After one month working as a direct primary care doctor, I have realized a common theme -- people need more and better quality sleep. Now that I finally have the time to really get to know people and ask about their overall health, I’m hearing so often that there just isn’t enough time to sleep. Sometimes, even when there is enough time, it’s just not coming naturally.
There was one time in my life when I hallucinated. I was on my surgery rotation during my third year of medical school, this was in the days when students didn’t have restrictions on how many hours they could work in a row. I had been awake for 36 hours, I came home to sleep, but I kept hearing the doorbell ringing and kept getting up but there was no one there. This had a profound effect on me, it solidified my desire not to become a surgeon for one, but it also helped me to really understand the power of sleep deprivation.
In today’s world, our culture often doesn’t support the need for sleep. Sleep might be seen as wasted time. Pulling an “all-nighter” is considered a badge of honor, a sign of a hard worker. I know during medical school and residency needing to sleep was a sign of weakness. However, sleep is thought by many experts to be one of the most important requirements for reaching our greatest health.
In Maslow’s Hierarchy of Needs Theory, our basic needs (air, water, food, shelter, warmth, sleep) must be met in order for us to move on to our secondary needs. Sleep, akin to food, water, and warmth, is an essential physiological need. Without it, not only would we not be able to reach our potential, we would not survive.
The Consequences of Sleep Deprivation
- Sleep deprivation leads us to make poor decisions and we are more likely to make errors. Some of the most famous disasters, Chernobyl, the Exxon Valdez oil spill, were related to workers who were sleep deprived.
- When we are sleep deprived our body creates more of the hormone Ghrelin. This is considered the hunger hormone. It makes us crave carbohydrates and sugars and can make us gain weight.
- Sleep deprivation can also profoundly affect our immune system, making us more susceptible to colds and other viruses.
Why Do We Need Sleep
We should spend 36% of our life asleep. When you turn 80 years old you would have spent 28.8 years asleep. So why do we spend so much time asleep? What’s the point? There are many theories for why, but no one is really sure. I will summarize two of them here.
The first theory is that sleep is for brain restoration. During sleep we are cleaning and maintaining our brain by clearing away toxic waste proteins like those seen in Alzheimer’s disease. It’s similar to having a party and not cleaning up after. If you don’t take the time to clean, the mess will pile up. Just as your brain is unable to clear out the toxins while you are awake and aware. You need sleep or toxic proteins will build up.
The second theory is that during sleep we consolidate our memories. During the day we are exposed to so much information, think of it like a bunch of puzzle pieces being thrown at you. We don’t have time during the day to put them all together. It’s during sleep that we put the puzzle pieces together. While we sleep, the synapses or neural connections that are important are linked and strengthened while those that are less important fade away. If you don’t sleep it’s more difficult for you to complete complex tasks. There is also a lot of evidence that sleep enhances our ability to be creative.
Circadian Rhythms and Melatonin Production
We all have an internal clock, our circadian rhythms,that helps regulate our time to sleep and wake. This is controlled by a group of cells in the brain that are sensitive to light and dark. These cells are directly connected to your optic nerve in the back of your eyes (where we sense light). When you are exposed to light in the morning the cells send signals to raise your body temperature and cortisol level, part of the natural rhythm of wakefulness. This group of cells also controls your production of melatonin. Melatonin is stored up during the day with exposure to sunlight and it is released at night. The release of melatonin at night helps promote sleep.
Sleep Through the Years -- How Much Sleep Do We Really Need?
When we are very young and need plenty of sleep, our circadian rhythms are not yet established and we sleep and wake based on our need to eat. As we age the length of time we need to sleep lessens. In the teenage years there is a phase shift in our circadian rhythm. We have a biological predisposition to go to bed late and wake up late. Because of this, early school start times can really disrupt a teen’s ability to get the 9 hours of sleep they need . As we age our sleep requirements are still 7-8 hours, but sleep tends to be more fragmented and less robust. Generally, as we age we wake a bit more easily and often don’t sleep continuously through the night.
So How Do We Get Good Sleep
Eating and Exercise
You can really help your nighttime sleep by focusing on your morning routine. Eating a healthy breakfast that includes protein shortly after waking up triggers a spike in cortisol levels. As a result, there can be a significant drop in cortisol in the evening which can help facilitate falling asleep and staying asleep at night. Getting exposure to sunlight in the early morning can help strengthen your circadian rhythm which can help you ease into sleep at night. Exercise is so important to helping get good sleep. However, try to get your exercise in before late in the afternoon, because exercise can be stimulating.
Letting go is an important part of getting good sleep. Often times when people are having trouble with sleep, there is an anxiety about how many hours of sleep they got. We often will put pressure on ourselves to fall asleep, looking at the clock and thinking “ok, if I can just go to sleep right now I will get at least 5 hours." This ends up being counterproductive. It’s not realistic to think you can force yourself to sleep. Instead, we should let go of tracking the hours of sleep and focus on how we feel. If the idea of going to sleep is provoking anxiety, we should let go and just say, “I will get my sleep when I need it." Along with this, if you are having anxiety about sleep and seeing your bed just makes you anxious, it’s important to avoid lying in bed for long periods of time not sleeping. Get out of bed and go do something relaxing, read a mellow book or listen to soothing music. Don’t watch stimulating TV or eat. Return to bed when you feel sleepy and if, when you get there, the anxiety returns, just do that all again. After enough nights of this, you will get sleepy enough that your time asleep in bed will naturally stretch out.
How about naps? If you are having trouble getting the sleep you need at night, a nap is a healthy habit. Aim for keeping your nap to under 30 minutes and try to wake from your nap before 4 pm. Sometimes, for a person who is struggling with insomnia, a nap can help ease the anxiety making it easier for them to sleep at night.
Mindfulness meditation is a great practice that can help you ease into sleep. Mindfulness meditation is easy to learn and do. Many people tell me they can’t meditate because they can’t “clear their mind” or "slow their thoughts down." That is an incredibly difficult task, so I can relate. However, that is not the goal with mindfulness meditation. Mindfulness is about letting your thoughts run but not getting absorbed in your thoughts. If you practice this, you can train yourself to get into that first stage of sleep which will often lead you to a full sleep cycle. You can set a goal of meditating only 5 minutes a day to start and this will gradually build into a powerful tool for you to get better sleep.
Your sleep environment is very important. You need a cold dark room. Using earplugs and eye masks can sometimes make all the difference. If you have pets or kids that wake you up, think of ways to change the routine to help stop any sleep disruptions. Exposure to screens (computers, phones, e-readers) at night can also disrupt your melatonin production and make sleep more difficult, so do your best to avoid these.
Caffeine and Alcohol
Caffeine generally has a half-life of about 6 hours, however, this can vary widely for individuals. This means after you have caffeine in 6 hours you will have half the amount of caffeine in your blood stream. Six hours after that it will half again. Therefore, a cup of coffee in the morning will still leave you with some caffeine in your system. If you are having trouble with sleep, cutting down on caffeine, or at least assuring that you minimize your intake after a certain hour will help.
Many people tell me that they want to have a glass of wine or a nightcap to help them fall asleep. Alcohol is sedative and for many people it will lead to sleep. However, alcohol is not good for sleep. It causes a disruption the normal sleep cycle. For the first half of the night the REM sleep levels are decreased, then the second half of the night we try to make up for the loss of REM sleep. This lead us to have disrupted sleep in the second half of the night. This effect is more pronounced with larger amounts of alcohol and is less likely to be noticeable with one glass of alcohol.
Sleep aids like Ambien or Lunesta have a similar effect as alcohol on changing the structure of sleep. These medications are meant to be used short term and long term can have consequences on our overall health and sleep quality.
Many people use over the counter sleep aids with sedative antihistamine the active ingredient. Examples of this are Zquil or Tylenol PM. In young people with no problems with balance or memory, these are safe. However, these can cause confusion and imbalance in older people or those with underlying medical problems that affect cognition. These medications often will cause drowsiness the next day, which is not great given the point is to feel better rested. Overall, I don’t recommend these for sleep, but if it’s working for you and you are young and healthy, it’s ok to take them occasionally.
Herbal supplements might have a mild effect on sleep and anxiety and are generally a safe option. A combination of lemon balm leaf 80 mg. and valerian root extract 160 mg. was shown to improve the quality and quantity of sleep in healthy people and those diagnosed with insomnia or sleeping disorders. The effects of these calming herbs are not as dramatic as prescription sleep aides but might help when used as part of an overall healthy approach to sleep.
Melatonin is commonly used as a sleep aide. It can be quite effective in helping with phase-shifting (ie for jet lag or shift workers). The benefit for people with insomnia isn’t as clear. However, similar to the use of herbals, using melatonin as part of an overall approach to healthy sleep might make a small difference. Most of the melatonin that is marketed is in doses that are higher than what our body produces. These higher doses (3 mg, 5 mg, 10 mg) are safe for short-term use and can be useful for jet lag, however, for long-term treatment of insomnia, the general thought is that you should use a lower dose that is more like what your body naturally produces. This is on the order of 1 mg. or less.
Like all of the best things in life, changing to a healthy sleep routine takes time. Little by little making these changes will lead to a better quality and quantity of sleep.