“The worst thing in the world is to try to sleep and not to.” F. Scott Fitzgerald

The negative effects of chronic sleep deprivation are underappreciated. Lack of sleep has negative physiological effects by raising insulin and cortisol levels. The raised levels can make you crave low-quality carbohydrates, thinking that food will bring you energy which it will not. Raised insulin and cortisol contribute to insulin resistance and obesity, which can cause hypertension and diabetes. What we all know is that we are miserable without proper sleep. Poor sleep can create or worsen depression, anxiety, and our ability to enjoy the day. Irritability that comes with lack of sleep strains personal relationships and negatively affects work performance. Insomnia has been linked to dementia. 

 “A good laugh and a long sleep are the best cures in the doctor’s book.” — Irish proverb

There is hope. The vast majority of people can improve the quality and duration of sleep by making simple changes. The changes are simple, however, the application is difficult. Change requires a commitment to change. Be patient. The problem does not resolve overnight. We have to relearn how to get restful, restorative sleep. Next, I will give a step-by-step approach to bringing good sleep back into your life.

Sleep Routine

Go to bed same time every night.

• Begin to relax for three hours before going to bed. Start by avoiding over-stimulating activities, which could include action movies or TV shows, conflict at home, work activities that create anxiety or disrupt a peaceful environment.
• Dim the lights, adjust settings on smartphones and tablets to “night-shift,” which changes the spectrum of light. Too much light suppresses melatonin, which is made naturally in the brain to promote sleepiness.
• Do not exercise vigorously close to your set bedtime. Try a relaxing walk after dinner instead.  

Wake up at same time every morning.

• By going to bed and waking up at the same time, we reset our circadian rhythm. This is no easy task, but stick to the program and you will get better sleep.
• Even if you are still tired, get up and out of bed. Turn on all the lights. Bright light suppresses melatonin and promotes wakefulness.
• First thing in the morning is a great time for exercise. If nothing else, take a walk outside. The light and fresh air will bring more energy to the entire day
• Caffeine intake is best in the morning, and all caffeine should be consumed before noon. The best sources are coffee and tea. Caffeine has about an 8-hour half-life, which means if you consume 100mg of Caffeine at noon you still have about 50mg in your system at 8pm. My personal approach is to drink tea upon wakening.

Only sleep during the prescribed times.

• Ø Avoid naps during the day.  Naps disrupt your circadian rhythm. 
• Ø If you must nap, make it a 15 minute “power nap.”  Longer naps will create “sleep inertia” and really disrupt your sleep cycle.

 Sleep Environment 

Your bedroom should be dark.

• Ideally, when holding your hand in front of your face, the hand should be hard to see.
• There is an evolving science around “light pollution.”  City life is bustling with noisy activity as well as excessive light. Thus, one needs to go through significant measures to create an environment conducive to sleep.
• If you can, use blackout shades for your bedroom windows. Eliminate or cover electronic devices that emit light in the bedroom.

Reduce noise level.

• Consider using a noise-canceling white noise machine.
• If a spouse is keeping you awake, you may need to enlist their support to help create a tranquil sleep environment.

Bedroom temperature is comfortable.

The bed is ONLY for sleep or having sex.

• No reading in bed
• No TV in bed
• No looking at your phone in bed 

Get out of bed when you can’t sleep!

This is the most difficult of all, but extremely important. If you find yourself unable to sleep for 15 minutes, get out of bed.

• Staying in bed while awake only reinforces sleepless behavior, making a negative association with being awake and in bed.
• To break that cycle, and to create a positive association with the bed as a place for sleep or sex, you must create a new routine.
• When you can’t sleep, get out of bed to a low-light environment.
• Next, take 10-15 exaggerated deep breaths. This is a relaxing exercise that helps calm your brain.
• This is a good time to do a meditative mantra or routine. Visualize you are relaxing under a shady tree. A gentle stream is going by. You see a leaf fall into the stream and gently float away. Then repeat. This helps silence thoughts that are keeping you awake.
• You can try writing down the thoughts you are having on a notepad or journal.  This helps decrease nighttime thinking and worrying. 
• When you feel sleepy then go back to bed, repeat as much as needed.

Other activities that contribute to insomnia.

• Alcohol is initially relaxing it is called a CNS (central nervous system) depressant. That is until it wears off, when it becomes a stimulant, causing increased CNS activity.  Even if you feel you can sleep only when drinking alcohol, the quality of sleep is disrupted, because the alcohol stops you from going into restorative sleep cycles. Thus, if you are having trouble sleeping, or feeling tired and sluggish the next day, this really needs to be addressed.

Hidden intake of caffeine. Caffeine is in energy drinks and some pain medicines like Excedrin. 

You should take a hard look at all supplements and medications you are taking that could be negatively impacting sleep. Please review with your Physician or Pharmacist if needed.

Sleep Aides

The only sleep aide I generically recommend is melatonin.

• Studies indicate the best dose is 1-3mg taken 3 hours before bed. Melatonin acts as a catalyst for your own body’s production of melatonin. Thus, the dose does not need to be higher as this dose prompts your brain to make melatonin. The melatonin gradually rises over a three-hour period, promoting the sleepy feeling at the predetermined time. If you create the routine as outlined above, this added measure can be very helpful.
• Avoid over-the-counter sleep aids that contain Benadryl or similar components. You may actually sleep with the medication, but like alcohol, it will keep you from getting restorative sleep.

Underlying Medical Conditions

Good sleep will be difficult to obtain if you have an underlying condition working against you. Thus, please work closely with your physician to make sure conditions can be mitigated. Below are some, but not all, of the conditions that should be considered.

• Chronic pain (this is common especially in the elderly)
• Thyroid disorder
• Restless Leg Syndrome
• Iron deficiency (can cause restless leg syndrome)
• Periodic Limb Movement Disorder
• Sleep Apnea (you may perceive you are sleeping but the quality of sleep is poor and you are likely waking up tired)
• Depression and Anxiety

I hope you found this helpful and good sleep is in your future.

Warm regards,

Douglas R. Hilbert, MD, FACP