to relax and sleep. “Emotional arousal, frustration, and worry are incompatible with sleep,” says Dr. Kuo. “Relaxation, not distress, is a necessary condition for sleep.” Even if the cause of the stress is long-term, relaxation techniques could help you to calm down enough at night to sleep.
If you lie there at bedtime with a rapid heartbeat, worrying about bad things that could happen, or have trouble falling or staying asleep, you may have an anxiety disorder. Anxiety disorders are highly treatable.
Conditioned insomnia. Another big cause of sleep problems is trying to sleep when conditions aren’t right for it. Some people spend too much time in bed; others don’t get enough activity during the day. Some think they should sleep more than their bodies really want. Dr. Buda says, “You can’t get more sleep than you need each night. When your body is rested, it just won’t sleep.”
Once people get into a pattern of struggling to sleep, they can have insomnia for years, just out of habit. The key is to start applying good sleep practices like the ones outlined later in this article. To determine whether you might have conditioned insomnia, ask yourself if you sleep better away from home. If you do, you could be conditioned to associate your own bed with insomnia.
Nothing bad happens when you miss one or two nights of sleep, as long as you’re careful about driving the next day. It’s chronic insomnia that causes problems. So if you regularly have problems falling asleep, don’t lie in bed tossing and turning. The late sleep specialist Richard Bootzin, PhD, formerly Professor of Psychology and Psychiatry at the University of Arizona, says that if you’re not asleep in 10 minutes, you should get up and go to another room. Dr. Kuo says it’s not the length of time that matters but that you should get up if you feel it’s taking too long to get to sleep or you’re getting frustrated. Then do something relaxing or soothing for at least 10 minutes, preferably out of bed. Don’t go back to bed until you’re really tired. If you still can’t sleep as quickly as you’d like, get up and try relaxing again. But if you’re comfortably relaxed in bed, Dr. Kuo says it’s OK to stay there, even if you’re not asleep. The idea is to associate your bed with relaxation, comfort, and getting to sleep easily, not with frustration and wakefulness.
To help your body and mind connect your bed with relaxation, get in the habit of using your bed only for sleep and sex. Don’t read, eat, talk on the phone, or watch television in bed. Once you’ve established sound sleep, you may be able to loosen up a bit.
Whatever you do, don’t try to go to sleep. Dr. Hauri says, “The harder you try to stay awake, the easier you will fall asleep. The harder you try to sleep, the longer you will stay awake.”
In Dr. Bootzin’s plan, it’s also crucial to get up at the same time every morning, whether you’ve slept or not. You’re trying to form a new habit of easy and regular sleep, and a couple of days of tiredness may be a small price to pay.
Be patient. Dr. Kuo says it takes at least two weeks to learn new sleep behaviors. “Changing long-time sleep patterns is a process. It’s not something you can change all at once. If you’ve had insomnia for a long time, it may take at least six to eight weeks to establish improvement. And many people benefit from the help of a sleep specialist.”
Sleep doctors recommend having a bedtime ritual, or a set of habits you can form that promote sleep. After sitting at a computer or watching TV, talking or doing physical exercise, many people find it hard to go right to sleep. You need to wind down first. You should faithfully go through your ritual every evening, if possible. Rituals vary from person to person. Whatever works for you is OK. Here are some ideas:
Some of these things can also help you get back to sleep after waking up in the middle of the night.
What you do during the day makes a big difference in how you sleep at night.
Exercise. Bodies need to move. If you don’t move all day, your body won’t want to stay still at night. Of course, exercise also helps blood glucose control. Exercising too close to bedtime could keep you awake, though, so it may be good to avoid vigorous exercises three to six hours before you go to bed.
Stress. Anything that makes your life less stressful helps you sleep, and vice versa. Relaxation and self-soothing skills are crucial and are taught at most sleep clinics. If worries keep you awake, Dr. Hauri suggests spending 10–30 minutes a day (not in the evening) in a “worry session,” thinking of all your worries and writing some ideas on “worry cards.” You know they’ll be there in the morning, so you don’t have to worry at night.
Blood glucose control. Maintain the best possible blood glucose control.
Excess weight. Overweight makes it harder to sleep and can cause sleep apnea. Another reason to get in shape.
Sunlight. Get some sun exposure during the day. Without sunlight, your brain is not properly cued to produce melatonin, the body’s natural sleep aid. Being unable to see sunlight is why most blind people have problems with insomnia.
Some people can sleep anywhere. Most of us need a quiet, safe, dark room. If you can’t get such a room, a blindfold and/or ear plugs might help. A “white noise generator,” a fan, or a tape of nature sounds can block unwanted noise. Use curtains or shades to block outdoor lights and morning light if it wakes you.
Get a comfortable mattress. Most people can sleep on any decent mattress. You probably don’t need to toss out your current one and spend tons of money on the most expensive model, but mattresses were not designed to last a lifetime, so you will need to replace them every so often. Pillows should also be comfortable. Thinner pillows may give better posture and more comfortable sleep to people who sleep on their backs, while people who sleep on their sides may need thicker pillows for more neck support. Some people like a pillow or bolster behind them when they sleep on their sides, or a pillow under their feet or between their knees to reduce back strain.
Temperature can also be a factor. An overactive radiator could have you waking up in a sweat, so be sure to set your thermostat appropriately.
Napping may leave you less tired at bedtime, setting the stage for insomnia. Some experts, including Dr. Bootzin, have a strict rule: No naps! Others are more flexible, but the National Sleep Foundation suggests limiting a nap to no more than 20–30 minutes, while the American Academy of Sleep Medicine says a nap should be less than an hour and no later than 3 PM. Long naps should be avoided if you have insomnia.
Studies on the health effects of naps have given conflicting results. But for some, napping can be a healing break from the stresses of the day. In a review of the medical literature, Masaya Takahasi, DMSc, of Japan’s National Institute of Industrial Health, found several studies that indicate that short naps (less than 20 minutes) may be linked to a reduction in the risk of heart disease.
Since so many things can hinder or promote sleep, many people find it helpful to keep a sleep diary to figure out what’s keeping them up or what works best to help them sleep. (This sample “Sleep Log” gives one format for keeping such a diary.) Each morning, write down when you went to bed, about how long it took to go to sleep (but don’t watch the clock for an exact time; clock-watching can keep you up), about how many times you recall waking up, when you got up, and how rested you feel. Record any naps you took the day before. Also rate your energy level and alertness during the day on a scale of 1 to 10.
Finally, write down what else happened. You won’t be able to record everything, so focus on three or four issues at a time. (Some people keep a separate “day log” for this.) Perhaps start with caffeine, nicotine, alcohol intake, and medicines. Record your bedtime ritual. Other possible issues to monitor: watching TV, exercise, family or work hassles, or anything else that may bother you. Over a couple of weeks, you might discover what helps you sleep and what gets in the way.
If none of this works, if you keep waking up all night, or if you have trouble waking up in the morning or staying alert during the day, you may want to consult a sleep specialist. You may have a treatable medical condition such as sleep apnea, or you may need help overcoming years of bad habits. Learning how to get a good night’s sleep can make a difference in your blood glucose control and your quality of life. As Dr. Buda says, “Sleeping better means living better.” And it’s not that hard to learn. Get started, and sweet dreams!
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