A third of people in the UK aren’t sleeping enough, with the average person getting around 5.91 hours per night.
It would be amazing if we could all fall asleep, as soon as our head touches the pillow, and wake eight hours later, feeling completely recharged and refreshed.
Poor sleep can have a really strong impact on our mental health, and this is probably the origin of the saying “they woke up on the wrong side of bed. It used to be thought that mental health problems led to poor sleep. It is now believed that poor sleep can directly cause mental health problems including anxiety and depression. So it is really important that we do all we can to make our sleep as effective and as recharging as possible.
Stages of sleep
There are two main sections to our sleep:
The first is called Rapid Eye Movement (REM) sleep.
The second is called non-Rapid Eye-Movement (N-REM) sleep and it is further divided into three sections called N1-N3:
- In N1 we are in the transition between being awake and asleep
- In N2 we are lightly asleep
- In N3 we are deeply asleep, we spend more time in N3 sleep early in the night
In each section: REM, N1, N2 and N3 our bodies have a different pattern of brainwaves, eye movement and body movement.
In N-REM sleep, the brain activity slows down. In REM sleep the brain activity increases (it is similar activity levels to when we are awake) and it is in REM sleep that we have vivid and intense dreams.
It is thought that REM sleep allows the brain to process emotional information from our memories. Lack of REM sleep seems to affect how the brain functions and appears to have a negative impact on our moods and emotions.
We would normally expect to go through each of the cycles at least 4 times a night. The normal cycle would be N1, N2, N3, N2 and then REM. As the night progresses we get more REM and less time in N-REM.
How much sleep do we actually need?
The amount of sleep we require changes with age, however each individual needs different amounts of sleep to function well and not feel tired during the day. Some people claim they function well, with only four hours sleep, however most adults need between seven and nine hours sleep.
Regularly getting less than 7 hours of sleep has been linked with poor health, including weight gain, diabetes, hypertension, heart disease and depression.
Some studies have suggested that more than 8 hours sleep is associated with an increase in heart problems, other research suggests that sleeping too much can negatively impact your mental and physical health, and can affect how well the immune system works. This only applies to people who regularly get more than 8 or 9 hours sleep per night.
The pattern for sleep is set in early adult life with most people falling asleep within 30 minutes.
Factors that can cause poor sleep
Age
When people get older they tend to sleep less, and less well at night. A more practical issue for many, is needing to go to the toilet at night. This can occur from as young as 30, and is common in pregnancy as the baby uses the bladder as a punch bag or for kicking practice. It is quite normal for men and women in their 50’s and 60’s to need to go once at night, but some people go 3-6 times at night which is very disruptive to sleep patterns. 60% of women describe disturbed sleep during the menopause, related to hot flushes.
Medical problems
Pain: Especially related to joint, muscle or nerve pain, but also period pain, can cause a delay in being able to get to sleep. It also causes a person to wake during the night if a painful area is stretched as we move in bed.
Breathing problems: Both from ear, nose and throat conditions such as rhinitis, nasal congestion and catarrh, and from lung conditions such as asthma and chronic airways diseases.
Obstructive sleep apnoea (OSA): Is a treatable problem found in 5% or women and 10% of men. The unusual fact about it is that the individual often has no idea that they have OSA, but their partner is very aware as the pattern of snoring or loud breathing, and then long pauses between breaths, followed by a gasp makes it quite difficult for a partner to get a relaxed night’s sleep.
High blood pressure: Can lead to insomnia and sleep disturbance, BUT poor sleep can cause or worsen high blood pressure and medication for blood pressure can affect sleep patterns.
Diabetes: Can have a profound affect on sleep. High blood sugar causes increased need to urinate through the night and increases the risk of restless leg syndrome and nerve pain that can affect sleep. If blood sugar dips too low, due to medication, this can also affect sleep.
Anxiety: Fear and anxiety often feels greater at night. When we are tired it is often harder for us to calm our anxious minds and to relax our tense bodies. These racing thoughts or ruminations, associated with anxiety make it hard for people to get off to sleep, and anxiety can also cause people to wake up in a panic several times during the night.
Depression: Sleep problems are a very common complaint in people with depression who often describe waking up very early (3-5am) and then struggle to get back to sleep.
Medication: Quite a lot of medication can affect sleep quality and cause difficulty getting to sleep. This includes some more commonly used medications:
- Antihistamines
- Some painkillers
- Nicotine replacement therapy
- Asthma medication
- Antidepressant medication
- Medication for blood pressure
Environment: The surroundings in which we sleep can have a profound effect on the quality of our sleep. A bedroom can be too hot or too cold, too dark or light, too noisy or a bed can be too hard or too soft.
How to improve sleep naturally
Routine
Having a regular sleep routine can be very helpful. This means having consistent unchanged bed times, and wake up times, apart from on weekends and holidays. This regulates your body’s natural sleep/wake cycle known as circadian rhythm. Part of the sleep routine should include a calm or calming activities before getting into bed, this might include:
- Reading a book – not a screen.
- Listening to calm music.
- Having a warm bath.
- Having a gentle massage which promotes relaxation, reduces stress and has been shown to increase levels of serotonin and melatonin in the body, which are hormones that help to regulate sleep.
- Having a cuddle before sleep can also help reduce stress and lead to better quality sleep.
- Having sex before bed can also help induce relaxation which makes falling asleep easier.
Screens
It’s important to avoid screens, especially smartphones and computers as they emit blue light. This type of light, especially at night, can affect the natural production of melatonin, a sleep regulating hormone. It is thought that the blue light makes the brain think that it is daytime, and therefore melatonin release is not required. The stimulation of watching a programme or film, or social media videos can lead to increased brain activity which affects the body’s ability to relax and sleep
Relaxation exercises
Relaxation exercises can form an important part of helping your body prepare for sleep, tension and stress tend to disrupt sleep. Relaxation exercises such as meditation, breathing exercises and progressive muscle relaxation can help overcome the tension making it easier for someone to get to sleep and have a better quality sleep.
Temperature
Studies have been carried out looking at the best environment in which to promote sleep. It is thought that a cool, calm, dark and quiet room as well as a comfortable bed and bedding can lead to better sleep. The ideal room temperature is around 15.5 to 19.5°C. Minimising light in the bedroom is important and the use of blackout curtains, dark blinds or a sleep mask can assist a quiet environment which is essential for improving sleep quality. Using earbuds or even a quiet fan to mask distracting noises can be helpful.
The bed
A comfortable mattress and bed clothes can help, but it is also important to think about your pillow. The best pillow to promote better sleep will be:
- One that provides good support for the neck and head ensuring that the spine is in its proper alignment.
- Helps maintain a comfortable sleep posture and doesn’t lead to unnecessary tossing and turning.
- There is no one single pillow that is suitable for everybody and it is important that you consider which type of pillow would best suit your needs. It is important to review this on a regular basis as over time the support from pillows can reduce leading to abnormal posture and poor sleep.
It is also important to think about your duvet or bed sheets, especially the thickness of the duvet. When you buy a duvet you will see a tog rating on the packaging. The tog rating of your duvet is a measure of how well it insulates and thus how warm it feels. A lightweight summer duvet is generally between 3 and 4.5 togs, a medium-weight spring or autumn duvet is 7.5 to 10.5 togs, a warmer winter duvet is generally 12 to 13.5 togs. The duvet that you need will depend on various other factors, such as whether your house is warmer or colder than average.
If you are finding it hard to get to sleep and you are very warm under your duvet it may be worth changing to a duvet with lower togs. It is also important to think about what to wear to sleep in.
The two factors that influence what pyjamas will help you sleep better are:
- How insulating the fabric is.
- How sweaty it will leave you feeling.
Natural fabrics such as cotton are more breathable than synthetic materials such as nylon, and pyjamas made from bamboo fibre should stop you from feeling sweaty in bed. Wearing nothing at all can be a good option for temperature control.
- Medication
Although some medications can affect sleep, there are also medications that can promote sleep. Before thinking about taking medication to help sleep, it is important to ensure that all of the factors mentioned above have been addressed and should only be used for a short term as with many medications there is a risk of dependence or addiction, tolerance which is where the medication loses its efficacy over time and side effects from the medication as well as interactions with your existing regular medication.
Over-the-counter-medication includes:
- Herbal remedies: Unfortunately there is limited scientific evidence around their effectiveness. There is also significant variation between individuals, so where one person might find these supplements helpful others may experience no benefit but possibly side effects.
- Sedating antihistamines: Have been used for many years, but they are not without side effects and should only be taken with medical advice and for a short period of time.
- Melatonin: Is a hormone that naturally regulates the sleep slash wake cycle and has been used for many years to assist people with sleep problems especially jet lag. It is available over the counter in many countries but in the UK is a prescription only medicine and it will be and you would need to see your your GP to obtain this and it is only licenced for short term use.
There are prescribed medications that can be issued to assist with sleep; the commonest medication issued is either a benzodiazepine or a non benzodiazepine hypnotic (Z- drug).
These work by increasing GABA, a chemical in the brain that helps promote relaxation and sleep. They all have significant side effects and prolonged use, even for more than 10 to 14 days, can lead to addiction and dependence on the medication.
Daridorexant is a recent addition to the medication to help sleep. It belongs to a group of drugs called orexin receptor antagonists. Orexin is produced in the brain and helps to keep you awake. Daridorexant blocks the action of Orexin to help you fall asleep more easily and stay asleep for longer. In the clinical trials it was not shown to be addictive, but it does have some side effects and it is uncertain as to whether or not that there are any long-term effects from use of Daridorexant.
Write-off your worries
If you find you are struggling to get to sleep because you are thinking about everything you have to do tomorrow or when you wake up in the night, your mind is thinking about all that has to be done and this stops you getting back to sleep … set some time aside each evening, before getting prepared for bed to make plans for the next day.
Write lists – this will hopefully help to calm your mind before bed and reassure you that your daily to do list is prepared before you settle to sleep.
Don’t fight insomnia
Try not to lie in bed tossing and turning, instead get out of bed after 20 minutes if you are still awake. Go into a different room that is comfortable and quiet, and engage in whatever activity you would be doing during your wind down time.
Try to avoid activities that are productive such as doing the ironing or washing dishes as you do not want to reinforce the idea of getting tasks done in the middle of the night, and then return to bed and try to get back to sleep again.
Once again after 20 minutes if you are unable to get to sleep, get up and re-engage in some of the gentle activities that you just tried to do. Repeating this over several nights may help to restart your normal sleep pattern.
Resist the temptation to ’just check the time’ on your phone or clock when you wake up during the night. Instead, set your alarm for the time that you want to wake up in the morning and then turn your clock around so you can’t look at it if you wake up during the night.
Don’t worry!
This raises an important point about sleep, probably the most important point is try not to worry about sleep; worrying about sleep tends to cause sleep quality to deteriorate. It is possible that you are getting enough, but less than you expect. Also, try not to take naps during the day as these affect the natural body rhythm and often add to your problems later at night.
When to seek help?
If, despite trying all the sleep hygiene methods above, you still feel that your sleep quality is poor, you need to get some help.
It may be that medication is affecting sleep. some treatments for asthma, migraine, anxiety and depression can affect the quality of sleep if that is the case, speak to a doctor or GP about the possibility of changing medication.
Seeing your GP about sleep can sometimes be frustrating and many doctors do not like to prescribe sleeping tablets, this is due to potential serious side effects associated with these tablets.
Side effects of sleeping tablets:
- Drowsiness the next day this can be quite marked, especially early in the day and would mean that you are NOT safe to drive or operate machinery.
- Accident risk at night – these tablets can cause clumsiness and confusion if you wake up in the night. A particular problem if you need to pass water as they cause a real risk of falling and hurting yourself.
- Addiction to medication – it is possible for the addiction to start within a couple of weeks of taking these tablets. You start to get withdrawal symptoms when the medication is not in your system. This can be frightening but it can take over your life so you are craving the medication.
- Tolerance to medication – this is where the medication stops being effective and you may need a higher and higher dose to get the same effect.
Therapy
Your GP may suggest psychological or talking therapy especially behavioural and cognitive therapy. We know that behavioural therapy and CBT work well for anxiety and depression, and there is evidence that they also work well for insomnia.
The various types of therapies used include:
Cognitive behavioural therapy helps us to understand our thoughts so that we can think about things more positively. Behavioural therapy helps us to change any of our actions that cause us harm or are unhelpful (for example, staying at home all the time because of a fear of something outside).
Cognitive and behavioural therapies are often used together because how we behave often depends on how we think about certain things or situations.
Cognitive therapy
Our thoughts include our ideas, mental images, beliefs and attitudes. These are called cognitive processes. Cognitive therapy is designed to help you to understand your current thoughts. It can help you identify any harmful, unhelpful and false ideas or thoughts that you have. The aim is then to change the way you think so that you can avoid these ideas. Cognitive therapy helps your thought patterns to be more realistic and helpful.
Behavioural therapy
This aims to change any behaviours that are harmful or not helpful.
For example, a common unhelpful behaviour is to avoid situations that can make you anxious. In some people with phobias the avoidance can affect day-to-day life.
A type of behavioural therapy called exposure therapy may be used to help. This involves you being gradually exposed more and more to the feared situation. The therapist will show you how to control anxiety and how to cope when facing up to the feared situations.
- Relaxation training – teaching how to reduce tension; one common way is the progressive muscle relaxation technique.
- Stimulus control therapy – teaching you to reassociate the bed and bedroom with sleep and re-establish a consistent sleep/wake pattern.
- Sleep restriction therapy – it involves limiting the time you spend in bed and trying to ensure for as much of that time you are asleep, you then progressively increase the time spent in bed, gradually increasing how long you sleep for.
- Biofeedback – with this technique, you are connected to electrical sensors which give you feedback by sounds and lights to show you what your body is doing. This is to help you control certain body functions (such as muscle tension).
- Paradoxical intention – this involves staying passively awake, avoiding any intention to fall asleep. It is used for people who have trouble getting to sleep (but not maintaining sleep).
- Hypnotherapy – has been noted to help SOME people with insomnia.
Shift work and sleep
Work that includes duties outside the normal working day is considered shift work. In the USA 16% of all workers are shift workers.
Many shift worker schedules includes partial or total night work which can affect sleep. Over time this may lead to ‘shift work disorder,’ which causes insomnia and excessive tiredness at work. This leads to reduced performance and output, and increases the risk of accidents.
There are many ways to reduce the impact of sleep disturbance in shift worker and reduce the chance of developing the condition:
- Maintain your sleep schedule, even on days off – this can be difficult especially as it does not fit in with the schedules of children and partners. Make family, room mates, neighbours aware of your sleep schedule and get their support in keeping noise down when you are sleeping.
- Reduce the effect of noise and light on sleep – minimise light effect with good blackout blind or curtains. Use ear plugs if noise may be a problem. Turn your phone off or set to do not disturb when you are sleeping.
- Wake closer to the start of the shift – rather than going to bed immediately a shift is finished, try staying up for a few hours and waking closer to the start of a shift.
- Before bed routines – hot bath or shower, meditation, relaxation. Anything that helps relax you prior to going to sleep is likely to promote better sleep quality.
- Do not drink alcohol or caffeine before going to sleep – despite people feeling alcohol helps get them to sleep, it reduces the quality of sleep and you are more likely to wake unrefreshed. Caffeine can make it harder to get to sleep.
Key messages
- It is not possible to force yourself to sleep, whatever actions are taken aim to allow it to come naturally.
- In some circumstances, including times of increased stress, you need to accept that sleep pattern is less than ideal.
- It is important to maximise what sleep we do have and recognise that even fragmented or short sleep episodes are better than none.
- It is important to aim for a regular routine of sleep pattern; going to bed and getting up at roughly the same time each day.
Sleep hygiene top 10 tips
- Regular routine
- Restful environment
- Comfortable bed(room)
- Regular exercise
- Less caffeine
- Less alcohol
- Don’t smoke
- Prepare for bedtime
- Write-off your worries
- Don’t fight insomnia and try not to worry
If you’re struggling with sleep and have tried the tips suggested above, speak to your GP. They can help you explore the most effective treatment options and, if appropriate, refer you to a specialist.
Book an appointment with Dr Adam Simon, call 0161 428 4464 or email info@privategpextra.com
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