This post is the practical “how to” post. I’m going to break my advice into five groups. The causes of the issues within all these groups are varied beyond the scope of this blog, but I’m going to try to give some practical insight into common problems and hopefully give you a framework on which to work on your sleep. There is a ton of overlap between these groups. Frankly most of us likely fall into a few of these categories, but in an effort to organize my thoughts, this is how I think about it.
Group 1: Sleeps enough, feels rested: continue. Keep doing what you are doing. Though I will say, it’s probably worth considering at least scrolling to the Group 4-sub b (below) with the advice on sleep hygiene. There’s no reason to give yourself sleep troubles in the future by treating your sleep poorly just because you were good at it for your first twenty or thirty years.
Group 2: Sleeps enough (8+ hours), feels they sleep “well” (don’t wake up, fall asleep well) and doesn’t feel rested. This group is another “easy one” actually. If you are really getting enough sleep, all the time, with no “getting called into work in the middle of night” (aka I’m in this group) from time to time or “2 year old is up in the night with an ear ache or other problem”, then you need to be evaluated by your doctor. There are a lot of people who spend 8-9 hours in bed all the time, feel like they are asleep the whole time but never feel rested. They wake feeling tired and are tired all the time. It gets somewhat more complicated from there of course, because there’s a difference between being sleepy (trouble staying awake while driving, fall asleep watching movies) and fatigued (a feeling of being tired without necessarily being sleepy) but that discussion is outside the scope of this post. Both groups (fatigued and/or sleepy) with adequate sleep quantity need evaluation. The most common cause here will be sleep apnea. I can’t even tell you how often I diagnose it, but it’s a lot. If you are in this group and snore…..yeah you need a sleep study.
If you are in group 2 but in that subcategory like me that gets interrupted sleep for any reason outside your control: try to be as diligent about getting enough as you can and limit the tiredness that will come from having interrupted sleep.
Group 3: Doesn’t get enough sleep. You know who you are. You are a good sleeper, when you do go to bed you fall asleep pretty well, you stay asleep, and when you get enough sleep you feel good and rested. This group: go to freaking bed. There’s a lot of people in the other groups that would throat punch you for your dumb pattern of just simply staying up too late and then feeling tired all the time. I already discussed in the first post in the series that it likely does increase your hunger and intake. There’s a lot of research on decreased exercise tolerance when sleep deprived.
Beyond that, I’ll use my wife as another example of this problem. She’s a pretty good sleeper and needs a fair amount of sleep (more then me). She will get into a pattern of staying up excessively late reading for fun. She will be tired the next day and she will have less job satisfaction (domestic engineer raising our two daughters at home), be more irritable with our daughters, everyone will have a worse day, then after the girls go to bed she will “need more free time” because she hated her day so much. What comes next? Her staying up too late and starting the pattern over again. A few days of this and I’ll basically make her go to bed early. She’ll have a great day the next day. Everyone will be happy. She’ll love her life and after the girls go to bed….she’ll be in a great mood and have no real need to stay up overly late. Those are days that I come home and there’s been a new photo shoot of the girls at play. Mom, kids, everyone is happy. I think many people fall into this group. You’ll like your life more if you just go to bed early enough. If you like your life more…..you won’t need to stay up so late.
Group 4: Trouble falling asleep: This is probably the group I get consulted on the most in my office. In some ways this is the most varied group because the differential diagnosis of trouble falling asleep is wide. Some common causes that I won’t spend some time on, but hopefully if you see yourself in here you will see your provider:
1) Untreated mood disorder, most commonly anxiety or PTSD, but also depression. 2) Drinking excessive caffeine during the day 3) Restless legs syndrome (an uncontrolled need to move the legs)
4) Magnesium deficiency: I’m putting this one a little separate because people in Group 4 should probably just try taking magnesium anyway. It’s likely that people that don’t get enough sleep don’t get enough magnesium. Supplementation can help with sleep and a variety of other symptoms (tremor, muscle cramps, insulin sensitivity, eye twitching, low potassium among others).
Ok, now the main Group 4 sub-categories I am going to cover are these:
Group 4-sub a: going to bed too late. There’s a huge number of people who will tell me “I can’t fall asleep until after midnight”. Frankly this group usually has a lot of overlap with Group 4-sub b, but there’s a particular pattern I see in this group all the time. They are actually tired at 9-9:30 PM. Even if they say they aren’t, usually they are. What happens then is they watch TV, read, Facebook, internet, whatever, until 11 PM and try to go to bed and can’t fall asleep for a long time. What happens is an increase in stress hormones there around 9 PM when you pushed past what should be your bedtime. Those stress hormones are often what is making you have so much trouble fall asleep at 10 or 11 PM. It’s just too late. Often these people also don’t have to be up very early so they end up in a pattern of being able to sleep in which partially makes up for their initial poor ability to fall asleep. In general people’s circadian rhythms are heavily influenced by the light of day and waking up much after the sun comes up is a pretty unnatural thing. People would be much better off going to bed earlier and waking up earlier, much like people 40 years ago did. Forty years ago the average American slept almost two hours longer than now. People will try to claim we are getting more done, but mostly that’s Facebook, internet or TV, not real money making productivity or home building productivity. Just entertainment and maybe some education, which is what I consider my work on this blog.
Group 4-sub b: Going to bed at a reasonable hour but bad sleep hygiene. Sleep hygiene in general is the idea of “promotion of regular sleep“. The CDC link has some tips and you can find tips all over the web. Here’s a few that can help: 1) Dark room, like complete darkness, even cover up your clock. 2) Don’t do anything in your bed but sleep and sex. Watching TV, reading or even just lying and daydreaming in your bed creates normalization of wakefulness in your bed. 3) Screen time before bed. I recommend turning off all screens 1 hour before your bedtime if you have trouble falling asleep. White light is the signal for our brains to be awake and all our modern screens shine white light directly into our eyes from a few feet away, yeah not ideal. 4) Habit creation: same time to bed, same time to rise every day. 5) Appropriate intake (not hungry and not sick full) leading up to bedtime 6) Avoiding activating medications before bed. If you’ve recently started a medication and find you can’t fall asleep now, consider asking your provider if switching it to the morning would make more sense.
Group 5: Trouble staying asleep. This group falls asleep pretty easily but has trouble staying asleep. There are overlap features with other groups in this one. Untreated mood disorder is in here also. People who are restricting calories will often have trouble staying asleep. People with sleep apnea will wake up frequently at night because their body is trying to make them breath all night long. Primary insomnia- some people have none of the above and just are light sleepers or wake up overly frequently. Some of those people may need a sleep aid. Reflux disease (at times associated with over consumption in the evening, other times anatomic factors including obesity) often wakes people at night from the burning chest pain.
Excessive alcohol, people who are drinking too much will often report waking in the early hours of the morning before they want to awake. Excessive caffeine- I actually fall into this category also. If I drink coffee at night I can fall asleep no problems, but I will awake, alert at 4 AM. The half-life of caffeine can be such that you will have enough left in the system in the early hours of the morning to provide wakefulness enough to make falling asleep harder. Bladder disorders, if you have to go more then once per night, consider talking to your doctor about that. It’s not normal, but it’s also an overly broad topic for this blog post so go talk to your doctor.
There you have it. My starting primer on sleep issues. This is not intended to be the all encompassing be-all, end-all review of sleep. Hopefully there’s something that can help you in here. For most people the best advice of all is: turn off the screen and go to bed earlier, your health will thank you.