SLEEP, PERCHANCE TO DREAM …
Dr Ewan Crawford explains about sleep and insomnia and how you can maximise your chances of getting a good night’s sleep
There are two distinct types of sleep: REM (rapid eye movement) sleep during which it is said we dream, and non-REM sleep which is divided into light sleep (stages 1 and 2) and deep slow wave sleep (SWS) (stages 3 and 4). Slow wave sleep is the deep restorative sleep that it is essential if we are to awake refreshed.
As we sleep we pass through the different sleep stages in cycles. When we go to bed we are awake for some minutes, then rapidly fall through the stages of sleep from 1 to 4. We then spend about forty-five minutes in deep sleep before going back up the stages to lighter sleep and having a period of REM sleep. The sleep then deepens again and we have a further period of SWS before another bout of REM sleep. And so it goes on throughout the night. As the night passes, however, the deepness of the SWS lessens. By the second half of the night the pattern alternates between REM and stages 1 and 2 of light sleep.
Most people will sleep for six to nine hours a night. As we age, our bodies require less sleep and, unfortunately, that sleep tends to be of a poorer quality. Sleeping like a baby is a very apt expression, as babies will sleep for hours at a time many times a day: I’m afraid that it is all downhill from then on!
CAUSES OF INSOMNIA
It is useful to divide causes of insomnia into short, medium and long term. We are all familiar with the short-term problems that cause insomnia: jet lag, stress, bereavement, exam nerves, interview anxiety, shift working (the list is almost endless). A short-term problem will disrupt our sleep pattern for a number of days but our pattern will rapidly revert to normal once the problem has been resolved. Medium term causes of insomnia include, as well as the problems above, medical problems, financial and marital difficulties and anything that causes anxiety or anger that is difficult to resolve.
Long-term insomnia can result from any of the causes of insomnia. It is tragically common for a short-term problem to lead to chronic insomnia. We are all creatures of habit. If we allow ourselves to get into the bad habit of not sleeping, that can persist long after the initial cause of insomnia has past.
GETTING A GOOD NIGHT’S SLEEP
There are a number of simple steps you can take to increase your chance of sleeping longer at night and improve the quality of your sleep.
MAKE THE BEDROOM CONDUCIVE TO SLEEP Ensure the bed is comfy (mattresses rarely last more than ten years) and the room as dark and as quiet as children or neighbours will allow.
AVOID STIMULANTS These include the obvious caffeine (in all forms – read the label) and the less obvious nicotine and alcohol. Some medication is stimulating so check with your pharmacist if a new medicine or herbal remedy coincides with the onset of insomnia. Eating too late also has a detrimental effect on sleep.
EXERCISE Exercise as much as is possible. Regular exercise will help you to sleep. You should, however, avoid exercise just before bedtime. Exercise too late at night has an awakening effect but is hugely beneficial earlier in the evening.
ENCOURAGE RELAXATION Resolve any conflicts long before bed. Empty your mind of anger and anxiety (easier said than done). At worst accept the issue cannot be resolved and decide to deal with it the next day. A hot bath aids relaxation and the subsequent cooling down can mimic the natural temperature dip that coincides with falling asleep.
BE TIRED Only go to bed when tired. There is a cycle of tiredness throughout the day and it is sensible to make sure you are ready to fall asleep when you go to bed. If we are not sleeping well it is temping to “catch up” through the day with a nap. This cannot help. The precious hours of SWS will be had in the afternoon; we will be less tired at night and will not have SWS to catch up on. Similarly sleeping late in the morning reduces sleepiness at night. By getting up at the same time each morning we will maximise the “sleep drive” when we go to bed at night.
RESERVE THE BEDROOM FOR SLEEP With one exception the only thing we should be doing in bed is sleeping! Eating, watching T.V. and other activities we regard as daytime, awake activities should be banned from the bed. Going to bed should mean going to sleep.
In outline, this is general advice on getting to sleep; and it is common sense. Persevere and you will increase your chances of getting a good night’s sleep. It is possible to sleep well and not follow a word of the advice above. But if getting to sleep is an increasing trial, it is worth looking at your sleep pattern and bedtime routine to check for problems. It is, however, possible to become too worried about sleep. In these circumstances the worry about not sleeping replaces the initial cause of your insomnia (now long gone). Your anxiety perpetuates your insomnia. If you can’t get to sleep try not to worry too much about it.
There are two situations that make the advice I’ve given incomplete. The first is people with antisocial, noisy neighbours; I think it a kindness to prescribe a mild sleeping tablet for use on an intermittent basis. Once or twice a week use will ensure a good night’s sleep, at least on those nights, and is a great relief. It will also ensure that the tablets maintain their effectiveness, and the patient does not become addicted.
The second situation is where there is a co-existing medical problem. Many medical problems can disturb sleep. This is understandable. Anything that disturbs our inner equilibrium will have an impact on our sleep pattern. It is therefore important that if you do suffer from medical problems, they are treated as fully as possible to reduce the impact they will have on your sleep.
Pain and depression are worthy of special mention. Depression is a major cause of chronic insomnia. Classic depression leads to early morning waking and ruminations. Depression is often mixed with anxiety. In anxiety, an overactive and “spinning” mind makes falling asleep very difficult. In the past, it was thought necessary to give a sedative antidepressant to help sleep problems. There is good news: it is now clear that treating the underlying depression alone will improve sleep.
I mention depression before going on to pain, but there is no doubt that the two are linked. It is simply not possible to be in significant pain without it effecting ones mental well being. The only way of separating the mind and the body is with a guillotine!
When dealing with chronic pain it is important that you do everything possible to maximise the chances of a good night’s sleep. You can help yourself by adhering rigorously to the advice above. You should be careful about napping. It is often soothing for the pain to lie down in the afternoon, but this must not become an hour’s sleep. If it does, it will restrict the amount of sleep possible through the night. If rest through the day is helpful for your condition, ensure that rest is taken away from your normal sleeping area. This will reinforce the “bed for sleep” message.
Getting up at the same time every day will make the “sleep drive” at night time more marked. When we sleep the time of waking is often the only thing over which we have control and we should make sure we use it to the best advantage.
Of course, the most important aid to sleep for a chronic pain sufferer is adequate pain relief. If you are using pain killers it is essential to optimise your analgesic regime and this is best done in discussion with your G.P. There are a number of types of analgesia. The most basic are paracetamol and aspirin. Both are excellent pain killers. Their effects can be slightly enhanced, but at the cost of increased side effects, by being combined with a mild opiate. Tramadol is a novel drug for mild to moderate pain that is beneficial to some patients. For more severe pain pure opiates (for example, dihydrocodeine) may be appropriate although these must be used with caution in view of their addictive nature, risk of abuse and the build up of tolerance. The non-steroidal anti-inflammatory drugs (NSAIDs, for example, ibuprofen) are useful if tolerated and are particularly effective if there is an inflammatory element in the pain.
Unfortunately chronic pain often responds less well to traditional pain killers than would be hoped. A number of preparations may be effective in this situation. These include gabapentin, pregabalin and carbamazepine (used for epilepsy), and amitriptyline (an antidepressant) which appear to alter the way we actually perceive pain and make it less intrusive.
Most GPs know that drugs are not the whole answer to pain. Cognitive therapy, physical therapies, TENS machines, exercise programmes, acupuncture and the whole range of alternative therapies have their place in helping the patient with chronic pain. Do whatever works for you and do not let other people’s experiences and opinions sway you from pursuing a potential solution to what is, after all, your problem.
Is there an answer to a good night’s sleep? In an imperfect world there isn’t a simple answer, but by relieving pain, relaxing, exercising regularly and going to a comfy bed when tired after a hot bath, you can greatly increase the chances of getting the sleep you need.
Dr Ewan Crawford is a GP with a special interest in sleep. He is medical adviser to the charity Sleep Matters. Further information from Sleep Matters, PO Box 3087, London W4 4ZP.
A Good Night’s Sleep © Ewan Crawford. All Rights Reserved.