February Provider Newsletter

Pillow Talk

“But [Pooh] couldn’t sleep. The more he tried to sleep the more he couldn’t. He tried counting sheep, which is sometimes a good way of getting to sleep, and that was no good, he tried counting Heffalumps and that was worse. Because every Heffalump that he counted was making straight for a pot of Pooh’s honey, and eating it all. For some minutes he lay there miserably, but when the five hundred and eighty-seventh Heffalump was licking its jaws, and saying to itself, ‘very good honey this, I don’t know when I’ve tasted better,’ Pooh could bear it no longer.” - A.A. Milne, Winnie the Pooh

Winnie the Pooh experienced a common obstacle to falling asleep, an active mind. He tried to count the Heffalumps until they started eating the honey that he loved. At that point, he could not take his mind off the honey and the possibility they might eat it all.

Getting quality sleep can be difficult at times.  Whether it be the result of more hours at the office, bad habits formed during injury recovery, or added stress because of the COVID-19 pandemic, life events can wreak havoc on your sleep. Have you ever had sleep problems? I’m not talking about the one night last week when you slept seven as opposed to eight hours. I’m talking about the times when you’ve crawled into bed early, equipped with a one-way ticket to Snoozeville, and then proceeded to flip and flop for three hours without even so much as a wink of sleep. If that sounds like something you have experienced or are currently experiencing, you are not alone.

Sleep loss and sleep disorders are among the most common, yet frequently overlooked and readily treatable health problems. According to the American Sleep Association (AMA), sleep disorders currently affect as many as one third of U.S adults. Insomnia, both acute or short-term insomnia, and chronic insomnia, is the most common sleep complaint.

In some cases, sleep disorders can be a symptom of another medical or mental health condition. These sleep problems may eventually go away once treatment is obtained for the underlying cause. When sleep disorders are not caused by another condition, treatment normally involves a combination of medical treatments and lifestyle changes.

Let’s break down what it means to get “enough sleep,” dissect the most common sleep complaint -  insomnia, highlight the major consequences of sleep deprivation, and look at ways we can promote quality sleep through healthy sleep hygiene.

How Much Sleep Do I Need?

The amount of sleep you need changes as you age. The CDC recommends the following amount of sleep for each age range.

While the amount of sleep we get each day is important, good sleep quality is also essential. These guidelines serve as a rule-of-thumb for how much sleep children and adults need while acknowledging that the ideal amount of sleep can vary from person to person.

For that reason, the guidelines list a range of hours for each age group. The recommendations also acknowledge that, for some people with unique circumstances, there is some wiggle room on either side of the range for “acceptable,” though still not optimal, amount of sleep.

The National Sleep Foundation recommends that each person should consider his/her overall health, daily activities, and typical sleep patterns to decide how much sleep is needed. Some questions that help you assess your individual sleep needs include:

• Are you productive, healthy, and happy on seven hours of sleep? Or have you noticed that you require more hours of sleep to get into high gear?
• Do you have coexisting health issues? Are you at higher risk for any disease?
• Do you have a high level of daily energy expenditure? Do you frequently play sports or work in a labor-intensive job?
• Do your daily activities require alertness to do them safely? Do you drive every day and/or operate heavy machinery? Do you ever feel sleepy when doing these activities?
• Are you experiencing or do you have a history of sleeping problems?
• Do you depend on caffeine to get you through the day?
• When you have an open schedule, do you sleep more than you do on a typical workday?

The Most Common Sleep Complaint – Insomnia:

According to the American Academy of Sleep Medicine’s ICSD-3 manual, insomnia is defined as “persistent difficulty with sleep initiation, duration, consolidation or quality.” Insomnia has many potential contributing factors and symptoms, but its diagnosis hinges on two essential components: sleep difficulties that occur despite adequate opportunities for normal sleep, and daytime impairment that directly results from poor sleep quality or duration.

Insomnia varies in how long it lasts and how often it occurs. About 50% of adults experience occasional bouts of insomnia and one in 10 suffer from chronic insomnia. Insomnia can occur by itself or can be associated with medical or psychiatric conditions. Insomnia can be short-term (acute insomnia) or can last a long time (chronic insomnia). It can also come and go, with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has insomnia at least three nights a week for a month or longer.

While insomnia can manifest in different ways, most diagnoses fall into one of two categories:

• Sleep-onset insomnia refers to difficulty falling asleep. This type of insomnia may occur with people who have a hard time relaxing in bed, as well as people whose circadian rhythm is not in sync due to factors like jet lag or irregular work schedules.
• Sleep maintenance insomnia refers to difficulty staying asleep after initially nodding off. This type of insomnia is common in elderly sleepers, as well as people who consume alcohol, caffeine, or tobacco before bed. Certain disorders like sleep apnea and periodic limb movement disorder can also cause sleep maintenance insomnia.

Some people may have mixed insomnia that involves both sleep-onset and sleep maintenance difficulties, and people with chronic insomnia may find that these symptoms shift over time.

Symptoms of Insomnia

• Difficulty falling asleep despite being tired.
• Waking up frequently during the night.
• Trouble getting back to sleep when awakened.
• Unrefreshing sleep.
• Relying on sleeping pills or alcohol to fall asleep.
• Waking up too early in the morning.
• Daytime drowsiness, fatigue, or irritability.
• Difficulty concentrating during the day.

The Effects of Sleep Deprivation

Not getting the proper amount or quality of sleep leads to more than just feeling tired. Sleepiness interferes with cognitive function, which can lead to learning disabilities in children, memory impairment in people of all ages, personality changes, and depression. People who are deprived of sleep have trouble making decisions, irritability, have problems with performance, and slower reaction times, placing them at risk for automobile and work-related accidents. Sleep loss can also adversely affect life by contributing to the development of chronic diseases such as obesity, diabetes, and heart disease.

The following depiction of the Effects of Sleep Deprivation is from Johns Hopkins sleep researcher, Patrick Finan, Ph.D

Promoting Sleep through Sleep Hygiene

If you have ongoing or worsening problems with insomnia, insufficient sleep, or daytime sleepiness, talking to your primary care doctor is the first step to getting relief. Your doctor will assess your situation, evaluate for any underlying health conditions (and refer for further testing or evaluation when appropriate) and recommend treatment that best suits your needs.

In almost all cases, the first step is to evaluate your daily routine - what you eat and drink, the medications you take, how you schedule your days and how you spend your evenings. These daily habits can significantly impact your quality of sleep. Even a few slight adjustments can, in some cases, mean the difference between sound sleep and a restless night. A focus on sleep hygiene – or a series of healthy sleep habits - is a central component of preventing insomnia and treating sleep deprivation. The following sleep hygiene tips are the cornerstone of cognitive behavioral therapy, the most effective long- term treatment for people with chronic insomnia.

• Keep a consistent sleep schedule.

One of the best ways to train your body to sleep well is to go to bed and get up at about the same time every day – this means even on the weekends or when you have the day off!

• Sleep when sleepy

Go to sleep when you feel tired or sleepy, and do not spend too much time awake in bed.

• Get up and try again after 20 minutes

Get up and do something calming until you feel sleepy if you have not been able to fall asleep after about 20 minutes. Sit quietly on the couch with the lights off (bright lights will tell your brain that it is time to wake up) or read something boring. Avoid doing anything that is too stimulating or interesting, as this will wake you up more.

• Avoid caffeine and nicotine

It is best to avoid consuming any caffeine or nicotine for at least 4-6 hours before going to bed. These substances act as stimulants and interfere with the ability to fall asleep.

• Avoid alcohol

It is also best to avoid alcohol for at least 4-6 hours before going to bed. Many people believe that alcohol is relaxing and helps them get to sleep at first, but it actually interrupts the quality of sleep.

• Use your bed only for sleeping and intimacy

Avoid using your bed for anything other than sleeping and sex, so that your body associates bed with sleep. If you use your bed as a place to watch TV, eat, read, work on the computer, and other things, your body will not learn this connection.

• No naps

Avoid taking naps during the day to make sure that you are tired at bedtime. If you cannot make it through the day without a nap, make sure it is less than an hour and before 3pm.

• Establish a bedtime routine

Develop your own bedtime routine to remind your body that it is time for sleep. Engage in relaxing stretches or breathing exercises for 15 minutes prior to bed each night. Taking a bath 1-2 hours before bed can also be useful, as it will raise your body temperature, causing you to feel sleepy as your body temperature drops again. Research shows that sleepiness is associated with a drop in body temperature.

• Exercise regularly

Regular exercise during the day helps promote sleep at night. However, try not to do strenuous exercise in the 4 hours before bedtime.

• Eat right and reduce fluid intake prior to bedtime

A healthy, well balanced diet will help you sleep well, but timing is important. Having a heavy meal within 2 hours of bedtime can interrupt sleep.

• Turn off electronic devices at least an hour prior to bedtime

TVs, cell phones, tablets, and computers can keep your mind stimulated, leaving you still wired when you want to go to bed. The light emitted by these devices can also interfere with your circadian rhythm. As a result, it is best to avoid using electronic devices for an hour or more before bed.

• Make your bedroom quiet and relaxing

It is important to make your bedroom quiet and comfortable for sleeping. A cooler room with enough blankets to stay warm is best. It is also a good idea to have curtains or an eye mask to block out early morning light and earplugs if there is noise outside your room.

• Don’t watch the clock!

Frequently checking the clock during the night can wake you up and reinforces negative thoughts such as “Oh no, look at how late it is, I’ll never get to sleep” or “it’s so early, I have only slept for 5 hours, this is terrible.”

In my opinion, sleep is underrated in our society, and sleep habits are an overlooked aspect of primary care visits, despite the prevalence and burden of conditions such as insomnia on the general population. I hope this information on sleep and how to promote quality sleep through healthy sleep habits encourages each of you to assess your own relationship with sleep and discuss it with your provider if needed.

Cheers to life, liberty, and the pursuit of a good night’s sleep!

Emily Sitomer NP-C

For more information on sleep disorders and sleep education:

https://www.cdc.gov/sleep/about_sleep/index.html

https://www.sleepfoundation.org/

http://sleepeducation.org/

https://www.sleepassociation.org/

Author

Emily Sitomer, FNP-C Emily grew up in McMinnville, TN and attended high school at the Webb School in Bell Buckle. She graduated summa cum laude from Vanderbilt University, majoring in Child Development and Medicine, Health, and Society. She continued at Vanderbilt to complete her Masters in Nursing in 2012. After graduation, Emily worked at a primary care practice in the Dallas, TX area prior to moving back to Nashville. She is a board-certified Family Nurse Practitioner and a member of the American Academy of Nurse Practitioners and Sigma Theta Tau, the International Honor Society of Nursing. Emily is passionate about providing individualized care to patients of all ages. Her goal as a health care provider is not only to manage health and diagnose and treat illness, but also to develop meaningful, trusting relationships with each patient.