It’s as necessary to good health as food and water. It’s simple to define, yet millions of people subsist on a fraction of what they need. Many of them insist that they want it, but persist in doing things that ensure they won’t get enough of it. Others struggle to clear barriers that thwart them from achieving it.
The object of desire is a good night’s sleep, defined for adults as at least seven hours a night. That’s an elusive dream for tens of millions of people in the United States who endure short- and long-term bouts of insomnia. More than the occasional sleepless night, insomnia is classified as acute (three or more bouts a week for three months or less) or chronic (regular sleeplessness for three or more months). The chronic variety plagues up to 10 percent of the adult population in the U.S.
Insomnia exacts a steep individual and societal price. At the most basic level, the army of the bleary-eyed routinely operate far below the top of their game. “People with insomnia don’t feel the way they want to in the morning,” said Dr. Katherine Green, a sleep specialist and medical director of the Sleep Medicine Clinic at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. “That becomes a habit unless they get treatment for the underlying issue.”
Habitual lack of sleep impairs individuals’ judgment, decision-making and productivity and increases their risk of depression, Green said. It also plays a role in the more than 70,000 crashes and 800 deaths annually the National Highway Traffic Safety Administration attributes to drowsy driving.
The long-term effects of acute and chronic sleeplessness are also under scrutiny, said Dr. Martin Reite, a professor of clinical psychiatry who specializes in treating insomnia at the UCH Sleep Medicine Clinic.
“The question is how much poor sleep contributes to impairment of cognitive function, and vice versa,” Reite said. He noted that studies have shown that a lack of sleep inhibits the brain’s clearance of beta-amyloid – a protein implicated in Alzheimer’s disease that forms clumps or plaques in the brain. That doesn’t necessarily mean that chronic sleeplessness is a long-term contributor to Alzheimer’s, Reite emphasized, but the National Institutes of Health continues to investigate the possible link.
A problem with such breadth and depth – and one that commands daily conversation and national attention – would seem a likely candidate for a concerted campaign in support of snoozing. But insomnia is an elusive foe that escapes easy categorization and methods of attack, Reite said.
“Insomnia is not a disease, despite symptoms that people report across the life span,” he said. “Sleep is something we all need for brain function, but it is underrecognized and is not taught in medical school. It does not fall under one single department, and is rarely part of the formal curriculum. Sleep doesn’t really fit anywhere.”
That ambiguity can make it difficult for insomnia sufferers to find help for a problem that has many sources, including underlying medical conditions, mental health issues, and lifestyle choices. Green, for example, looks first for evidence of obstructive sleep apnea (OSA), which causes throat muscles to relax, collapse, and block the upper airway, arousing an individual from sleep. Once it’s diagnosed, many patients get relief from OSA with a CPAP machine, which uses continuous pressure to keep the airway open, or surgery.
A sleep study in a controlled environment, like the Sleep Lab at UCH, is the gold standard for diagnosing OSA, but a complaint of chronic sleeplessness can yield an early warning. “We see patients with sleep apnea whose only signal is insomnia,” Green said. “They don’t have a bed partner to tell them they’re snoring or stopping breathing. If we treat the sleep apnea, the insomnia problem goes away.”
It’s also very important to diagnose other medical disorders that can disrupt sleep, such as fibromyalgia, rheumatoid arthritis, asthma, and gastroesophageal reflux disease (GERD), Reite said. These can cause pain, shortness of breath, anxiety and other symptoms that disrupt sleep. In those cases, Reite refers these patients to the appropriate specialists to treat the underlying disease, with better sleep being a welcome additional benefit.
“It’s critical to make the most accurate diagnosis possible at the outset of the visit,” Reite said.
Mental health issues are also frequent companions of insomnia. It’s not always easy to pinpoint the culprit, Reite said. For example, did a person’s underlying depression or anxiety produce sleeplessness or did chronic sleeplessness cause depression and anxiety? Reite said he can treat the issues independently, with judicious use of sleep medications for short-term help with the insomnia and cognitive behavioral therapy and other techniques to address mental health issues, depending on the specific diagnosis.
Behavioral wake-up call
In many cases, people can treat their insomnia themselves by making lifestyle changes. The most basic revolve around recognizing and respecting the importance of the circadian arousal drive – simply put, the body’s mechanism for awakening when the earth’s light tells it to, and dropping into sleep when the light fades and darkness descends. It’s the natural clock that is a very reliable driver of sleep, if we adhere to it.
But that requires maintaining healthy sleep habits, and as Green puts it, “We as a society have terrible sleep hygiene. Our society doesn’t prioritize it.” Instead, many people cling to bedtime activities like watching television, checking email, and gazing at cellphone and other mobile device screens. The result: aroused brains that respond to information and light at the time they should be shutting down for the night.
“The light inhibits the receptors that tell the brain to go to sleep,” Green said. She noted that light also disrupts the body’s production of melatonin, a natural hormone that regulates the sleep cycle. Melatonin levels should surge in the middle of the night, but introducing light at the wrong time in effect fools the body and decreases the amount of sleep fuel, Green said.
“The misuse of technology has a major adverse effect on sleep,” Reite agreed. “Light at the wrong time of day – i.e., before sleep – is a disruption because it causes arousal to the circadian system. I tell people don’t use your iPhone in bed. Try to shut those things off at least an hour before bed.”
That’s easier said than done, Green acknowledged. Many people associate getting into bed with turning on their cellphones or TVs. “It’s hard to break that cycle if you’ve been doing it for years,” she said. “You may make a sleep association with the TV, but the bed should be the cue for going to sleep.”
Seeing the light
While too much light at night is a sleep inhibitor, Reite added, people also need enough exposure to light during the day to keep their internal clocks set. Getting outside to exercise, garden or walk is a great help, but that can be difficult as people get older or struggle with physical limitations.
“I tell patients to figure out what in fact they can do,” Reite said. “There are very few who can’t do anything. The question is how to go about implementing that in their day-to-day existence. I like to help people learn to take control of themselves.”
As an example, Reite described the case of a man living in a high-altitude community outside Denver with a chronic insomnia problem that produced anxiety and difficulty turning off his thoughts at night. Medications had provided minimal help for his insomnia. The patient wasn’t in good aerobic shape, so Reite suggested, among other things, increasing his physical activity through walking, biking or other exercises and using a device like a Fitbit to track his progress.
After several months, the patient called Reite to report that he had purchased a Fitbit and used it to track his activity and sleep levels, both of which improved significantly. The approach had helped him not only to sleep better but also to decrease his use of the sleep medication, and his wife was sufficiently encouraged by the results that she planned to follow his lead.
“I think this is one example of how a better understanding of an insomnia problem, along with the development of a non-pharmacological treatment approach, can result in improved sleep, with less anxiety about sleep, as well as decreasing the need for sleep meds,” Reite said.
The case also illustrates how important good data is to improving sleep. Before the advent of electronic devices, Reite counseled patients to keep sleep diaries to understand their wakeful periods, but they proved of limited use.
“Sleep diaries aren’t very accurate,” he said. “It turns out that people just aren’t that good at determining their sleep states.”
Fitbits and other devices, on the other hand, provide a pretty good objective record of sleep in addition to giving individuals a clear look at their activity levels – or lack thereof. “The data gives them a target to move toward,” Reite said.
No magic bullets for bedtime
Objective data can also help people stop worrying about sleeping, which is in itself a reason they have a hard time sleeping, Green said. Any device that provides a reliable measure of activity and rest, she said, helps to make people less stressful about their bedtime struggles.
“When people get a good measure of their sleep time, it helps to calm their anxiety. That’s important because the more you think about sleep, the worse it gets,” Green said.
As for sleep medications, Reite said he is “a believer” in them as one tool to treat insomnia, but he emphasized it’s essential to choose the drug that is most appropriate for the condition. For example, if the underlying cause of insomnia is a psychiatric condition like bipolar disorder, a mood stabilizer could help improve sleep. For acute periods of insomnia with no underlying medical or mental health condition, prescription medications like Ambien, Sonata and Lunesta, all of which have been widely studied, can offer short-term help. They are not, however, a long-term solution.
“There are situations that a pill can help as part of an overall scaffolding strategy for treatment,” Reite said.
“There are no silver bullets in treating insomnia,” Green stressed. “For many patients, it takes a commitment to a program and a long-term goal to break years of habits. Sleeping aids can be a good Band-Aid, but combination therapies are where long-term success lies. That’s why an interdisciplinary approach to sleep medicine is so important.”