Brain Health

The Scoop on Sleep

Identifying and Addressing the Issues With Sleep Hygiene

Have you noticed that your sleep isn’t as restful as it used to be? Either you wake up in the middle of the night, can’t get to sleep, or wake up too early. There are many ways that poor sleep cycles impact the quality of your life, but it can often be hard to understand and pinpoint the root of the problem. Considering that the average person spends almost a third of their life in a state of slumber, maintaining healthy sleep hygiene is vital to living a full, active and healthy life, and the cornerstone to wellness.

Why is sleep important?

Most people tend to conceptualize sleep as a time when the mind and body shut down to achieve much needed rest. However, this is not the case: the brain is almost always most active during sleep. Sleep is vital for important information processing, strengthening neural pathways, and pruning disused neural connections over the night.

Various Levels of Sleep and Brain activity

One critical role of sleep is to help us assimilate short-term memories from the previous day into long-term memory – a process known as “consolidation”. A good night’s rest actually will allow better retention and recall of recent events. Think about that the time you pulled an “all-nighter” and how it actually was more detrimental to your memory than getting the necessary rest.

Sleep also allows for an untangling of any strong emotional reactions from daily stressors in the amygdala. Sleep deficit was associated with greater amygdala reactivity and association with stress and depression Conversely, it has been found that those diagnosed with post traumatic stress disorder have a less effective sleep cycle and less of an ability to extinguish a negative memory from storage. This may implicate that the process of emotional detachment from painful sensory stimuli is not occurring during inefficient rest.

Emotional issues aren’t the only effects of poor sleep. Many medical outcomes are linked to irregular rest or shortened sleep: increased risk of stroke, atrial fibrillation, heart attack (myocardial infection) and other cardiovascular outcomes, memory problems and dementia, and even immunodeficiency, cancer risk and longevity.

Exactly why sleep happens is still a mystery to researchers, but what is commonly agreed upon is that sleep is directly related to achieving optimal health and long term well being.

How Do You Know if Your Sleep Quality is Poor?

Before we can address how to fix sleep issues, we must define what a good night of sleep is. First and foremost, a beneficial night of rest means that the individual wakes up feeling fully rested without much difficulty rousing themselves into awareness – i.e. without an alarm clock. Usually this is achieved in an adult with about 7 to 10 hours of sleep. The mood of the sleeper should be neutral or positive after the sleep cycle has ended, and they should be able to take on the challenges of the day without much exhaustion, difficulty, or mood perturbation.

What are some common signs that your sleep quality needs to improve? If you get less than this average amount of time sleeping, it takes you more than thirty minutes after laying down to fall asleep,or you are waking up multiple times even for brief periods, then you likely have an issue with your sleep hygiene – or an underlying sleep disorder. Your current rate of productivity may not feel sustainable when the quality of sleep is degraded, you may snap more often at friends or family, or your mood may fluctuate rapidly. Pay attention to how your emotional state shifts after you wake up.

Common Sleep Disorders

There are a wide variety of sleep disorders and chronic conditions which impact how well-rested you feel after you wake up. When in doubt, reach out to a medical professional to determine the root issue. Below are just a few of the most major impacts of poor sleep quality below:

Sleep Apnea

Sleep apnea is a potentially very serious sleep disorder in which breathing stops and starts repeatedly throughout the night, disrupting one’s ability to achieve deeper states of sleep. Surprisingly, it can be difficult to determine if you have sleep apnea, even if you share a bed. If you find that you snore so loudly that you wake yourself up at night, or you feel tired even after a full night of sleep, you might have this condition which affects over 22 million Americans . It’s estimated that over eighty percent of cases go undiagnosed.

The two forms of sleep apnea are Obstructive and Central, though in a clinical setting these conditions may overlap. Obstructive sleep apnea (OSA) occurs when air entry is mechanically hampered, either through blockage at the level of a the mouth (e.g. mouth construction hindering air entry or the tongue is sufficiently compressing the throat), neck and chest wall. The likelihood of significant sleep apnea, including risk of atrial fibrillation (tied to stroke) increases linearly with the body mass index of a person.

Central sleep apnea (CSA) occurs after a stroke or other neurodegenerative conditions, after prolonged significant OSA, in cardiopulmonary conditions such as COPD (Chronic obstructive pulmonary disease) or pulmonary hypertension, or can be induced through the use of opiates or rapid ascent to high altitude. In central sleep apnea, the trigger to breath does not occur in the brain (the “apneustic centers” of the brain in the medullary pons). Neurons in the brain are triggered mainly by carbon dioxide levels in the blood followed by oxygen levels. In the setting of insensitivity, these levels are not regulated, resulting in higher levels of carbon dioxide and lower levels of oxygen in the blood. The health consequences of significant central sleep apnea can be grim.

A more severe form of sleep apnea is referred to as Ondine’s curse, where the affected individual completely stops breathing after falling asleep. Usually, this is a congenital condition and requires extensive respiratory support during the night. Adults with severe central sleep apnea can approach a similar severity.

By contrast, Pickwickian syndrome is a condition where severely overweight people don’t breath deeply enough during both the day the night. This results in depressed oxygen levels and high blood carbon dioxide. These patients have a significant mortality rate as the condition persists undiagnosed.

Work Shift Changes and Sleep Asynchrony

If you work rotating shifts every week or every few nights, you are at risk for Work Shift Sleep Disorder . This condition is characterized by excessive sleepiness, lack of refreshing night sleeps despite sleeping through the night, and drowsiness during waking hours. The condition rears its head because the circadian rhythm, which regulates sleep and hunger, gets thrown off by constant changes to the body’s routine.

The Cleveland Clinic estimates that between ten to forty percent of nontraditional shift workers suffer from SWSD. Chronic sleep deprivation can be dangerous and impact the quality of work for these individuals. A worker’s SWSD is believed to be partially responsible for Chernobyl Disaster in 1979.

Similar to SWSD, general sleep asynchrony problems can have devastating impacts on the life of the sufferer and their community. Frequent time zone changes, irregular routines around eating and drinking, and unpredictable behavioral patterns all contribute to sleep problems. Even the one hour lost after the “fall-back” time can impact health risk, with a 24% increased risk of a heart attack the Monday after the switch.

Substance Induced Sleep Disorders

Medication-induced sleep disorders are the official diagnostic name of sleep issues caused by the use of alcohol, drugs, and taking certain medications regularly over a long period of time. Often, this disorder compounds on pre-existing sleep issues such as genetic insomnia or can actually change a person’s epigenetics so that they develop issues over time. Substance-induced sleep issues can complicate mental health issues, such as depression, anxiety or bipolar disorder.

Restless Leg Disorder

Restless Leg Disorder, also known by Willis-Ekbom Disease , causes unpleasant sensations in the legs and an almost irresistible need to move them. Symptoms start in the late afternoon or evening hours and are most severe when the sufferer is resting. Despite mostly impacting the sleep, this disorder is known as a neurological sensory disorder.

More than eighty percent of sufferers experience periodic limb movement during sleep every fifteen to twenty second. RLS can be compounded by frequent drug and alcohol use, pregnancy, and iron deficiency.

When Should You Suspect a Sleep Disorder? What are some initial approaches?

There’s a huge variety of symptoms to pay close attention to that impact your night of rest and point to a potential underlying disorder. Pay attention to how these symptoms manifest and change over time.

First, address the decisions you’re making that are related to your sleep – are you getting more irritable in the afternoon? If you are taking naps longer than thirty minutes per day or drinking more than two cups of coffee everyday and after 4pm, you may have a sleep disorder. If you are finding yourself resorting to sleeping medications, such as benadryl, zolpidem, eszoplicone or even drinking alcohol at night to sleep, there is likely an underlying issue that you should address with your primary care provider.

The blue light produced by electronics can interfere with your sleep, so tuck away any gadgets at least thirty minutes before bed time. Set your bedroom thermostat a light lower, try and follow a consistent sleep schedule even if it’s difficult to fall asleep, and create a relaxing pre-sleep ritual every night.

Next, address the more long term issues that are consequential. Is your BMI over 27, do you have a neck circumference of over 16 inches for women and 17 inches for men? If so, you are at increased risk for sleep apnea and related conditions caused by obesity.

Sleep Disorders Work-up

These conditions are usually diagnosed in a clinic through consultation with your primary care doctor or a sleep specialist. Co-existing conditions such as obesity, leg swelling and nighttime urination, high blood pressure (hypertension), atrial fibrillation and stroke may alert a doctor to consider testing. A doctor may ask you to fill out questionnaires and take measurements as well, before deciding on whether or not you should receive a sleep study. Newer smart phone technology may be useful to determine if further study is necessary. (Refer to Patient Education and Guideline section for more details of testing).

Epsworth Sleepiness Scale: 0-7: Unlikely Sleep abnormalities, 8-9:You have an average amount of daytime sleepiness. 10-15:You may be excessively sleepy depending on the situation. You may want to consider seeking medical attention. 16-24:You are excessively sleepy and should consider seeking medical attention.

What Do You Do About Poor Sleep?

While your sleep issues might not go away immediately, you can take steps to increase the restfulness of your nightly routine to slowly address the issue. Here is a list of ten great steps to take:

1. Optimize your weight to healthy range and shift your diet from high-fatty carbohydrates to a whole foods.
2. Get to sleep at the same time each evening and for the same duration.
3. Limit caffeine intake and avoid taking it after noon and limit alcohol intake and avoid taking it right before bedtime.
4. Avoid strenuous exercise at night but make sure to get at least twenty minutes of physical activity every day.
5. Avoid spending long periods of time in bed during the day.
6. Avoid hot baths or sauna before bedtime.
7. Keep your room on the cooler side and invest in a weighted comforter to mimic the feeling of the womb
8. Keep room dark with limited light from clocks, electronics, or external light, including the blue light of phones.
9. Limit ambient sounds like music and keep the window shut to reduce noises from outside sources
10. If you cannot fall asleep after thirty minutes, get up and engage in a light, low stress activity such as reading or cleaning in dim light

The best method to address poor sleep hygiene is by making slow, incremental changes to your habits. Without even noticing, you can adopt behaviors that chip away at healthy bedtime behaviors. A good night of sleep is vital to the quality of your waking life, relationships, and work performance.

For more information on the why of sleep, check out this youtube link Sleep is Your Superpower by Matt Walker.

Please refer to the Patient Guidelines section for additional information of work-up.

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