Your guide to a better night's sleep
By Sally E. Smith
Although seemingly mundane, there are few experiences as sweet as waking up feeling well rested, refreshed and rejuvenated. Greeting the new day with the mind focussed and the body fine-tuned creates the sense of limitless possibilities, as though there's nothing preventing us from plucking the juiciest fruit from the orchard of life.
But if instead of harvesting the riches of rest, you wake up feeling withered on the vine, you're not alone. According to a National Sleep Foundation (NSF) poll, seven in ten American adults say they experience frequent sleep problems and one in five say daytime sleepiness interferes with their daily activities.
It's hardly a surprise that we aren't reaping the benefits of shuteye, given the prevalence of sleep deprivation in our society. Sixty-three percent of adults do not get eight hours of sleep, reports the NSF, and 31% report sleeping less than seven hours each weeknight. This results is what experts term a "sleep debt," an accumulation of missed hours of rest.
Our sleep debt has increased over the last five years, in part because we're working longer hours than ever before. "There is a direct relationship between hours worked and its negative impact on sleep," says NSF Vice President James C. Walsh, Ph.D. "This is particularly noticeable for people working more than 40 hours per week."
As any mom knows, children can also sow the seeds of parental sleep deprivation. A baby crying to be fed, a child's nightmare or an adolescent's rebellion provides fertile ground for parental insomnia or interrupted sleep.
Busy lifestyles and the 24/7 availability of everything from electricity to email also contribute to sleep deprivation, asserts Holly Vance, clinical pharmacist and patient education specialist for drugstore.com. "As people's lifestyles get busier and busier, they sleep less and less," she observes.
Vance is quick to recite a litany of repercussions of sleep deprivation. "Not getting enough sleep causes drowsiness, irritability, decreased productivity at work and problems with judgement," she says. Lack of sleep also contributes to larger societal problems, such as an increase in traffic accidents and workplace injuries. "Not sleeping well does have a far-reaching impact on society," Vance concludes.
"Sleep deprivation has severe consequences," agrees William "Joel" Culpepper, a sleep disorders researcher and a biostatistician in the Office of Research at the University of Maryland-Baltimore's School of Nursing. "Research-wise, we have not be able to definitively pinpoint the restoration that occurs during sleep, but we all know from our experience when we don't get enough. We're tired, we're sleepy, we're not nearly as productive, and we're susceptible to colds and bugs." In studies where rats were deprived of sleep for long periods, he says, "You saw marked deterioration in these animals. They stopped grooming, they stopped eating and they became ill. If you deprived rats (of sleep) long enough, they died. That was the bottom line."
Sue Langford, a publishing executive and single mom in Northern California, feels like one of those lab rats. Langford has a demanding job and a five-year-old son that consume most of her waking hours. "I adore my son and I love my job, but I walk around like a zombie most of the time. I operate on about six hours of sleep a night, and I know that's taking its toll." Unlike many people who sleep in on weekends, thereby "catching up" and reducing their sleep debt, Langford rarely has that luxury. "Miles is raring to go at 6:30 in the morning, every morning, including weekends."
Because she has so little time to herself, Langford finds that she stays up until midnight most nights. "When he takes a nap at preschool, Miles doesn't go to bed until about 10:00, and I just need a couple of hours alone to decompress," she says. When Langford tries to get into a routine of going to bed at the same time as her son, "I feel like I'm trading my sanity for the sake of sleep."
Still, Langford snatches up opportunities to catch up on sleep when she can. "If my son takes a nap on weekend days, I'll head off to bed, as well. And even though I feel guilty, on some mornings I'll let Miles get up and watch cartoons, and I'll doze for another half hour." A recent experience makes Langford determined to make sleep a higher priority. "My son spent the night at a friend's house, and for the first time in over a year, I actually slept - uninterrupted - until my body was ready to wake up. I felt like a new person, as though the fog had lifted, and it was a great feeling!" she exclaims.
The foggy or zombie-like feeling that Langford experiences is a typical symptom of problem sleepiness. Memory lapses, problems with concentration, and struggling to stay awake while watching TV or reading are weeds that flourish when the garden of sleep is neglected. According to the National Center on Sleep Disorders Research (NCSDR), the first step in remedying problem sleepiness is to evaluate how much sleep you're actually getting. If it's consistently less than eight hours, the NCSDR recommends gradually moving to an earlier bedtime, going to bed 15 minutes earlier each night for four nights. If your schedule doesn't allow for a full eight hours of nighttime sleep, they suggest, try a daily nap.
While Langford's sleep debt accumulated due to inadequate sleep, there are can be other causes of problem sleepiness. According to the NCSDR, certain medical conditions - such as asthma or those accompanied by chronic pain - can disrupt sleep, as can some prescription medications. Any of these can result in daytime drowsiness and compromised mental acuity. While alcohol can make a person go to sleep more easily, it causes sleep disruption during the night. Caffeine and nicotine are both stimulants, which can make it hard to both fall asleep and sleep through the night.
Problem sleepiness can also be a symptom of one of five more serious sleep disorders: insomnia, sleep apnea, narcolepsy, periodic limb movements in sleep and restless legs syndrome.
Virtually everyone will have an episode of insomnia during their lives - lying awake in bed watching the second hand rotate endlessly around the face of the clock, waking up at an ungodly hour and not being able to get back to sleep or waking up every hour on the hour. According to the NCSDR, there are three classifications of insomnia: transient, which lasts from a single night to a few weeks; intermittent, in which transient episodes recur from time to time; and chronic, which occurs on most nights and lasts a month or more.
While women with a history of depression and those over the age of 60 are predisposed to chronic insomnia, transient and intermittent sleeplessness can be caused by environmental or emotional factors. Stress, noise, extreme temperatures, jet lag and side effects from prescription medications can all affect our ability to get to sleep and to stay asleep.
For those who suffer from insomnia, the problem of daytime sleepiness pales in comparison to the emotional roller coaster of anxiety about sleep. Each night becomes a battle, and anxiety mounts about whether or not sleep will come. Yet, even when insomnia feels entrenched, there are some relatively simple strategies you can use to get off the merry-go-round of sleeplessness.
Drugstore.com's Holly Vance enumerates a myriad of tips to combat insomnia, but says that taking stock of your sleep habits should be first on your list. "You might not even realize you have bad sleep habits until you evaluate them." Vance says, and advises, "The most important step in breaking the pattern of sleeplessness is getting in the habit of a regular sleep schedule. Go to bed at the same time each night, and wake up at the same time each morning - even on weekends." In addition, Vance recommends that the insomniac eliminate naps. "This may be tough to do, but a lot of people fall into the habit of taking a nap in the afternoon, and it just perpetuates the cycle (of sleeplessness)."
Making your boudoir sleep-friendly is another key to a restful night. "If you live in a noisy home or apartment," says Vance, "introduce white noise that drowns out cars or trains." And keep your bedroom off limits to anything other than sleep or sex. "A lot of people bring work or laptops to bed - that's a no-no. Don't sit in bed and watch movies. All of these things can contribute to poor sleep habits."
Vance also suggests trying relaxation techniques, such as yoga, meditation or visualization, before going to bed, and encourages regular exercise, though not right before bedtime.
If these techniques don't work, Vance indicates that an over-the-counter sleep remedy might be appropriate once or twice a month. Diphenhydraamine (under the brands names Sominex and Nytol) and doxylamine (Unisom) are actually antihistamines, which have drowsiness as a side effect. "You're actually taking advantage of the side effects to help you sleep," Vance says, but cautions, "You don't want to use them regularly; after a few days, they're going to become less effective."
For sporadic insomnia, you could also go herbal and try Valerian, a root which, according to Vance, "increases deep sleep and dreaming, but doesn't cause a morning hangover and drowsiness."
While touted as a miracle drug a few years back, melatonin has lately received mixed reviews. "Melatonin is a hormone involved in the sleep cycle," says Vance, "but it's a little controversial. (Researchers) are not sure how it works and who it's going to work for, plus there are conflicting studies about its effectiveness."
If your sleep habits are impeccable and over-the-counter and herbal remedies still leave you grasping for slumber, a trip to the doctor might be in order. A health professional can not only rule out more serious sleep disorders and underlying medical problems, but can also, if necessary, prescribe a sleep aid. "Prescription drugs," says Vance "can break the cycle of sleeplessness." She does caution, however, that they are generally only recommended for short-term use, since prolonged use can trigger dependence problems.
Drugs like Halcon and Restoril (known as benzodiazepines) cause drowsiness when taken 30 minutes before bedtime, though they can result in a morning hangover. According to Vance, Ambien and Sonata are slightly different drugs and can have fewer side effects.
Antidepressants, such as trazadone and amitriptyline, are also used to promote sleep. "No one is sure how they work," says Vance. "Some think they affect the sleep cycle and others think they have a drowsiness side effect, and you're just using that side effect."
For Leslie DiMaggio, sleep apnea was like a creeper vine that was slowly choking the life out of her. In the beginning, "I would wake up in the middle of the night with a feeling of fear and an adrenaline rush," she recalls. "Then, for over a year, I had chronic bronchitis, which I couldn't figure out." One day, she started having the need to "go unconscious - I can't even call it sleeping. I couldn't drive more than half an hour without having to pull over somewhere and go unconscious." She experienced a subtle emotional shift toward depression, which led her to start taking the antidepressant Zoloft. Eventually, she began waking up every hour with dry mouth and the need to go to the bathroom.
DiMaggio, a business owner in Salinas, Calif., took the first step toward regaining her breath and her life when she picked up a pamphlet on sleep apnea at a convention of the National Association to Advance Fat Acceptance. "I read the symptoms, and I basically had all of them," she says with a laugh. She went to a sleep specialist shortly thereafter and, DiMaggio recalls, "When she examined me, she could tell by looking in my mouth that I was a candidate for sleep apnea because of the shape of my throat and my palette."
In obstructive sleep apnea, the airway becomes blocked, causing breathing pauses during sleep. According to the National Center on Sleep Disorders Research, the sleeper struggles to breathe, but air cannot easily flow into or out of the nose or mouth. Heavy snoring, lapses in breathing and frequent waking characterize this sleep disorder, which affects as many as 18 million Americans. Symptoms can also include choking sensations, early morning headaches and problem sleepiness. Sleep apnea is considered a life-threatening disorder, as it is associated with irregular heartbeat, high blood pressure, heart attack and stroke.
"That's the best thing to do, because some doctors are better at dealing with the large-size population than others," agrees Dr. Deming. "I don't think all of us are comfortable with every disease process or medical problem. Some are not willing to invest time and energy in the needs of a particular group. I say, find one who is."
The doctor scheduled DiMaggio for a sleep study at a local hospital. Typically, sleep apnea is diagnosed using polysomnography, which records brain activity, eye movement, muscle activity, heart rate, respiratory effort, air flow and blood oxygen levels during sleep. DiMaggio reported that the experience, "wasn't painful, but it wasn't pleasant, because they glue little sensors all over your head and face and chest." After seeing her test results, DiMaggio's doctor told her she had stopped breathing 188 times during the night. "That was only moderately bad," DiMaggio somberly recalls. "For a lot of people, it's much worse."
While behavioral changes, such as discontinuing the use of alcohol, tobacco and sleeping pills, may shorten apneic periods during sleep, treatment most often involves the use of a continuous positive airway pressure (CPAP) device. The mask of a CPAP fits over the nose and mouth, and pressure from a blower forces air through the nasal passages, and prevents the throat from collapsing during sleep.
Once DiMaggio began using a CPAP, "waking up with feelings of fear stopped right away. I haven't had bronchitis since, and no problems with driving. Plus, as my doctor predicted, I got off the Zoloft within three months." Although some people have difficulty adjusting to a CPAP, DiMaggio adapted easily. "You just learn little tricks, like putting the hose under the covers with you if the air's too cold, or using a humidifier if the air's too dry." She says, "My CPAP is my lifeline. I go nowhere without my CPAP. That's my baby."
Treatment for sleep apnea can sometimes include dental appliances, to reposition the lower jaw and tongue, and oxygen administration. And while some surgical procedures have been developed to remove excess tissue at the back of the throat, the NCSDR estimates only a 30-50% success rate for surgery. They caution that long-term side effects and benefits of the procedures are not known, and that there is no way to anticipate who will benefit from this procedure.
Supersize people sometimes have extra tissue in the throat and mouth, which can contribute to sleep apnea when combined with an abnormality in the upper airway. Yet, given the 95-98% failure rate of weight loss attempts, dieting is hardly the first-line treatment for the sleep disorder. DiMaggio, who is supersize, reports that her doctor told her that "Fat can aggravate sleep apnea, but it's not the cause of it."
DiMaggio encourages anyone who suspects they might have sleep apnea to get tested. "It slips upon you gradually, so that you don't remember what it was like (before). It's definitely, absolutely life threatening, but it doesn't seem like it. It's a condition that you can't see, so it's easier to let it slide."
According to the National Center on Sleep Disorders Research, narcolepsy is as common as Parkinson's disease or multiple sclerosis - as many as 200,000 Americans have this sleep disorder. Narcolepsy is characterized primarily by overwhelming sleepiness during the day - even after a good night's sleep. People who have narcolepsy may also experience episodes of sudden loss of muscle function, called cataplexy, which are triggered by emotional reactions such as laughter, anger or fear. Sleep paralysis, a temporary inability to talk or move when falling asleep or waking up, and hypnagogic hallucinations, vivid dream-like experiences that occur while dozing or falling asleep, are two other symptoms of this sleep disorder.
The University of Maryland's Joel Culpepper says that, although there's not a definitive scientific explanation for narcolepsy, "It's believed that somehow those areas of the brain that control motor function during sleep manifest themselves when (the person is) awake. The border is considerably blurred." He adds that there's a strong genetic component to narcolepsy, and recent research has isolated a gene in dogs. "There's still considerable work to be done," Culpepper says, "but they're honing in on (the gene).
"For those with narcolepsy," Culpepper continues, "it's such a dramatic event in their lives. It can have a rather sudden onset, usually in the late teens or early twenties. Sleep attacks, where there is literally the inability to fight against sleep onset, are scary and startling."
Narcolepsy, like sleep apnea, is typically diagnosed with a polysomnogram. A multiple sleep latency test, which is administered during the day and measures how fast a person falls asleep and the time it takes to reach the various stages of sleep, is also used in diagnosing the disorder, since people with narcolepsy usually fall asleep and enter the REM (rapid eye movement) stage of sleep rapidly.
While there is no cure for narcolepsy, treatment includes central nervous system stimulants, drugs - such as antidepressants - that suppress REM sleep, and scheduling two or three short naps during the day.
Restless Legs Syndrome
Periodic Leg Movements During Sleep
While restless legs syndrome (RLS) and periodic leg movements during sleep (PLMS) are thought by some to be at two points on the same sleep disorder continuum, Culpepper maintains that the latest scientific literature treats them as two separate disorders. "There's a basic distinction between the two. With RLS, there is uncomfortable tingling and cramping (in the legs) as you're trying to fall asleep. PLMS symptoms are very characteristic - the toes come up toward the knee, there's a rhythmical pattern, and it occurs in spurts throughout the night. (PLMS) is associated with arousals and, in severe cases, full awakening."
Since childhood, Julie Young has lived the nightmare of both disorders. Young, 25, who works as a construction company office manager in Nantucket, Mass., and who has a web design business on the side, remembers times in her girlhood when she would cry herself to sleep at night because her legs hurt so badly. "When I was young, I used to thrash around in my sleep, and my mom didn't want me to sleep with her because I would kick her all night," she recalls. When she got older, Young would wake up with bruises on her legs, mystified as to how they got there. Looking back, "I assume they were from kicking myself during bouts of PLMS," she says. When she was in college, Young's boyfriend (Matt, now her husband) would complain - echoing the lament of other PLMS sufferers' significant others - that she was "running" in her sleep.
According to the National Center on Sleep Disorders, the involuntary jerking or bending leg movements that characterize PLMS typically occur every ten to 60 seconds during sleep, and some people can experience hundreds of movements per night, which severely impacts the quality of their lives. Young and her husband took turns sleeping in the spare bedroom because her PLMS was keeping Matt awake. "It put a strain on our relationship," Young recalls, "because we were losing that closeness." In addition, she says, "I was always tired and cranky from lack of sleep. I started to get very depressed. I was sullen and irritable all the time. My productivity at work began to slip, and I was getting called on it. I tried everything I could, but I was still always tired."
Restless legs syndrome manifests when the person lies down or sits for long periods of time. The RLS sufferer describes creeping, crawling, tingling, or painful sensations in the legs, along with an irresistible urge to move them. Young recalls that, "Driving for long distances or sitting for long periods of time became difficult. I would have to move my legs or the 'creepy crawly' feelings would start." When she and Matt moved from Maryland to Kansas a few years ago, "We had to stop many times on our cross country trip so that I could stretch my legs. The sensations weren't painful, just annoying, and nothing seemed to stop them."
While some cases of RLS are transitory - it's not uncommon for pregnant women to experience symptoms in the third trimester, but they usually disappear after delivery - most are permanent, although the severity of the disorder may ebb and flow over a lifetime. Because there is no diagnostic test for RLS or PLMS, health professionals rely on the patient's (or her significant other's) report of her symptoms.
Unfortunately, there is no definitive treatment for either PLMS or RLS. In the medication arena, central nervous system depressants do not fully suppress symptoms, but may allow sufferers to get more rest. Drugs used to treat Parkinson's disease can also reduce symptoms of both disorders, but they do not work for everyone. Pain-killing opiates sometimes work for people with very severe cases of PLMS or RLS, but have their own drawbacks.
Young's experience in treating her sleep disorders has been nothing short of nightmarish. Her online research led to her self-diagnosis and a trip to a sleep specialist. Since then, Young has variously taken a central nervous system depressant, three different drugs used to treat Parkinson's disease, and an anti-depressant. Some helped her get more sleep but did nothing for her PLMS; others worked for awhile, but stopped when she developed a tolerance to the drugs; and another made her deathly ill. Currently, Young is taking the dopamine agonist Mirapex, which is more commonly used for Parkinson's patients. It's working fairly well, and Young says, "It allows me to get a good night's sleep and my husband doesn't seem to notice the kicking so much anymore. My work and relationships have improved, since I'm getting more sleep and have my RLS under better control."
Young doesn't consider it a wonder drug, however. "I'm still exceptionally tired most of the time, I sometimes have a hard time concentrating on things and I occasionally have a short-term memory problem. I will stay with Mirapex until it stops working, and then I will look into other medicines."
Although much research has been devoted to the science of sleep, answers to why slumber is so beneficial have been elusive. The reigning theory is that sleep allows our brains to consolidate our memories and enables the recovery of our organs and metabolism. But regardless of the science, sowing the seeds of good sleep habits and reaping the benefits of eight hours - or whatever your body needs - of shuteye is crucial to our health and well-being.
Good nutrition, exercise and sleep are the triumvirate of good health, but sleep often takes a back seat to the other two. As Joel Culpepper says, "The trend continues to be for people to pay close attention to their (nutrition and exercise), and we need to put the same emphasis on sleep. It has an impact on every aspect of our lives. If we find ourselves nodding off at our desks, that should be an indication that we need to make some changes."
The Great Escape
Your bedroom should be haven where you can retreat from the world. When furnishing your oasis, don't neglect what Better Sleep Council Director Andrea Herman calls "the heart of the comfort zone" - your mattress. The Better Sleep Council, a non-profit organization funded by the mattress industry, suggests that, when shopping for a new mattress, you follow these guidelines:
1. Support: The mattress and foundation should gently support your body at all points and keep your spine in the same body position as a good standing posture
2. Comfort: Trust your body to tell you which mattress feels best. Mattresses don't have to be hard as a board to be good for you
3. Space: Choose a mattress size that gives you enough room for free, easy movement, especially if you're sleeping with a partner
4. Matching Sleep Sets: Matching mattresses and foundations are designed to work together. The foundation acts as a giant shock absorber, and lends added support and durability
5. Durability and Warranty: The performance of a poor quality sleep set can deteriorate very quickly, while top quality sets can provide comfort and support for a number of years. The warranty protects again product and workmanship defects
6. Value: Shop for the best value, not the lowest price. Buying the best you can afford is a healthy investment in yourself.
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