Why you have trouble falling asleep
Why you have trouble falling asleep
It turns out that the definition of normal sleep goes out the window as we age. Much of the trouble has to do with shifting hormones at midlife – for men, too! – that affect the amount and type of rest you get. Chronic conditions that often come with age such as arthritis, sinus congestion, and acid reflux can also disrupt sleep. With age, there is a decrease in growth hormone and evening elevations of the stress hormone cortisol as well as an increase of the immune system messengers called inflammatory cytokines (especially interleukin6) – all of which negatively affect sleep and reduce the amount of time spent in the more restorative stages 3 and 4 of non-rapid eye movement. This means that older people are predisposed to have problems not only with sleep quantity but sleep quality – with inevitable consequences for both their health and energy.
Some of the trouble with aging can be addressed with better stress management. By age forty, levels of the stress hormone, cortisol, tend to be elevated for most people, which scientists now believe may be a result of that hormone not reaching its low point at night. Managing stress during the day so that you are able to get to sleep earlier and sleep longer may promote beneficial declines in cortisol at night. In some cases sleeping more can be seen as an antiaging potion – circulating testosterone levels in healthy men are known to decline with advancing age, but when men sleep longer they are able to make more testosterone. Which just goes to show sleeping is not for sissies!
One of my favorite observations from sleep medicine labs is that people of a certain age (65 and up) tend to believe that their sleep is worse than it actually is. Much of the trouble has to do with attitude. With meticulous psychological surveys, scientists have determined that whether a person views getting less sleep as insomnia or merely accepts it as a normal part of aging depends largely on his individual attitude about growing old. One of my longtime patients who cruised into her seventies with abundant energy once told me that she had learned to accept getting less sleep as "No big deal." I'm not suggesting you ignore a sleep problem, but I am encouraging you not to become one of those folks of an advanced age who sit around complaining about sleep – that's a sure energy-draining activity.
Page 1 of 5
Excerpted from The Source, copyright 2008 by Woodson Merrell. Used by permission of Random House Canada. All Rights Reserved. No part of this excerpt may be reproduced except with permission in writing from the publisher. Stress
Unbridled stress causes difficulty falling asleep as well as sleep disruption (waking in the middle of the night with trouble getting back to sleep). People wracked with stress can't turn off the worry: when they lay down their minds race; or when they wake up in the middle of the night, their worries take hold and keep them awake. Researchers have begun to follow the destructive path of the stress hormones and other biochemical messengers that keep your neuroendocrine system hyperactive, even into the middle of the night.
Stress per se doesn't necessarily keep you awake, but worrying about stressful things can keep you awake. And because sleep deprivation mimics the effects of stress by elevating stress hormone levels and activating anxiety-promoting areas of the brain, you set up a vicious cycle: you're stressed so you can't sleep; then the lack of sleep makes your stress worse. You quickly become perpetually exhausted. Unremitting stress has also been shown to trigger nightmares, increasing demands on your nervous system.
The many negative effects that unbridled stress produces in your nervous system can have serious consequences during sleep. The early morning between 4:00 and 8:00 a.m. – when rapid eye movement (REM) is at its peak – is the time of day with the highest incidence of heart attacks (and this doubles on Monday mornings). This is largely due to stress-induced declines in your heart's ability to handle the shift from the calming, parasympathetic nervous system dominance of non-REM sleep to the stimulating, sympathetic nervous system dominance of REM sleep. As your nervous system starts to wake up, a stressed heart sometimes just can't take it. Clearly, cardiovascular problems need to be diagnosed early and treated by a specialist. Along with proper treatment, a conscious stress reduction program coupled with regular moderate exercise will help to protect the heart during times like the early morning when nervous system shifts require healthy flexibility of the heart muscle.
One further caveat has to do with managing stress when you actually do wake up. If you wake up, jump out of bed, and go straight into panic mode over your work responsibilities it can be tough on your ticker. Starting your day with your stress under control will keep it in better control all day and give more consistent energy.
Scientists are undecided about the health consequences of general nonapnea snoring. Light to moderate snoring is not caused by any abnormality, but rather originates from vibrations of tissue in the throat and air passageways. Your own snoring episodes can cause blood pressure to rise (not to mention what it does to your spouse), but snoring is not considered a cause of daytime hypertension. My primary concern is what snoring does to your ability to get a good night's rest: The resistance that snoring produces in your airways can cause frequent arousal and fragmented sleep. It can throw off the normal balance of calming, parasympathetic nervous system domination during sleep. Snorers have an increase in stimulating sympathetic nervous system dominance during sleep, which consumes energy and can lead to daytime fatigue.
Snoring solutions are the same as for sleep apnea. Try reducing alcohol intake and changing your sleep position before making the bigger financial and lifestyle commitment of obtaining a prescription device like the CPAP. Sometimes helpful is a surgical procedure called a uvulectomy, removal of the small punching bag (uvula) that hangs at the back of the throat to prevent it from obstructing the airway.
Page 2 of 5
Excerpted from The Source, copyright 2008 by Woodson Merrell. Used by permission of Random House Canada. All Rights Reserved. No part of this excerpt may be reproduced except with permission in writing from the publisher. Chronic sinus congestion
The common cold or chronic stuffiness from allergies can pose a real challenge to a good night's sleep and can even lead to sleep apnea. You really do need the full cooperation of your nose to get adequate oxygen during sleep. A stuffy nose reduces the capacity of your major air passageway; and it forces you to work harder for air, which can make it easier for the back of the throat to collapse. Scientists even believe nasal congestion can block receptors in the nose that signal the brain that it needs air. A bout of a cold virus is not a big deal, but if you're routinely stuffy, I highly recommend working with an ear, nose, and throat doctor to determine the cause of chronic congestion and eliminate it. A 1998 study at Penn State University's Division of Allergy showed that targeted use of nasal steroids (like Nasonex) to quell inflammation improved sleep and reduced daytime fatigue for people with chronic sinus congestion. But there are remedies you can try short of using steroids.
Amazingly, the simple little device called a Breathe Right Strip – a stiff Band-Aid that sits on the bridge of the nose and physically pulls the nostrils open – can be a big help for congested sleepers. More permanent remedies – such as identifying subtle food allergies – that target the source of congestion are key. Getting acupuncture and chiropractice treatments from experienced practitioners can often help chronic sinus problems.
GastroEsophageal Reflux Disease (GERD)
The reflux of stomach acid into the esophagus – which is increasingly recognized as the cause of a wide range of problems including chronic sinusitis, asthma, bronchitis, and chest pain – does much of its dirty work during sleep and can be a major factor in sleep apnea. In a November 2007 study at Chicago Rush Medical Center's Department of Ear, Nose, and Throat Medicine, correcting the hyperacidity of GERD significantly improved sleep apnea, sleep quality, and daytime fatigue of 70 percent of patients.
The classic conventional remedy for GERD is acid-blocking medications. These certainly work. I recommend using antacids to get the problem under control if it's bad, and then targeting the causes of acidity. If necessary, have an endoscopy by a gastrointestinal specialist or ear, nose, and throat doctor to rule out significant anatomic abnormalities. Remedies other than antacids include elevation of the pillow, so that by decreasing the force of gravity, stomach acid doesn't backflow into the esophagus; and eliminating nighttime acidic foods (especially tomatoes), spices, caffeine, and alcohol.
Chronic pain is a doubleedged sleep sword: it can interrupt sleep, which degrades pain-inhibition processes in the brain, making pain worse the next day. Sleeping less doesn't affect pain as much as sleeping poorly does. A 2006 study at Walter Reed Army Hospital found that pain reduced the quality of sleep in 55 percent of patients, poor sleep worsened the pain, and a poor quality mattress magnified both problems. Evaluate your mattress and don't just live with pain. There are a number of avenues to explore including working with a pain specialist (often resulting in the use of stronger pain medications), a physical therapist, hypnosis, acupuncture, and working to reduce inflammatory elements of the diet.
Page 3 of 5
Excerpted from The Source, copyright 2008 by Woodson Merrell. Used by permission of Random House Canada. All Rights Reserved. No part of this excerpt may be reproduced except with permission in writing from the publisher. Inflammatory conditions
In conditions like arthritis, autoimmune diseases, multiple sclerosis, Lyme disease, even during a bout of influenza, the balance between proinflammatory and antiinflammatory chemicals (especially cytokines such as interleukins, TNFalpha and others) that are produced by white blood cells of the immune system plays an essential role in regulating how well you sleep. These chemicals are produced during infections as important signaling messengers, but in chronic inflammation a steady stream of them can wreak havoc on your sleep and energy. In a study of elderly folks, higher evening levels of proinflammatory cytokines (especially Interleukin 6) were related to getting less sleep. A very slight increase was associated with an increased waking time of about 20 minutes. Obesity also results in a chronic inflammatory state – visceral fat is highly active in producing harmful cytokines that can interfere with sleep.
The single most important solution for reducing inflammation is lifestyle change: reduce weight and stress, exercise and sleep more, and eat an antiinflammatory diet. Cut out sugar and processed foods especially, reduce meat consumption, and incorporate antiinflammatory foods such as fish oil, spices, and herbs.
If you're having problems with sleep or insomnia, you should consider cutting back on alcohol. When you drink alcohol as long as five hours before falling asleep, it can make sleep apnea or snoring worse (even if you don't normally have those problems). Alcohol triples the tendency for restless limb movement that causes frequent awakening. When you drink, you can fall asleep quicker and get to a deeper, slow-wave sleep faster (you pass out), but as the alcohol is metabolized by the middle of the night (usually after the first two 90-minute sleep cycles), sympathetic nervous system activity increases, which produces fitful sleep (you wake up in the middle of the night with a parched mouth, feeling lousy). Alcohol increases your deeper sleep at the beginning of the night and causes more restless sleep in the last portion of the night, so it can have an overall negative effect on sleep. While a glass of wine with dinner is ok. Bottom line: For anyone having trouble sleeping, imbibing a couple of nightcaps is not the cure.
America's favorite drug, the chemical stimulant caffeine can contribute to insomnia – even in your morning cup of Joe. The half-life of caffeine is three to six hours, meaning that if you have a cup at noon, a quartercup's worth could still be in your system at midnight (as it could if you drink a larger dose, says, a two-cup sized Grande, at 6:00 a.m.). Caffeine has been shown to block the adenosine receptors. Studies have shown that caffeine blocks this mechanism and disturbs proper sleep. As with its distant cousin, amphetamines, caffeine can cause significant withdrawal symptoms when eliminated – fatigue and headaches can develop after stopping even a one-cup per day habit. If you have insomnia and consume daily caffeine, wean yourself off slowly and stop for two full weeks to see if you sleep better and have more overall energy.
Page 4 of 5
Excerpted from The Source, copyright 2008 by Woodson Merrell. Used by permission of Random House Canada. All Rights Reserved. No part of this excerpt may be reproduced except with permission in writing from the publisher. Medications
It is truly shocking when you look at the list of medications that negatively affect sleep. Insomnia is a commonly listed side effect of numerous prescription and over-the-counter drugs; they can cause a wide variety of disruptions in the sleep cycle including nervous system overstimulation in the early stages of sleep and nightmares in the later stages. Drugs affect the chemicals called neurotransmitters, which govern brainwave activity. Pseudophedrine (in Sudafed and other cold medicines) is a good example of how medicines affect sleep; many people using it regularly suffer unwittingly from debilitating over-stimulation – including insomnia from even a small daytime dose of decongestants. Antihistamines in cold remedies, on the other hand, actually make you drowsy. Many of the most commonly prescribed medications in America are on the list of drugs that affect sleep (unbeknownst to patients and, usually, their doctors, as well) including blood pressure medications, antiseizure medications, antihistamines, decongestants, and antidepressants. This is just one of many reasons that my goal for all patients is to reduce the number of medications they take by implementing lifestyle changes whenever possible.
Sleeping pills are useful when acute stress or health conditions occasionally interfere with falling or staying asleep. They can also be used to reset the circadian rhythms of your biological clock when you're traveling. They become a problem when people use them chronically. First of all, sleeping pills do not guarantee healthy sleep architecture or complete elimination of daytime sleepiness. To do that, you need to treat the underlying condition and get to the source of the problem that causes insomnia (i.e., daytime anxiety). You will not get a magic, permanent fix from a pill. The quick-fix mentality can actually lead to a worsening of the sleep problem over time and to the appearance of other problems related to lack of sleep. Polypharmacy – the prescribing of multiple medications, often for the same conditions – has been an increasing problem, occasionally with tragic consequences, from the 1962 death of Marilyn Monroe to 2008's Heath Ledger.
A brief synopsis of medicinal sleeping aids contains two broad categories: those that leave you drowsy in the morning and could become habit forming, and those that produce addiction and/or dependency. The former group includes soporific antidepressants (tricyclics such as Elavil and SSRIs such as Paxil), the newer melatonin receptor agonist Rozerem, and OTC antihistamines (Sominex, Benadryl). The other group contains solely prescriptive sleeping medications that can be addictive – such as barbiturates (phenobarbital, Seconal), benzodiazepines (Dalmane, Valium, Klonopin), and narcotics (codeine, hydrocodone) – or can produce dependency such as Ambien, Sonata, and Lunesta.
I am not dismissing the use of prescription sleeping pills: I prescribe them myself sometimes (though rarely compared with most other physicians). Judicious occasional use of these powerful medications can be helpful for acute distress or jetlag, and are necessary for others with more severe medical conditions or severe sleep disorders, especially when overseen by a sleep disorders specialist. But there are many other ways that sleeping problems can and should be addressed.
• The top 10 mental healh myths
• The top 10 ways to fight stress
• 8 cures for crankiness
Page 5 of 5
Excerpted from The Source, copyright 2008 by Woodson Merrell. Used by permission of Random House Canada. All Rights Reserved. No part of this excerpt may be reproduced except with permission in writing from the publisher.