30 Days to Better Sleep: Day 9 — Create a Relaxing Buffer Zone with Sleep Rituals

Okay, so you don't need a bed made out of pillows to get to sleep. Nevertheless, you can sleep better by creating a relaxing buffer zone prior to trying to sleep. As part of this, you can incorporate sleep rituals that will put your mind to ease and help you fall asleep.

One of the first tasks is to draw a line in the sand. Let's face it, your day will never end. You will always have more work to do, another chore to complete, just one more thing to take care of. Even if you are not working, you might not be ready to go to bed. If your evening is your "me time", there are endless TV programs or movies to watch, sports to play, books to read, and hobbies to indulge. If you let these pastimes creep into your devoted sleep time, there will be no end to the sacrifice. Once you have elected to make sleep a priority, you must start by concluding your day and transitioning towards sleep.

Many people find it helpful to create an artificial closure to the day. This is accomplished by selecting a time that you pronounce to be the end of your day. If you want to go to bed at 10 PM, you might select 8 PM as the time that works best for you. You want to allow yourself several hours to relax. As part of this, you must put aside your work. Those e-mail responses can wait until tomorrow. It's the time to turn off your phone. You have permission to ignore those unfinished tasks. You are only human, and your day has come to its close.

How should you fill the several hours before going to sleep? Try to indulge in an activity that you find relaxing. This activity should not be stimulating; nothing that gets your heart racing or your blood boiling. Pick something that, in the buffet of life, is oatmeal. Many people enjoy reading, taking a bath, stretching, or listening to music. You should probably avoid exposure to light, especially from screens such as your tablet or laptop computers. If possible, it is best to have some time completely free of electronics. This is time that will help you unwind and transition towards sleep.

Once you have identified activities that you find relaxing, make this a habit. Just as children benefit from a nightly bedtime routine, your body will appreciate a consistent transition to sleep. These "sleep rituals" will mentally, emotionally, and physically prepare you for the transition to sleep. Ultimately, it will make it easier for you to crawl into bed and fall asleep quickly. This can be especially helpful if you have insomnia.

Another useful tip is to make this buffer zone free from anxiety and stress. As part of this, it can be helpful to schedule a "worry time" earlier in the day. By focusing your energy on relaxation and rest in the hours before bedtime, you will sleep better and wake feeling refreshed.

30 Days to Better Sleep: Day 8 — Go to Bed Only When Sleepy

After carefully considering the difference between sleepiness and fatigue, you can now make an important choice: go to bed only when sleepy. Among people who suffer from difficulty falling asleep, a common occurrence as part of insomnia, this can be a life-changing decision. It also may defy common practice.

In early life, there is no decision made about when to go to sleep. A sleepy child is soon asleep. When the desire for sleep comes, no matter the timing, it is quickly indulged. As we get older, sleep becomes complicated by our behaviors. We may choose to stay awake, even fight sleepiness, to pursue pastimes. Alternatively, if we have trouble sleeping and feel like we need more sleep, we may go to bed early. We may stop listening to our body's natural cues.

Sleepiness or drowsiness is a cue to get ready to sleep. We should naturally prepare ourselves by settling down into bed. We make ourselves comfortable and, if everything goes to plan, we are soon asleep. In contrast, other descriptions of how we feel - fatigue, tiredness, and exhaustion - may not reflect a desire for sleep if they do not promptly proceed into sleep. Therefore, if we crawl into bed feeling fatigued, this may not result in sleep. Instead, we may be setting ourselves up for insomnia.

People with insomnia often complain of feeling fatigued or tired, but if given the opportunity to sleep, they will struggle mightily. Insomniacs cannot routinely take naps, for instance. If they lie down to rest in the afternoon, they will lie there awake. Insomnia is often described as feeling "tired but wired". Sleep is desperately wanted, but opportunities to sleep are corrupted by wakefulness.

Let's imagine a common scenario that occurs with insomnia and how someone might end up going to bed when he or she doesn't feel sleepy. Insomnia may be provoked by a stressful situation, but it is perpetuated by the resulting changes that are made around sleep. Insomnia is defined as difficulty falling asleep, difficulty staying asleep, or sleep that is not refreshing (in the absence of another sleep disorder). Sleep may become fragmented due to anxiety, with normal awakenings stretching into prolonged wakefulness during the night. By spending several hours awake in the night, it may seem natural to extend the time in bed. Rather than going to bed at 11 PM and getting up at 7 AM, a person with insomnia may go to bed at 10 PM or even 9 PM. In an effort to get more sleep, the time spent in bed is lengthened. However, something inadvertent has happened: this person may now be going to bed when they are less sleepy.

There are two major contributors to the ability to sleep: homeostatic sleep drive and circadian rhythm. The sleep drive is the desire for sleep that builds throughout the day; the longer a person stays awake, the sleepier they become. The circadian timing relates to when we should naturally be awake and asleep, and for humans sleep should occur overnight. (Nocturnal creatures like rats, on the other hand, should be sleeping in the day and awake at night.) By going to bed 1 or 2 hours early, there is less drive to sleep and the timing may be off. As a result, this insomniac may go to bed feeling less sleepy.

As a result, there is a diminished ability to sleep. It would not be unexpected for this person to now have a problem lying awake at the start of the night. By going to bed before sleepiness or drowsiness has developed, the ability to sleep is likewise lost. Similarly, lying awake for prolonged periods in the morning can be detrimental. Even short periods of sleep will diminish the sleep drive and could affect the circadian rhythm.

Therefore, train yourself to go to bed when you are feeling sleepy, not because the clock says it is time to sleep or because you are fatigued. You will find that you fall asleep more easily and sleep better through the night. To help yourself feel more sleepy, you can also work on creating a relaxing buffer zone before bed, a project to commence next.

30 Days to Better Sleep: Day 7 — Learn the Difference Between Sleepiness and Fatigue

It may seem like semantics, arguing over the meanings of similar words, but it really does matter: What is the difference between sleepiness and fatigue? Not only may discriminating between these distinctive feelings identify different causes, but it may also help to treat insomnia.

Some people lose touch with what it feels like to be sleepy. Sleepiness or drowsiness is the extreme desire to fall asleep. Imagine that you are sitting after lunch in your most comfortable chair. You are cozy and relaxed. Your eyelids become heavy, each time they close they stay that way a moment longer. You are ready to doze off. You are sleepy.

Contrast this sleepiness with a different collection of words: fatigue, tiredness, exhaustion, and low energy. These sentiments are felt deep in the bones and muscles, a heaviness to the limbs, as if you just ran a marathon. You can't summon the energy to accomplish what you need to. You are physically and mentally dragging through the day. This may occur in the setting of other illness, such as anemia, hypothyroidism, or even cancer. It may even be labeled as chronic fatigue syndrome.

No matter how extreme the fatigue, it does not result in sleep. People who feel fatigued may lie down to rest or take a nap. They do not, however, fall asleep. People with extreme sleepiness or drowsiness will be able to sleep if given the opportunity. Why does this matter?

Sleepiness often occurs in sleep deprivation among those who get inadequate total sleep time. It may also be a symptom of sleep disorders such as sleep apnea or narcolepsy. In contrast, fatigue is a common complaint among those with insomnia.

Not only does distinguishing between sleepiness and fatigue lead to a different set of possible causes, but recognizing sleepiness can also contribute to improving insomnia. How might this work? This concept will be discussed more in the next article, but it is critically important for people to only go to bed when they feel sleepy. If fatigue is used as a prompt to go to bed, this may result in lying awake for prolonged periods of time at the start of the night, trying to fall asleep. This is a major contributor to insomnia.

Consider carefully whether you are having more difficulty with sleepiness or fatigue. It may point to a distinct underlying cause and correcting it will depend on a different set of treatments. As you work to sleep better, use this exercise to reflect on your own needs.

30 Days to Better Sleep: Day 6 — Pay Off Your Sleep Debt

In these economic times, we are perhaps overly familiar with financial matters, including debts. As we put our collective financial house in order, it similarly may be appropriate to focus on improving our sleep by paying off our sleep debt. What is a sleep debt and what can be done about it?

The concept of sleep debt is meant to highlight that there are consequences to failing to meet your individual sleep needs and that, to a limited extent, you can correct this sleep deficit. As previously discussed, everyone has a specific sleep requirement in order to feel rested. Although it may average close to 8 hours, there is some variability, with some people requiring more or less. When you fail to get enough sleep to meet your requirement, you will begin to accumulate a sleep debt.

The most important consequences of inadequate total sleep time relate to sleep deprivation. There are specific symptoms that occur, from sleepiness to poor concentration to mood changes. There may be physical effects, including weight gain and decreased pain tolerance. Some people will experience hallucinations in extreme sleep deprivation. It may even increase your risk of death.

Many people will attempt to recuperate lost sleep by varying their sleep schedules. If you have to get up early to go to work on weekdays, you may not get an adequate amount of sleep. By the weekend, when you have more control of when you wake up, you may sleep in to catch up on the lost sleep. In a sense, you are running up a sleep debt during the week (which manifests as sleep deprivation) and then paying it off by sleeping more on the weekend.

How might this work? One important occurrence during sleep is the clearance of a neurotransmitter in the brain called adenosine. This chemical contributes to sleepiness and is responsible for the homeostatic sleep drive, in which the longer we stay awake, the more likely we are to fall asleep. When we do not have enough pillow time, we cannot fully clear out the accumulated adenosine. We are left with the residual mental effects described above. By extending the total sleep time on the weekends, we can finish clearing it out.

There are limits to this ability, it seems. If we had a period of sleep deprivation in the remote past, we are unable to make up for it by catching up on sleep now. It is unclear what long-lasting consequences result from sleep deprivation, but the health effects of sleep disorders suggest that these may not be insignificant.

If you find yourself running up a sleep debt, it is rather simple to correct the situation. Once you have determined your sleep needs, you should ensure that you allow an adequate amount of time in bed to meet it. Initially, you may need to sleep in several days in a row to make up for the recent sleep that you have lost. By thereafter maintaining an adequate sleep period, you will avoid the undesirable consequences of chronic sleep deprivation.

As you make broader changes to sleep better, it will be key to build a solid foundation and start by paying off your sleep debt.

30 Days to Better Sleep: Day 5 — Sleep at the Right Time for You

It is amazing how many people struggle to sleep due to the simple fact that they are trying to sleep at the wrong time. In order to better understand when you should be sleeping, it might be best to start by considering the two major reasons we sleep at all.

There is admittedly much that we don't know about sleep. Our current understanding nevertheless identifies two processes that contribute to our ability to sleep: homeostatic sleep drive and circadian rhythm. The first concept is rather simple: the desire for sleep builds the longer that we stay awake. No one will argue with this; it's easy to test. The science behind it relates to the gradual accumulation of a chemical within the brain, or neurotransmitter, called adenosine. It makes us feel sleepy. And, incidentally, blocking it is what makes caffeine effective as an alerting stimulant.

The other major player in the timing of sleep is our circadian rhythm. This is the pattern of internal processes that are synchronized to the natural day-night cycles. This directs key functions of our body and associated behaviors, including: body temperature, blood pressure, hormone levels, hunger, and sleep. It strongly dictates when we feel tired and when we are most awake.

As a brief aside, each and every cell of our body has "clock genes" that direct the activity of the cell. Even our fat cells follow a circadian rhythm! This helps the body to coordinate its activities. There is a part of the brain that is responsive to light called the suprachiasmatic nucleus (SCN). The SCN is the central pacemaker of the body, coordinating all the peripheral clocks with carefully timed hormonal changes. Therefore, sunlight (especially morning light) seen through the eyes and relayed to the SCN has a powerful effect on our circadian patterns, especially when we sleep.

With the circadian patterns of sleep, there is also clear variability between people in the timing of the longest sleep period. This sleep phase may be delayed in people who identify as night owls or advanced in morning larks. Night owls often feel most productive into the late evening and may not go to bed until 2 AM or later. This delayed sleep phase syndrome is especially common among teenagers. Conversely, elderly people are more likely to have an advanced sleep phase and go to bed and rise earlier. This has important implications on the appropriate timing of attempted sleep.

If you are a night owl and your body's natural tendency is to go to sleep at 2 AM, what do you think will happen if you try to go to bed at 11 PM? It should be no surprise that you would complain incessantly of difficulty falling asleep (insomnia). It might take 2 or 3 hours before you fall asleep; coincidentally, right about the time that your body is ready for you to be sleeping. Imagine what would happen if you forced someone with a "normal" sleep phase to go to bed early. Instead of hitting the hay at 10 PM, this person is forced to go to bed at 7 PM. No one would be surprised if they complained of trouble falling asleep. When we attempt to sleep is key to our ability to sleep.

Many people are aware of their natural tendency, whether they prefer to go to bed early or stay up late. It may be clear throughout life, but it can also change subtly. For those who find themselves needing to sleep at more standard times, there are ways to harness the power of the SCN to fall asleep easier and wake feeling refreshed, no matter what time it is. If you have trouble falling asleep, take an honest look at your sleep patterns and consider whether you are trying to sleep at the right time for you.

30 Days to Better Sleep: Day 4 — Calculate Your Sleep Needs

You have been told that you need 8 hours of sleep, right? Well, that may not be completely accurate. In fact, there's a lot more to the story. Since you are setting out to sleep better, it's a perfect time to figure out what your goal should be.

Certainly 8 hours is often touted as the "average" amount of sleep an adult needs, but it is just that, an average. Let's expand that a little. The average healthy adult needs 7.5 to 8.5 hours of sleep each night. Even still, it is probably safe to think of this as a bell-shaped curve that extends to the extremes. There are some people who need 4 hours of sleep and others who need 10 hours. In fact, just as many people need more as those who get by with less than 8 hours. This amount also changes dramatically throughout the lifespan.

These needs are likely determined, at least in part, by our genetics. Some people are short sleepers and others are long sleepers. It is the luck of the draw. And this tendency persists throughout life. How do you calculate what your personal needs may be?

It is relatively straightforward to figure out your sleep needs. With a few simple steps, you will know how much you need to be sleeping to feel rested. First, you need to have the luxury of getting enough sleep. (This speaks to an important topic that will be discussed later this month: Make sleep a priority.) You cannot allow work schedules, family obligations, hobbies and pastimes, or other activities encroach on your sleep period. This can be tough to arrange. The hope, ultimately, is that you will be able to go to bed and sleep until you naturally wake up. Initially, you will be sleeping off your sleep debt, but (in time) the length of your time spent sleeping will approach an average. This is your sleep need.

What if you fail to meet your sleep need? You will soon develop symptoms of sleep deprivation. Experiments have shown that humans need 8 hours and 10 minutes of sleep to avoid detrimental effects on daytime function (again, an average). Let's say that you calculate that you need 9 hours of sleep. Every night that you get 7 hours of sleep, you will be sleep deprived by 2 hours. It is easy to understand how important it is to determine your own need. The cumulative effect of chronic sleep deprivation may have dramatic consequences, and could even cause your death.

So once you have determined your individual sleep need, you will have established a clear goal in your efforts to sleep better. Now that you know how much you should be sleeping, your efforts can turn to improving the quality of the sleep that you get.

30 Days to Better Sleep: Day 3 — Lock the Pets Out of the Bedroom

In order to continue the advances made to create an ideal sleep environment, there is one additional heart-wrenching task: lock the pets out of the bedroom.

Many people insist that they wouldn't be able to sleep without their faithful cat or dog nestled amid the covers. In fact, some might even suggest that this favored pet would be unable to sleep without their human companions. If this sounds like a dependent relationship, it probably is, but it doesn't have to be.

You have been able to sleep without your pet and, much to your personal chagrin no doubt, your pet can sleep without you. In fact, you will probably sleep better without each other's presence. Why might this be so?

First, you are bound to awaken more in the night with a pet present in your bed. It is natural to have awakenings from sleep. Unfortunately, when there are more people or animals in a small space, these awakenings will become disruptive and the causes can run the gamut. Your dog may start scratching its ear. Your cat may walk across your pillow to get to the other corner of the bed. A noise may provoke barking or meows. There may even be pleas for food or a trip outside. If you have multiple animals, a fight may even break out in the night! Bottom line: it is a disturbance that you don't need.

Animals also inevitably introduce pet dander into the sleep environment. If you are prone to allergies or asthma, this fur may disrupt your breathing. You may have worsened snoring or even breathing problems such as upper airway resistance syndrome (UARS) or sleep apnea as a result. Though you may not be able to sneeze during sleep, it may keep you awake.

Depending on the size of your pets, they may also restrict your movement during sleep. If you feel like you can't change positions without disturbing your companion animal, you may subconsciously be still. If you are sleeping on your back, you may put yourself at risk of sleep apnea as well.

You will have to consider your own needs. If you sleep soundly, it may not ultimately bother you to have your pet in the bedroom. However, if you suffer from difficulty falling or staying asleep (a condition known as insomnia), then you should make your bedroom a space that is best for sleep.

If you are seeking ways to sleep better, put your pets outside the bedroom door and close it tight. They will sleep more soundly - and so will you.

30 Days to Better Sleep: Day 2 — Remove the Electronics from the Bedroom

On the path to better sleep, today's task requires a little manual labor: remove the electronics from the bedroom.

Ideally, your sleep environment should be a space that is maximally conducive to sleep. For most people, this involves having a devoted room in the home with a bed. It should be cool, dark, and quiet. It should be a space reserved for sleep and sex. It should be preserved as an area devoted to sleep. In order to accomplish this, you must remove the electronics.

Start by unplugging the television. Many people enjoy falling asleep to TV, but this can be a very disruptive part of the sleep environment. It can delay your bedtime and reduce your total sleep time. As you finally doze off, the noise may cause you to awaken. If it remains on, this can occur throughout the night. Along with the television, clear out your gaming systems, VCR, DVD player, Blu-ray player, and any other entertainment devices.

Next, turn your attention to your computers. Power off the desktop, pack away the laptop, and remove your tablet computers. It may even be advisable to clear out your electronic readers such as your Kindle or Nook. These devices are small, quickly slip into bed, and can easily be a source of distraction and sleep disruption. If you wake in the night and begin using your computer to pass the time, you lose the association between your bedroom and sleep. Instead, it becomes the place where you can lie awake at night and surf the Internet. Moreover, the exposure to low levels of light may disrupt your circadian rhythm and your ability to fall asleep, resulting in insomnia.

Additionally, leave your cell or mobile phone in the other room when you go to bed. These phones are increasingly recognized as a source of sleep disturbance in children and adolescents, with many "sleep texting" inadvertently. If your phone sounds with an alert for a text message or if a call rings through, this will disrupt your sleep. Don't let this disruption intrude into your sleep environment. If possible, you should not have any phones in your bedroom space.

Before reveling in the success of accomplishing today's task, do one final sweep of your bedroom. Is there any other technology that might be a source of distraction or disruption? Are there devices that will prevent you from having a quiet, soothing sleep space? You may clear out radios, alarm clocks, portable music players, and anything else that has a power cord and an on/off switch. Preserve your bedroom as an electronics-free zone.

Your bedroom is for sleeping, and by removing these electronics you will begin to re-establish the healthy relationship between this space and the expected associated behavior. You will reduce your exposure to disruptive low levels of light and intrusive noises at night. Moreover, with this simple task you will begin to initiate changes that are integral to sleeping better.

30 Days to Better Sleep: Day 1 — Wake Up at the Same Time Every Day

If you have resolved to sleep better, you may be overwhelmed with where to even begin. When sleep problems creep into your life, it can be difficult to identify the entangled issues and set things right. Chances are that your trouble sleeping didn't fully develop overnight, so allow yourself the time you need to improve your sleep. Over the next 30 days you will be introduced to specific changes that you can make to sleep better. Depending on your individual needs, you may be able to pass by a recommendation without a second thought. However, for the advice that hits closer to home, take the time that you need to resolve the issue. Together let's set out on the path to better sleep!

The first challenge may seem inconsequential, but it typically yields results quickly: wake up at the same time every day. Ideally, you would be able to sleep as much as you need to and wouldn't wake with an alarm clock, but to begin with you can use one. You should select a wake time that you can observe every day, including weekdays and weekends. For most people, this would mean selecting a time that would allow you to get to work or school during the week and then getting up at the same time on Saturday and Sunday.

Once you have selected your wake time, consider whether it is feasible. This isn't about making yourself an early bird if you are a night owl. Though society may pressure you into believing that waking earlier is somehow better, more moral, reflective of a hard-working nature, what evidence is there for this? Plenty of successful people stay up until 2 A.M. and sleep in until 10 A.M., so don't fall into that trap. Consider your own body and your needs. Pick a wake-up time that you can maintain and don't let it be too early or inconsistent with your typical, natural pattern.

Why does it matter to wake up at the same time every day? Think of your wake time as the anchor to your day. Our bodies follow a circadian rhythm and this relies on consistency. There are many things that you do at about the same time every day, not the least of which is sleep. Anchoring your wake time in place is a cue (or zeitgeber) to your body about when you should be awake and when you should be asleep. Waking at the same time every day will actually help you to sleep better at night. This is especially important for people who have difficult falling or staying asleep, characteristic of insomnia.

It is important that when your alarm goes off at your selected wake time, you get up. You cannot hit the snooze and stay in bed for 9 minutes or even an hour. You want consistency, and this requires ruling yourself with an iron fist. You might put your alarm clock across the room if you are apt to hit the snooze while half asleep. In order to track your success, you can record your bedtime and wake time on a sleep log. This information will be useful as you implement further changes to improve your sleep.

If adhering to a fixed wake time daily proves to be a difficult task for you, allow yourself 1 to 2 weeks of consistency in your wake times before you make further changes to sleep better.

What Is Home Sleep Apnea Testing?

By Brandon Peters, MD

No one really sleeps very well in a sleep laboratory for an overnight sleep study. Clearly there are better ways to sleep. Many patients question the results of their testing when they have a bad night of sleep. What is the alternative? Fortunately, home sleep apnea testing may be an attractive consideration. What is home sleep apnea testing (HSAT)? Consider this convenient option, whether it might be appropriate to diagnose your sleep disorder, and the costs and limitations associated with home sleep studies.

What Is Home Sleep Apnea Testing?

As the name implies, home sleep apnea testing is the administration of a sleep study in the comfort of your home for the diagnosis of obstructive sleep apnea. There are various devices available for this testing. These might be accessed through a sleep specialist, primary care provider, or even independent for-profit companies.

Most home sleep apnea testing measures parameters useful to detect sleep-disordered breathing. Though devices vary, many detect blood oxygen levels with an oximeter, heart rate, breathing effort with a stretchy abdominal belt, snoring vibrations, and airflow through the nose with an oxygen cannula. Some devices record further measures, such as limited brain waves for sleep staging, sleep position, and even movements.

Is Home Sleep Apnea Testing Right for Me?

There are specific criteria that are used to identify patients who can undergo home sleep apnea testing. These guidelines will maximize the success of the test and ensure the proper diagnosis.

Currently, it is recommended that pediatric patients still undergo an attended diagnostic polysomnogram. Therefore, HSAT is restricted to those people who are 18 years or older. Those with a high likelihood of moderate to severe sleep apnea based on presenting symptoms and contributory anatomy should be selected for home testing. Some of the most important symptoms include:

• Loud snoring

• Witnessed apnea (pauses in breathing during sleep)

• Excessive daytime sleepiness (Epworth score >10)

• Nocturia (waking frequently to urinate)

• Bruxism (teeth grinding or clenching)

• Fragmented sleep with insomnia

• Obesity

• Middle to older age (Including post-menopausal women) 

It is often important for a board-certified sleep specialist to evaluate you to determine the appropriate test for you. In some cases, there may be contraindications to home sleep testing.

Conditions That Require In-Lab Sleep Study Evaluations

Due to the nature of the testing and its limitations, the following exclusion criteria are observed. In some cases, the factor may interfere with the proper administration of the test at home. There are also some medical conditions in which a formal sleep study in a testing center is required to properly diagnose the disorder. The most common reasons to not to have a home sleep apnea test include:

• Cognitive or language barriers that interfere with test administration

• Moderate to severe pulmonary disease

• Neuromuscular disease

• Congestive heart failure

• Suspected central sleep apnea

• Suspected periodic limb movement disorder (PLMD)

• Primary insomnia

• Circadian rhythm disorders

• Parasomnias

• Narcolepsy 

Testing may be considered on a case-by-case basis among patients who are unable to have attended polysomnography due to immobility, safety, or critical illness concerns. Patients who are insured by Medicare may require a higher index of suspicion given the more stringent scoring criteria used.

Arranging and Performing a Home Sleep Apnea Study

Patients who have been screened and are deemed appropriate for HSAT will proceed with evaluation. After your doctor has ordered the study, a technician or medical assistant will demonstrate how to apply the equipment. You will take it home and perform the test, typically over one or two nights. After the testing has been completed, the device is returned to be downloaded so the doctor can review the data and make a diagnosis and treatment recommendations.

The Pros and Cons of Home Sleep Apnea Testing

There are certain obvious benefits to having a home sleep apnea test. One of the biggest attractions is the greater convenience being able to sleep in your own bed at home. If you are a responsible caretaker for another person, including children, this may make things easier. There are fewer wires required for measurement, which makes the testing less intrusive and more comfortable. The testing is generally less expensive, often costing just several hundred dollars compared to the more than $1000 that in-lab studies frequently cost. Due to the increasing availability, it might be done more quickly with a speedy turnaround to start treatment.

Before choosing to have a home sleep apnea test, you should also consider the potential cons to this testing. As noted, this testing is used to diagnose obstructive sleep apnea alone. It is not appropriate for the evaluation of central sleep apnea, insomnia, restless legs syndrome, circadian disorders, parasomnias, narcolepsy, seizures, and other disorders.

If the test comes back as negative, with a normal result, this may not necessarily be accurate. Mild sleep apnea may be missed. This is especially important in younger women and people of normal body weight. Any time spent awake will reduce the average number of sleep apnea events observed per hour. This could change the diagnosis or lead to a false sense of normalcy. If something goes wrong in the application of the sensors or the measurements recorded, the test may have to be repeated.

Generally, if the home sleep apnea test fails to diagnose sleep apnea, an in-lab test will be recommended to definitely evaluate the condition. If central sleep apnea is detected with a home sleep apnea test, an attended titration study for bilevel therapy is often needed. If the test does show sleep apnea, it will be easy to move along to treatment.

If you are interested in learning more about home sleep apnea testing as an option, find a board-certified sleep specialist near you and get evaluated to finally get the therapy and quality rest that you need.

Source:

Collop NA et al. “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.” Journal of Clinical Sleep Medicine. 2007;3(7):737-747.

Help Me Sleep: Ways to Sleep Better Tonight

By Brandon Peters, MD

It seems like sleep should come naturally, but when it doesn't, you might quickly find yourself pleading, "Help me sleep!" It can be a frustrating, unnerving experience to have difficulty falling or staying asleep. When you awaken without feeling refreshed, this problem quickly becomes a drag on the rest of your life and health. What are reasons why you can't sleep? Are there tried and true ways to sleep better tonight? What should you do if you have tried everything and it just isn't working? Let's explore these issues and discover the help you need to sleep.

What Is Wrong with My Sleep?

We have an expectation of perfect sleep; that we will crawl into bed, fall asleep within minutes, sleep without interruption, and awaken fully refreshed and ready to start our day. But is this a reasonable standard?

Children are often hailed as a model of perfect sleep because (for the most part) they are able to do just what we've described. As we mature, our bodies change and our sleep seems to likewise deviate from the ideals of childhood. Life, in a sense, gets complicated. There are new time pressures, our sleep is disrupted by others (including bed partners and our own children), and other health problems (such as nocturia, heartburn, and even pain) compromise our sleep.

As a result, we may not enjoy the sleep we knew in your youth. Indeed, even the timing of our sleep may shift. Those who are in the twilight of their lives may more often find themselves waking early, unable to stay asleep as they once did.

Some of our expectations regarding our sleep may be slightly misguided. As an example, the thought that we will fall asleep almost immediately upon retiring to our beds may be improper. In fact, people who fall asleep in less than 5 minutes may be "pathologically sleepy". This means that they are so sleepy that they fall asleep quicker than might be normal. In some cases, this ability to fall asleep quickly -- and enter rapid eye movement (REM) sleep quickly -- can be seen in excessive daytime sleepiness that might occur in sleep deprivation or narcolepsy.

Some sleep researchers believe that it might be normal to be awake some during the night. The fact that you sleep straight through the night without budging may again be a sign of inadequate time spent sleeping. This phenomenon is called "quiet wakefulness" and is often observed when the sleep habits of other non-Western cultures are studied. When people sleep in a group in close quarters, there is more time spent awake during the night. This makes sleep a more fluid concept. Time may be spent chatting, eating a snack, or engaging others around you. In history, fragmented sleep with periods of wakefulness in the middle of the night were common, reflected in the midnight adventures seen in the plays of Shakespeare, for example.

When we find ourselves waking in the night, no matter the cause, we may conclude that something is wrong. If there are no consequences in daytime function, however, this may not be the case. (Waking to go to the bathroom is so common as we get older that you would be hard-pressed to call it "abnormal".) The problem begins when our poor sleep compromises our lives. If difficulty falling or staying asleep at night begins to have consequences, there is a motivation to seek the cause.

Common Causes of Difficulty Sleeping

When we find ourselves lying awake, watching the minutes tick past in the red light of our alarm clocks, the desperation to sleep quickly escalates. There are many reasons this could occur and getting to the bottom of it may require some reflection on your situation. 

The most common reason why you can't sleep is also the most obvious: you are not tired. Your desire to sleep will be greatly diminished if you are trying to sleep at the wrong time. Imagine lying down three hours before your normal bedtime. The chance of you being able to fall right to sleep is pretty slim. This has to do with the circadian rhythm of our bodies. This system helps to coordinate our activities, including our desire for food and sleep, to the external environment. Problems with the timing of sleep may occur in the circadian rhythm sleep disorders as well as in temporary conditions like jet lag. If you spend more time in bed than required by your sleep needs, you will also be subject to long periods of wakefulness. Another reason you might be diminishing your desire to sleep at night is because of naps you take during the day.

A very common cause of difficulty sleeping relates to stress and the intrusion of stimulating substances and activities. You may have trouble falling asleep the night before a big test or presentation. In periods of emotional stress, such as after the death of a loved one, you may also have trouble sleeping. This is called acute insomnia. It usually passes when these stressors resolve. Similarly, stimulants such as caffeine and even nicotine can disrupt your sleep. You may be surprised to learn that exposure to light at night -- such as from a television or computer screen -- may make it difficult for some people to fall asleep. Additionally, late-night exercise may rev you up and provoke insomnia. For those who have chronic insomnia, the bedroom space may become a trigger for insomnia through conditioning.

The sleep environment is meant to be comfortable and facilitate sleep.

It should be cool, quiet, and free of distractions. Ideally you would not allow a television or pets in your bedroom. Bed partners may be disruptive and some people choose to maintain separate sleep spaces for this reason.

Another common cause of difficulty falling asleep is the activities that precede your bedtime. If you eat or drink too late, you may suffer from heartburn or frequent nighttime trips to the bathroom. There are general guidelines to improve sleep and many of these are meant to reinforce positive sleep habits. You should go to bed and get up the same time every day. Irregular sleep schedules may set you up for sleep disruption. You should follow a bedtime routine, including quiet, relaxing activities to help transition to sleep. If you fail to unwind prior to bed, you may find yourself struggling to drift off to sleep.

Finally, there are medical conditions that may keep you from sleeping well at night. These may be common problems such as heartburn or pain, but there are also multiple sleep disorders that might cause difficulty sleeping. Some of these include:

• Insomnia

• Sleep apnea

• Restless legs syndrome

• Circadian rhythm sleep disorders

Whether you suffer from one of these conditions or not, you may be interested in learning about some of the treatment options if you find yourself struggling to sleep at night.

Home Remedies When You Can't Sleep

The first task to sleep better at night is to improve your sleep hygiene, which refers to following the guidelines for better sleep. These steps may initially seem straightforward but because they involve modifying your behaviors in relation to your sleep, this can be challenging. If you have mastered these changes, you may be compelled to look at other options.

For those who have difficulty with insomnia, there are a handful of options to help you sleep. One treatment option is sleep restriction. This involves limiting the amount of time that you spend in bed, so that the time you are there you are more likely to spend asleep. It can also be useful to make a behavioral change called stimulus control. Stimulus control helps to break the association between not being able to sleep and your bedroom.

There are other non-medication options that might be helpful. Some people find benefit with the use of aromatherapy. Various relaxation techniques, including the use of biofeedback, may also establish a connection between your mind and body. This can be incorporated into your bedtime rituals and make it easier to relax and transition into sleep.

Finally, you may find yourself turning to over-the-counter medications to help your sleep. One of the most common is the naturally occurring hormone called melatonin. It is sold in many pharmacies and herbal supplement stores. It can be highly effective if you have insomnia related to a poorly timed circadian rhythm. As it has a low risk of major side effects (the most frequent is sleepiness), it might be an option to consider. Other herbal supplements (such as valerian root) do not have a lot of research supporting their efficacy.

If you still struggle to sleep, you may be compelled to look at other options.

Serious Help for Difficulty Sleeping

For those who still need help sleeping after exhausting changes in your sleep routine and at-home remedies, it may be necessary to turn to a professional. You may want to start by discussing the matter with your primary health care provider, but you may also choose a sleep doctor.

There are diagnostic tests that can be helpful for assessing your sleep problems, with special tests for insomnia. It may be helpful to keep a sleep log or use an actigraph to track your sleep patterns. Further testing with a home sleep apnea test or an overnight sleep study called a polysomnogram can also be helpful to identify sleep apnea or leg movements related to restless legs syndrome.

The other benefit of speaking with a health care professional is that you can discuss the use of sleeping pills. In addition, you can ask for a referral to a psychologist who might be able to teach you cognitive behavioral therapy for insomnia (CBTI) techniques to help your sleep.

This is a very serious matter, as the consequences of poor sleep can undermine your health and may even lead to your death. There are serious symptoms and physical effects of sleep deprivation, including hallucinations. For all these reasons – and more – it is absolutely worthwhile to get the help that you need in order to sleep well and wake refreshed.

What Causes Early Morning Awakenings?

By Brandon Peters, MD

There is something disappointing about waking up earlier than is necessary. It may be nice to doze in and out of sleep in the early morning hours, but it is especially upsetting if you cannot fall back asleep. What might cause someone to wake up before the alarm clock goes off? There are specific conditions, including a fair number of sleep and mood disorders, which might cause early morning awakenings.  By understanding these potential causes, you may be able to find a treatment that will keep you asleep until your desired wake time.

The Role of Insomnia

The most important cause of difficulty staying asleep near morning is insomnia. Insomnia is defined as difficulty falling or staying asleep or sleep that is simply not refreshing. These awakenings may occur throughout the night, but they tend to be more frequent in the second half of the night. This is due to a diminishing ability to sleep toward the morning hours.

The ability to sleep is linked to two processes, one called the homeostatic sleep drive and the other being the circadian rhythm (which will be discussed more later). The homeostatic sleep drive is the gradual desire for sleep that builds the longer a person stays awake. It relates to the gradual accumulation of a chemical within the brain called adenosine. This “sleepiness signal” eventually helps to initiate sleep. During sleep, it is cleared away, so that midway through the night, the desire for sleep is depleted. By morning, it should be completely gone.

If a person awakes in the night, especially if this awakening occurs toward morning, the ability to return to sleep will be compromised due to the lower levels of adenosine. Sleep may be greatly delayed, fragmented, or disrupted in insomnia, but awakenings near morning can be especially troublesome.

Anxiety and Depression May Provoke Awakenings

Any of the mood disorders, most notably anxiety and depression, can provoke awakenings. These typically occur in the several hours before the intended awakening. For example, if the alarm is set for 6 AM, someone with depression may start waking at 4 AM for no good reason. How can this be addressed?

As with insomnia, it is important to address the underlying contributing factors that lead to these awakenings. In the setting of psychiatric distress, these problems can persist. It is therefore necessary to treat any coexisting depression or anxiety. This may require the use of medications or counseling with the assistance of a psychologist or psychiatrist. Studies have shown that both, used in combination, are the most effective. Insomnia is especially well-treated with cognitive behavioral therapy for insomnia (CBTi).

It is clear that sleep can undermine mood. Conversely, mood problems can greatly affect sleep. By working on both issues together, the complexity of this relationship can be unraveled.

The Unexpected Influence of Sleep Apnea

It may seem peculiar to imagine that a breathing disorder such as obstructive sleep apnea may contribute to early morning awakenings. To better understand this relationship, it is necessary to carefully consider the structure of sleep.

It is artificial (but useful) to divide the night in half when considering the stages of sleep. In the first half of the night, slow-wave sleep more frequently occurs, especially among young people. In the second half, rapid eye movement (REM) sleep makes a more frequent appearance. Though the cycles of sleep occur regularly through the night, REM sleep becomes more prolonged towards morning. Therefore, we are more likely to awaken from it near morning and recall the vivid dreams that are associated with the state.

Sleep apnea is also more likely to occur during REM sleep. The muscles of the body are actively paralyzed during this stage, so that we are unable to act our dreams out. (If this does not occur, a condition called REM behavior disorder may result.) Muscles lining the upper airway are also paralyzed. This makes the airway more collapsible and when collapse occurs, it manifests as disrupted breathing and sleep apnea. Sleep apnea is often worsened during REM for this reason.

Therefore, morning awakenings may occur in the setting of sleep apnea that is worsened during the periods of REM that become more frequent and prolonged towards morning.

Morning Larks, Circadian Rhythms, and How Sleep Changes in Aging

The last major contributor to early morning awakenings is the class of conditions that are collectively known as circadian rhythm disorders. These include the natural tendency to wake early in the morning (so-called early birds or morning larks), advanced sleep phase syndrome, and natural changes that occur in sleep ability as we get older.

There are some who are just naturally morning people. They may prefer to fall asleep earlier (such as at 9 PM) and wake earlier (by 5 or 6 AM). This may be a lifelong preference. It isn’t necessarily abnormal, but it may lead to morning awakenings. If a sufficient amount of sleep is obtained before getting up for the day, then there is no reason to give it a second thought.

As we get older, our ability to maintain a continuous, uninterrupted period of sleep diminishes. The “machinery” of sleep (whatever we might conceive this to be) isn’t working as well as it used to. Sleep may become more fragmented. There may be more time spent awake in the transition to falling asleep and during the night. Slow-wave sleep diminishes. The total sleep time may be reduced. As part of this, early morning awakenings may occur.

In some cases, a condition called advanced sleep phase syndrome may become apparent. In this circadian rhythm disorder, the onset and offset of sleep moves forward by several hours. If it is disruptive to social life, it may be treated with the use of properly timed melatonin and light exposure at night.

If you suffer from morning awakenings, you should reflect on your situation and consider what might be contributing to the occurrence. If there is evidence for mood disorders, these should be addressed by a doctor. When a clear explanation cannot be identified, it may be useful to speak with a sleep specialist who may be able to provide additional insight. 

What Factors Lead to Insomnia?

By Brandon Peters, MD

It’s 1 a.m. again. You can’t sleep. You have been lying awake for hours. Just when sleep seems within your grasp, you are cruelly pulled back to wakefulness. How are you going to function tomorrow? Why can’t you get to sleep? If you find yourself struggling to fall and stay asleep, learn how you can master the factors that lead to your insomnia and get the rest that you need.

Sleep Depends on Drive and Circadian Rhythms

There are certain factors working in your favor that should help you get to sleep at night. When these are corrupted, however, they may quickly start working against you and lead to insomnia. To better understand how this may occur, it is important to first consider the patterns that lead to sleep and why some people can’t sleep at night.

Sleep depends on two independent processes: sleep drive and circadian rhythm. Sleep drive is the desire for sleep that builds gradually during wakefulness. Put simply, the longer you are awake, the more you want to sleep. This is thought to be due to the gradual accumulation of a chemical within the brain called adenosine, one of the neurotransmitters. Sleep is a time to clear adenosine away, and when you are awake it piles up and leads to increased sleepiness. A poorly timed nap during the day will diffuse the chemical and diminish your ability to sleep at night.

The other factor that determines when (and whether) you can sleep is something called the circadian rhythm. Our bodies respond to the natural daily patterns of light and darkness, linking certain biological processes to these rhythms. One of these processes is sleep.

There are certain factors that affect these circadian rhythms. Melatonin is a hormone that has a key role in regulating sleep patterns. Exposure to light exerts the most powerful influence, however. Taken together, the circadian rhythm encourages the specific timing of sleep and wakefulness. Sleep that is attempted counter to our natural desires is often ineffectual. Moreover, a prolonged shift in the timing of sleep may represent a circadian rhythm sleep disorder.

What Factors Cause Insomnia?

Insomnia is defined as difficulty falling asleep, staying asleep, or sleep that is simply not refreshing. How this happens is best understood by considering a theoretical model of what causes someone to have insomnia. According to Dr. Arthur Spielman’s model, there seem to be three considerations, summarized as predisposing, provocative, and precipitating factors.

First, it seems that some people have a predisposition towards insomnia. The threshold for developing insomnia will vary for each person. Believe it or not, there are people who rarely or never develop trouble sleeping at night. On the other hand, some people may be unlucky and are simply predisposed to have insomnia. This likely relates to genetic factors (insomnia often runs in families), age, sex (more often women), substance use, and other medical and psychiatric conditions.

Insomnia may also be attributed to an increased alerting signal. This relates to the sympathetic nervous system, which is responsible for the so-called “fight or flight” response. Some people may have an increased sympathetic drive, meaning they are primed to respond to an external threat. This signal can keep you awake during the day – but it also keeps insomniacs up at night. Some have described this as being “tired but wired”.

Even though you might have a predisposition towards insomnia, it has to be triggered. These triggers are called provocative factors. Insomnia might occur transiently and be secondary to stress, a cup of coffee, or an uncomfortable sleep environment. About 25 percent of people cannot identify the trigger for their insomnia. If you hadn’t encountered the trigger, however, you might continue to sleep without difficulty. Instead, you find yourself in the throes of acute insomnia. In time, this may resolve. But sometimes it doesn’t.

The final components that transform a passing difficulty sleeping into chronic insomnia are the precipitating factors. These are the elements that perpetuate the difficulty sleeping. These can best be understood by considering an example.

Let’s imagine that you lie awake several hours in the middle of the night, a common occurrence in insomnia. You recognize that you need 8 hours of sleep and by lying awake you are cutting into this time. You decide to start going to bed 2 hours earlier to compensate. This helps some, but now that you are going to bed extra early it is taking you more time to fall asleep. As you lie awake more of the night, your frustration increases and you compound your initial insomnia.

There are a variety of choices that might perpetuate your insomnia. Some people choose to limit their daytime activities because of sleepiness. This avoidance may reduce your physical activity. Since you are less tired, you may be less able to sleep. You may start working on your computer in bed to make the most of your time spent awake. This light and activity may worsen your ability to sleep. In addition, you may start napping during the day to get some sleep, and this could undermine your sleep drive and ability to sleep at night. All told, perpetuating factors are going to prolong your battle with insomnia.

How to Get to Sleep

Now that you understand the factors that might lead you to have difficulty sleeping at night, you no doubt wonder how you are going to get to sleep. In general, you can follow these simple rules:

1.    Build up your sleep drive through sleep restriction.

Work to make yourself tired by limiting your time in bed with sleep restriction. Avoid naps that may diminish your ability to sleep at night. Do not sleep in divided periods. If you find you cannot sleep, do not allow yourself prolonged wakefulness in bed, but observe stimulus control. These interventions can increase the quality of your sleep.

2. Respect your circadian rhythm, and sleep at the right time for you.

Acknowledge your body’s desired timing of sleep. If you are a night owl, don’t go to bed too early and lie awake. If you wake early, allow yourself adequate sleep time by going to bed early as well. There are ways to adjust the timing of your sleep, but start by sleeping when your body desires.

3.    Avoid triggers that can precipitate insomnia.

If you can identify the causes of your insomnia, do your best to avoid these triggers. Start by eliminating caffeine, especially after noon. Consider other ways that you may be ruining your sleep. Don’t forget about treating other sleep disorders, as these can also trigger difficulty falling or staying asleep.

4.    For those with chronic insomnia, seek professional help.

Finally, if you are suffering from chronic insomnia, lasting more than 3 months, you may need to seek professional help. When insomnia becomes prolonged, it is necessary to pursue other interventions. Sleeping pills may help in the short term, but other treatments are preferred for chronic insomnia. It can be very helpful to address the beliefs, thoughts, and feelings that surround your insomnia with a treatment called cognitive behavioral therapy.

If you suffer from insomnia, start by considering the factors that underlie your difficulty. Then talk with your doctor and if appropriate ask for a referral to a sleep specialist.

Sources:

Kryger, MH et al. "Principles and Practice of Sleep Medicine." ExpertConsult, 5th edition, 2011.

Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10(4):541-553.

Are Light Therapy Glasses Right for Me?

By Brandon Peters, MD

They look a little futuristic, casting a blue light over the eyes and onto the face. In some ways, they are. Light therapy delivered via glasses also relies on science that is as old as time. The use of light therapy glasses may be helpful to manage circadian mood and sleep disorders like seasonal affective disorder (SAD), insomnia, and jet lag. They may offer a boost of energy on a winter morning. How do light glasses work and are they right for you? Learn about phototherapy, circadian rhythms, and the usefulness of artificial light delivered via glasses for several conditions.

What is Light Therapy?

Light therapy, or phototherapy, is the use of light to treat a medical condition. It may be helpful to treat problems that occur when the internal circadian rhythm is misaligned to the natural patterns of light and darkness. This may impact the ability to sleep, the release of hormones including melatonin, and even mood and energy levels.

Light therapy may be done by properly timed exposure to sunlight. Unfortunately, living at northern latitudes may make this more difficult in the winter months. In some cases, an artificial source of light may be needed.

There are certain medical conditions that respond extremely well to this treatment, but how is it delivered?

Light Boxes Versus Light Glasses

Historically, light boxes were used to artificially deliver phototherapy. Initially quite large, the technology has become more portable. In fact, there are now several brands of light glasses that are capable of performing the task:

Ayo

The smallest glasses are available for $299 from Ayo. With a well-integrated app, it is possible to personalize the program by providing information on sleep habits and lifestyle. The light intensity, timing, and duration varies based on the mode and purpose. Boost energy, optimize the sleep-wake cycle, or even beat jet lag and adjust to the new time zone faster. There is some built-in flexibility in the timing of their use. The glasses are comfortable, with a sleek visor-like design that is unobtrusive. It is easy to charge the glasses by placing them in a pill-shaped pod that connects to a computer with a USB cable.

Luminette

For a lower price point, consider the light therapy glasses offered by Luminette. For $199 to buy, or $39 for a trial, similar technology is used to deliver the light therapy directly into the eyes. Unlike a light box, which may require 10,000 lux to be effective, the blue light directed into the eye accomplishes the same treatment with a lesser intensity. There are 3 intensity levels offered: 500, 1000, and 1500. The glasses themselves are larger, broadly situated above the eyes. It is recommended that they be used for 30 minutes daily for best effect.

Re-Timer

Similarly priced, at $199, Re-Timer delivers blue-green light into the eyes for the purposes of phototherapy. Designed to frame the eyes, these glasses were developed at a university based on 25 years of research. It is recommended that the glasses be used for 60 minutes daily, the longest recommended usage of the three models.

Conditions That Respond to Light

The circadian rhythms of the body are mostly affected by exposure to blue light. This part of the light spectrum is present in full-spectrum sunlight. It can also be isolated and delivered at a lower intensity with equivalent effectiveness. What conditions respond best to light therapy delivered via light glasses?

Seasonal affective disorder

Also known as winter depression, it occurs seasonally when the lack of light availability leads to a deterioration of mood. It may be associated with increased sleeping, lack of initiative and social isolation, and changes in appetite and weight gain.

Insomnia

Difficulty falling asleep may be especially responsive to the use of phototherapy. Artificial light exposure in the evening may be a problem, but using light glasses in the morning upon awakening may help to realign the circadian rhythm.

Delayed sleep phase syndrome

Night owls experience this condition that leads to both difficulty falling asleep at a conventional time as well as difficulty waking in the morning at an earlier time. Bedtimes may be at 2 a.m. or later and waking may naturally occur mid-morning or even mid-day. Though it does not necessarily have to be associated with insomnia, it often does when social pressures require sleep-wake timing that is not consistent with this genetic tendency.

Morning sleepiness

Difficulty getting out of bed in the morning due to sleepiness may be relieved with phototherapy. Light naturally wakes us. It initiates the circadian alerting signal. Consistent use in the morning may help to align sleep’s place to the darkness of the night.

Jet lag

In the modern age, jet travel allows a rapid misalignment of the body’s circadian rhythms to the patterns of light and darkness in the environment. It may take one day to adjust to each time zone crossed, but light therapy may make this adjustment occur more quickly. 

Cautions and Side Effects

Phototherapy is generally well tolerated. If it is bothersome, it should be discontinued. Any perceived side effects should resolve once the light glasses are no longer being used. In some cases, the following side effects may occur:

Headaches

Artificial light therapy may trigger headaches or migraines in those predisposed. In this case, a lower light intensity for a more prolonged period may be useful.

Insomnia

Light at the wrong time may lead to difficult sleeping. For example, using light glasses at bedtime may cause a shift in the timing of sleep later. This will make it hard to fall asleep, and hard to wake. Avoid this by following the instructions associated with the light glasses program.

Photophobia

Sensitivity to light may occur. This may lead to pain or simply an aversion to exposure characterized by squinting. It will go away when the light stimulus is removed.

Fatigue

Rarely, fatigue may occur with phototherapy. This may have to do with the changes that occur in the sleep-wake schedule. Following the directions of the program should help to minimize this risk.

Hypomania

For those who have a history of bipolar disorder, light therapy needs to be used with caution. There is a risk that the light may lead to a state of hypomania. This may be associated with an elevated mood, increased productivity, hypersexuality, or other symptoms.

Irritability

Although mood would typically improve with light therapy, in some cases it may lead to irritability. Like the other side effects, it should resolve by stopping the use of the light therapy glasses.

Importantly, there is no ultraviolet (UV) light exposure with the use of light therapy glasses. Therefore, the risks associated with this—such as damage to the eye or cancer—would not be present.

Conclusion

If you are interested in learning more about your sleep, consider evaluation by a board-certified sleep physician. In some cases, consultation with this specialist may optimize your response to the light therapy glasses. Should you experience any problems with their use, seek further assistance by an expert.

Sources:

Peters, BR. “Irregular Bedtimes and Awakenings.” Evaluation of Sleep Complaints. Sleep Med Clinic. 9(2014)481-489.

Reid, KJ and Zee, PC. “Circadian disorders of the sleep-wake cycle,” in Principles and Practices of Sleep Medicine. Edited by Kryger MH, Roth T, Dement WC. St. Louis, Missouri, Elsevier Saunders, 2011, pp. 470-482.

What Causes Sunday Night Insomnia and What Can Help?

By Brandon Peters, MD

It’s been a great weekend and now it’s time to settle into bed to get a good night of sleep before the busy week ahead. After waiting for a few minutes, you start to get a little anxious: you aren’t falling asleep. You start to worry about your function the next day. Then you realize that trouble falling asleep seems to occur every Sunday night. What causes Sunday night insomnia? Learn about some of the contributing factors, including sleeping in, taking naps, caffeine or alcohol use, and anxiety about the week ahead. By identifying and resolving some of the causes, you can finally get to sleep on Sunday nights easily without feeling dread for Monday morning.

Anticipating the Week of Ahead May Provoke Anxiety

What makes Sunday night so special? Of all the nights of the week, it seems to be mostly commonly associated with difficulty falling asleep that characterizes insomnia. Insomnia is defined as trouble falling or staying asleep. When it takes more than 20 to 30 minutes to drift off, this may be a sign of a problem.

There are lots of potential causes of insomnia. When it occurs, anxiety may make it worse. Pressure to fall asleep, or even the slightest focus on it, makes it nearly impossible to doze off. Sunday night may be the time that you start to think about the week ahead. If you hate your job, or if it is stressful, you may approach the week with dread. You might think about the coworkers who drive you crazy. You might ruminate on the projects that seem overwhelming. You might ponder the biggest stressors that you face in the week ahead. None of these thoughts will be conducive to falling asleep.

It may be helpful to use scheduled worry time or relaxation techniques to relieve this stress. You may be able to distract yourself from these thoughts, and fall asleep more easily. If you have persistent anxiety, you may need further help with the use of medication or psychotherapy from a counselor.

Weekend Sleep Patterns May Worsen Sleep Initiation

There is also good evidence that changes in the sleep patterns of the weekend may make it harder to fall asleep on Sunday night. It is very common to be sleep deprived during the week. You may get to bed too late or you may have to wake early. Getting the children ready for school, or making the commute to work, may prompt an earlier wake time. You may get to bed to late due to projects that delay your bedtime. As a result, you may note meet your individual sleep needs during the week. Each night, you may short yourself a little. Night after night, your desire for sleep grows stronger. When Saturday morning rolls around, you may sleep in. You “catch up” on lost sleep and pay off the accumulated sleep debt. If you don’t get up early Sunday morning, the same indulgence may recur. How does this impact sleep?

Our sleep is enhanced through two processes: homeostatic sleep drive and circadian rhythm. The sleep drive is the desire for sleep that builds the longer we stay awake. If you were to stay awake for 30 hours, at the end of 30 hours you would be very sleepy, and fall asleep very quickly. You would probably sleep longer and deeper than you normally would. All wakefulness builds this desire for sleep. Conversely, if you sleep, you diminish the sleep drive. By sleeping in, there is a delay in starting to build the desire for sleep. It is almost like going to bed early. If you sleep in 2 or 3 hours on the weekend, it’s like going to bed that much earlier. If your bedtime is normally at 11 PM, but you crawl into bed at 8 PM, is it any wonder that you can’t fall asleep?

Another contribution to poor sleep on Sunday night is our circadian rhythm. We have a natural tendency toward sleep that is synchronized to the day-night patterns of light and darkness. This is reinforced by our genetics as well as morning light exposure. By delaying the wake time, and getting light to our suprachiasmatic nucleus in the brain a little later, the pattern shifts. It makes it harder for us to wake up and harder for us to fall asleep.

Our bodies respond best to regular patterns, and this includes the pattern of sleep and wakefulness. Keep a regular wake time (with an alarm, if needed), even on the weekends. Go to bed when you feel sleepy, but try to get 7 to 8 hours of sleep through the week to meet your sleep needs. Try to avoid catching up on sleep on the weekend; get enough sleep every night to feel rested.

Afternoon Naps May Diminish Your Ability to Fall Asleep

Weekends are when we can most easily indulge in a nap. Though these don’t usually occur in the morning, they may frequently interrupt the afternoon. Imagine how often you have seen someone dozing on a lazy Sunday afternoon! Sports, movies, and reading seem perfectly paired for dozing on the weekends. Unfortunately, naps can diminish the drive for sleep.

Try to avoid taking prolonged naps, especially if you have difficulty falling asleep at night. Naps lasting 2 hours or more are especially problematic. (These naps may also be sign of a sleep disorder, such as sleep apnea.) As much as possible limit naps to shorter periods, perhaps 15 to 20 minutes. These can be refreshing, without impacting sleep at night. In addition, try to time the naps to mid-afternoon and avoid sleeping in the late afternoon or evening. Falling asleep in the hours before bedtime will make it especially difficult to get to sleep.

If your insomnia is especially entrenched, cut out the naps completely until your sleep improves.

Selecting a Bedtime and Going to Bed Sleepy

As noted above, try to keep a regular sleep schedule, including week nights and weekend nights. By going to bed at the same time every night, you will fall asleep more easily. It is also important to listen to your body and go to bed when you are feeling sleepy.

Sleepiness or drowsiness is different that fatigue, tiredness, or exhaustion. One can feel exhausted, and not fall asleep. Sleepiness is the strong desire for sleep that immediately precedes its onset. It may be associated with heavy eyelids, a warm sensation in the body, and loss of focus in vision.

Go to bed when you feel sleepy, including on the weekends. Don’t choose an optimistic bedtime based on when you would like to fall asleep. If you need to adjust your schedule, it is actually easier to change your wake time with an alarm. Subsequently adjust your bedtime earlier to correspond with when you are feeling sleepy. Insomnia is more likely to occur if you crawl into bed too early to get enough sleep to start your week.

If you are not falling asleep, observe stimulus control. Get up after 15 minutes, do something else relaxing, and come back to bed when you are feeling more sleepy.

Decreased Physical Activity and Consumption of Alcohol and Caffeine

There are other things that can impact your ability to fall asleep. These include changes in physical activity and the varying consumption of alcohol and caffeine.

Some people have very physical jobs. The weekends might be their opportunity to recover and rest. Decreased physical activity, including exercise, on the weekend may make it heard to fall asleep. As much as possible, try to maintain similar levels of exercise on the weekend (or even increase them, if possible).

Alcohol may enhance adenosine levels and increase the desire for sleep. Unfortunately, it is metabolized very quickly. The levels drop, and the desire for sleep disappears. Avoid alcohol intake in the hours before bedtime. Importantly, do not use alcohol as a nightcap.

Caffeine consumption can also impair our ability to sleep. Some people are very sensitive, and caffeine found in coffee, tea, soda pop, energy drinks, or chocolate should be avoided after noon. In others, reducing intake after mid-afternoon may be sufficient. If you have insomnia, try eliminating late consumption of caffeine to learn if it is impacting you.

Final Considerations for Sunday Night Insomnia

When difficulty falling asleep persists, consider other potential causes of Sunday night insomnia. Are you reluctant to go to bed because it means ending the weekend? Are you avoiding the stress of the work week? Is it time to make serious changes in your life to relieve stress?

If your insomnia persists, consider speaking with a sleep specialist about treatment options that may be helpful, including cognitive behavioral therapy for insomnia (CBTI). In rare cases, the use a sleeping pill on Sunday nights may be helpful.

You can sleep normally, even on Sunday nights.

Turning the Alarm Clock May Help with Insomnia

By Brandon Peters, MD

What is the first thing you do when you wake up at night? If it’s look at what time it is, you might consider how turning your alarm clock around may actually help your insomnia. Learn how checking the clock may provoke emotional reactions that disrupt sleep even further and how a simple solution may help you to sleep better.

Insomnia is defined as difficulty falling or staying asleep. For many people, it manifests by taking a long time to fall asleep initially or by frequently waking up in the night with trouble returning to sleep. There are multiple causes of insomnia, but paying attention to what time it is can actually make the condition worse.

If you wake up at night and immediately check the clock, there may be consequences to this seemingly innocent action. First, looking to the clock can become a habit. Every time you briefly return to consciousness in the night, rather than simply letting yourself fall back asleep, you may instead wake even further to look to the clock. Depending on what you find, you may put yourself into an emotional state in which returning to sleep becomes even more difficult.

Let’s take an example in which you check the clock and it’s 3 AM. This piece of information may be rather harmless if noted in isolation. It really shouldn’t matter what time of the night it is. However, in the context of your difficulties sleeping, it is a loaded experience. “Oh great,” you might promptly think, “I’m wide awake again.” This may incite a negative reaction, causing you to feel upset, angry, frustrated, or even despondent. How likely is it, when experiencing those feelings, that you will be able to calmly and easily fall back asleep? Quite the contrary, you are more likely to be worked up, aroused further, and stay awake even longer.

To counter this tendency, set your alarm for the time you wish to wake up in the morning. Then, turn the clock around so you can’t see the time. When you awake in the night, you may check it a few times until you remember that you can’t see it any longer. If you awake, tell yourself that you do not hear your alarm blaring, therefore, no matter what time it is, you can return back to sleep. Whether you awake early or late in the night, this will help you to doze off more easily. There will no longer be emotional reactions that can further disrupt your sleep.

There is no reason to keep track of the time at night. It only will further your difficulty returning to sleep. Instead of checking the hour, allow yourself to remain quiet and comfortable until sleep resumes. It is normal to wake up at night – to change positions, adjust the covers, even roll over – but it becomes a problem when this wakefulness persists. Use relaxation techniques such as breathing, muscle relaxation, or guided imagery to distract yourself from any effort related to falling back asleep.

If you find yourself checking your alarm clock at night, the simple step of turning it around may allow you to ease yourself back into sleep. This step can be an important part of other interventions offered by cognitive behavioral therapy for insomnia (CBTI). For those with persistent insomnia, you may wish to speak to a sleep specialist about your treatment options.

Are You a Night Owl? Delayed Sleep Phase Syndrome Overview

By Brandon Peters, MD

Night owls rule the evening roost. What explains the natural desire to stay up late and sleep in, especially in teenagers? With this overview, discover the causes, symptoms, diagnostic testing, and treatments of delayed sleep phase syndrome. Consider the consequences, including insomnia and sleep deprivation, and what can be done to keep the condition in check.

What Is a Night Owl?

First, how is a night owl defined? Anyone who stays up later than most may be viewed as a potential suspect. However, those with delayed sleep phase syndrome may be birds of a different feather.

If the natural tendency to fall asleep is delayed by at least several hours compared to the average person, with a sleep onset closer to 1 to 3 a.m., this fits the bill. In some cases, the delay may be even more extreme, with a night owl going to sleep closer to sunrise.

The desire to wake up is similarly delayed by at least several hours. Someone who is characterized as a night owl may not desire to wake until 10 a.m. or later. With a sleep onset closer to sunrise, the affected person may not desire to wake until into the early afternoon.

How Common Is Delayed Sleep Phase Syndrome?

It is estimated that 10 percent of the population could be characterized as night owls with delayed sleep phase syndrome. It may be more common among teenagers, who are susceptible to a slight delay in their sleep timing, but it can persist throughout life. There are many retired people who experience the condition once the alarm clock is silenced!

What Causes a Delayed Sleep Phase?

There seems to be a genetic predisposition towards developing delayed sleep phase syndrome. Some of this science is understood. For example, a mutation in the CRY1 gene alters the human circadian clock, delaying sleep by 2 to 2 1/2 hours compared to non-carriers. There will likely be more genes identified that have a role. 

Approximately 40 percent of people with delayed sleep phase syndrome report a family history of the condition.

Beyond genetic programming, there are environmental factors that may unmask the condition. Most importantly, light has powerful effects on the timing of the circadian system. It may provoke the delay in sleep timing, and may also be used to correct the condition.

Understanding the Circadian System and Sleep

Sleep is dependent on two processes: sleep drive and the circadian alerting system. If isolated in a constant environment, like a cave, the genetically determined circadian timing will become evident. It is controlled by the suprachiasmatic nucleus, a region of cells in the hypothalamus of the brain, and highly influenced by light exposure. Every cell, and organ, in the body follows a circadian pattern.

For most people, this internal clock is programmed to run a little long, perhaps resetting every 24 1/2 hours. In the cave, without exposure to light variance, an isolated person would naturally fall asleep and wake 30 minutes later, shifting later each and every day. In a week, the timing of sleep would move 3 1/2 hours. In a month, it would shift 14 hours, so that the person would want to sleep during the natural day and be awake in the natural night. This natural drift in the circadian timing is reset with morning sunlight.

Exposure to natural light in the early morning hours is a signal to the brain for wakefulness. It makes it easier to wake. It also slightly shifts the timing of sleep earlier, making it easier to fall asleep. This helps to align the desire for sleep to the natural period of darkness overnight. Without it, significant problems can develop with sleep and health.

What Are the Symptoms of Delayed Sleep Phase Syndrome?

People with delayed sleep phase syndrome will generally experience two symptoms: insomnia and sleepiness. Why would these seemingly contradictory symptoms occur in the same person? Again, it comes back to a question of when—it comes back to timing. 

Insomnia

Most night owls will experience significant insomnia if they attempt to go to bed earlier than their natural desire for sleep onset. Crawling into bed at 10 p.m. may result in hours of lying awake, tossing and turning. This can provoke anxiety, frustration, and anger—feelings that make the insomnia worse. When left to stay up late on weekends or during vacation breaks, it suddenly becomes much easier to fall asleep.

Morning sleepiness

In the early morning hours, it can be difficult to wake a night owl. It’s like trying to wake the dead. Teenagers have to be dragged out of bed, splashed with water, or roused with threats from despondent parents. This morning sleepiness can be profound. Depending on the hour, it is akin to waking someone with normal sleep timing in the middle of the night. It is extremely difficult to wake and function. By midday, however, the sleepiness abates. When the late evening rolls around, the night owl feels very awake, repeating the cycle again.

Social Pressure Leads to Sleep Deprivation

Unfortunately, night owls are not typically allowed to sleep and wake when their bodies tell them to. If they could always go to bed at 2 a.m. and wake at 10 a.m., there would be no sleep problem. They would fall asleep easily, without insomnia, and wake easily without conflict. Unfortunately, pressure from the rest of society—parents, spouses, bosses, school systems—may be quite disruptive. Without accommodation, chronic tardiness and absenteeism can lead to educational and professional dysfunction.

If someone does not naturally fall asleep until 2 a.m., but has to wake at 6 a.m. to be to work on time, sleep deprivation inevitably results. Unfortunately, 4 hours of sleep is not enough to meet even basic sleep needs. This can have profound effects on health and well-being. Consider some of the symptoms associated with sleep deprivation:

• Sleepiness

• Fatigue

• Difficulty concentrating

• Memory problems

• Mood changes (depression, anxiety, or irritability)

• Errors or accidents

• Physical pain

• Hallucinations

• Paranoia

There is some evidence this can be fatal. This is likely due to the chronic effects of sleep deprivation. One study suggests that people with delayed sleep phase syndrome have a 10 percent higher risk of dying compared to controls.

How Is Delayed Sleep Phase Diagnosed?

With proper education, it becomes fairly easy to recognize night owls who are likely experiencing delayed sleep phase syndrome. It may be a lifelong affliction, starting in adolescence and persisting for decades. How can it be diagnosed?

Fortunately, testing is not required to reach a diagnosis. A careful history by a board-certified sleep physician can typically identify the condition. In some cases, sleep logs kept over weeks may aid the recognition. Rarely is testing with actigraphy needed.

In research settings, the measurement of melatonin levels can help to identify the circadian timing. In particular, the dim light melatonin onset (DLMO) measured via blood or saliva can establish the pattern. Unfortunately, the repeated sampling requires a carefully controlled laboratory environment. This is virtually never done in a clinical practice. More recently, a blood test called TimeSignature has been developed, but it is not widely available.

Treatments of Delayed Sleep Phase Syndrome: Light, Melatonin, and More

If a condition is genetically determined, and potentially lifelong, it may seem like a life sentence. Fortunately, for delayed sleep phase syndrome, this is not the case! There are some effective ways to keep the timing of sleep in a normal phase. It may require a little extra effort, but consider these potential helpful interventions:

Sleep schedule consistency

There is good evidence that night owls can maintain a socially acceptable sleep timing. This requires consistency, especially in regard to the wake time. Get up at the same time every day, including weekends. Do not sleep in. Go to bed feeling sleepy, even if this initially requires a delay in the preferred bedtime. This will make it easier to fall asleep faster, relieve pressure to sleep, and reinforce the sleep quality.

Morning sunlight

It is especially important to reset the timing of sleep with morning sunlight. This is most effective immediately upon awakening. Try to go outside for 15 to 30 minutes upon awakening. Wake with an alarm, throw on clothes, and immediately get outside. Take a walk. Read the newspaper in the garden. Check social media while facing the sunrise. Light should hit the eyes, but don’t stare directly into the sun. Even a cloudy or rainy day, try to stick to the routine. In winter months, a light box may be necessary for phototherapy. The effects may take up to 1 month to become evident.

Avoid light at night

Artificial screen light should be minimized at night, especially in the hours preceding bedtime. It may shift the timing of sleep to occur later, causing insomnia and morning sleepiness. Devices may be switched to night mode, cutting out the blue light that can shift sleep timing. Blue blocker sunglasses (with an amber tint) or screen covers may be employed. Best yet, simply shut down the electronics in the 2 hours before bedtime. The buffer zone before the goal bedtime should be spent relaxing.

Melatonin

Melatonin is a hormone produced overnight by the pineal gland in the brain. It can be an external signal to the circadian system, most effective among the blind. If taken up to 6 hours before the desired bedtime, it may help night owls to fall asleep earlier. The effects may be somewhat weak, and certainly overpowered by the effects of light.

Cognitive behavioral therapy for insomnia (CBTI)

This effective treatment helps to improve the patterns of sleep and one’s relationship to it. Sleep consolidation, stimulus control, mindfulness, and relaxation techniques may be integrated into a program. It may be guided with help from a psychologist, class, online course, or book.\

Chronotherapy

Rarely, it may be necessary to adjust the timing of sleep incrementally in a structured environment. It is difficult to carry out at home and may require hospitalization. Over successive days, the sleep period may be delayed by 1 to 2 hours until the desired timing of sleep is achieved. Poorly timed light may complicate the efforts, and strict adherence to the final schedule must be observed.

Prescription medications

Sleeping pills and stimulant medication to enhance alertness have a limited role in this condition. Generally, they will be weakly effective. As a result, they may be overused and even abused. The risk of overdose in night owls, especially when these medications are used in combination with alcohol, is high. Instead of masking symptoms with a drug, the underlying timing of the circadian rhythm should be corrected.

Social awareness

Education may help parents to appreciate what their teenager is experiencing, to know that it is not laziness or defiance. High schools should continue to accommodate this natural timing among their students by shifting the school day. Later school start times enhance academic performance, reduce tardiness and truancy, and even diminish car accidents among teens. 

Conclusion

Sleep deprivation can have serious impacts on health and well-being. If you are struggling with delayed sleep phase syndrome, consider seeking the guidance of a board-certified sleep physician. Start with some simple advice: Go to bed feeling sleepy (even if later), keep a consistent wake time, and get sunlight upon awakening. If more help is needed, seek it out.

How the Best Sunrise Alarm Clocks Make Waking Easier

By Brandon Peters, MD

It is pretty normal to use an alarm clock to wake up. What is not as common, however, is for the clock to mimic a sunrise and wake you with a gradually increasing amount of light. How do the best sunrise alarm clocks make waking easier? Learn how a dawn simulation light works, why it might be preferable to an audible alarm, who benefits most from its use, and what alternatives exist that may help to enforce a circadian pattern, easing insomnia and making it easier to wake and get up.

What Is a Sunrise Alarm Clock?

A sunrise alarm clock, or dawn simulation light, is an artificial light source that is integrated into a standard digital clock. It is timed to gradually wake a person at a selected time. It does this by mimicking the steadily increasing light of sunrise, often over 30 to 40 minutes, but some models may allow the timer to be adjusted from 15 to 60 minutes.

These simulators may have a full-spectrum white or yellow LED lightbulb. The color spectrum, or color temperature (think of this as the “warmth”), of this light may vary slightly from one model to the next. Most are of modest intensity, often 100 to 300 lux, with less light than a standard light box.

There are a variety of models, most costing less than $25 to $100, including:

• Philips Wake-Up Light HF3520

• Philips HF3505

• Philips Somneo HF3650

• hOmeLabs Sunrise Alarm Clock

• Mosche Sunrise Alarm Clock

• INLIFE Wake Up Light Alarm Clock

• NATPLUS Sunrise Alarm Clock

• iHome Zenergy Bedside Sleep Therapy Machine

• totobay

• Sharp Sunrise Simulator

• Lumie

The add-on features also vary widely from one product to the next. Many have the ability to adjust the light intensity, snooze features, and associated standard alarm sounds or music. There may be USB ports integrated for charging devices. Beyond encouraging a gradual awakening, some can even dim light gradually (a so-called sunset feature), making it feel more natural to fall asleep.

How Do Dawn Simulation Lights Work?

Dawn simulation lights can make it easier to wake, but how do these devices work? It is important to consider the natural patterns of light and darkness and how the circadian rhythm enforces optimal sleep and wakefulness.

Humans, like most animals, have evolved to sleep overnight during darkness. Light, conversely, has a waking effect on the brain and body. It suppresses melatonin and activates the circadian alerting signal. Light at the wrong time, like from a screen prior to bedtime, may make it hard to fall asleep and contribute to insomnia. In the morning, when incorporated into a sunrise alarm clock, it may make it easier to wake.

Light exerts this impact by traveling from the eyes via the optic nerves to an area of the brain that regulates the body’s circadian rhythm. This area of the brain, called the suprachiasmatic nucleus, lies in the hypothalamus. It is the master clock of the body. Without it, the patterns of sleep and wakefulness, metabolism, hormone release, cortisol levels, body temperature, and other processes would run amok.

Fortunately, light at the proper time may help us to sleep and feel better. Even artificial light, if appropriately timed, may enforce the normal patterns of our body that would exist if we slept in a perfectly natural environment. A gradual increase of light in the morning hours, even in the natural darkness present in winter months at northern latitudes, may reinforce a normal pattern of waking.

Why Is Light Better Than Sound?

The sudden, blaring sound of an alarm clock will definitely wake someone. However, this abrupt shift from sleep to wakefulness can be disorienting. If full wakefulness is not attained, the snooze button may be pressed and sleep may quickly resume. Short awakenings, such as those lasting less than 5 minutes, may go unremembered. If the alarm clock is simply turned off—or smashed into 1,000 pieces—trouble may ensue!

Light may wake a person more gently and more gradually. The transition from sleep to wakefulness is more orderly. This may help to relieve sleep inertia, that profound sense of sleepiness that is difficult to shake when first opening your eyes. It is something that feels more natural. The sky does not go from pitch black to glaring sunshine. As the sun creeps over the horizon, the amount of light hitting our eyes (even through closed eyelids) steadily increases. It may reach a threshold where it finally wakes us. This may make it less likely a person would want to hit snooze repeatedly and fall back asleep. Even the thought of it seems more pleasant.

Who Should Consider a Sunrise Alarm?

Although there are certain groups who may benefit more from using a sunrise alarm, scientific research suggests that many of us could yield positive health impacts.

There are a surprising number of important benefits from the use of dawn simulation lights. Research suggests it may:

• Improve cardiac function and reduce the risk of heart attacks

• Provide a boost to the brain’s function (in select cognitive domains)

• Enhance performance in tasks done immediately after waking

Clearly there are certain conditions or groups of people who would likely enjoy the effects of a sunrise alarm even more. Consider these possibilities:

Night owls

Delayed sleep phase syndrome is a circadian disorder characterized by difficulty initiating sleep (insomnia) and profound morning sleepiness. It affects 10 percent of the population, usually starting in the teenage years. Most night owls feel naturally sleepy close to 2 a.m. and may not naturally wake until 10 a.m. The use of a dawn simulation light may make waking a little easier. In some cases, a light box may be more effective to reinforce an earlier circadian phase.

Winter depression

Seasonal affective disorder, or winter depression, impacts people living in northern latitudes during the winter months when the nights are long and the days are short. Darkness can make it hard to wake in the morning. This may lead to increased depressive symptoms, lethargy, prolonged sleep, weight gain, and other symptoms. An artificial light may help the morning to start a little easier.

Teenagers

As noted above, teenagers are susceptible to delayed sleep phase syndrome. As a general rule, teens are more likely to have a slight delay in sleep timing, even with a less profound shift in the pattern. This can make it hard for adolescents to fall asleep at a desirable time. It can also make it very difficult to wake them in the morning. This can lead to early morning fights with parents, tardiness, absenteeism, and other problems like car accidents, inattention, and academic failure. Consider how desirable it might be to have a gentle light do the waking, and let the drama of the morning fade away.

Shift workers

Those who work atypical shifts—second, third, graveyard, rotating, or even call coverage—are subject to many sleep problems. When the desire for sleep and wake is forcibly misaligned from the patterns of darkness and light, it can be difficult to function optimally. This may lead to increased errors, accidents, and health problems (including a higher risk for cardiovascular disease, weight gain, and breast and colorectal cancers). Artificial light, if properly timed, may help to alleviate some of this misalignment.

Jet lag 

For every one time zone crossed, it can take one day to adjust the circadian rhythm. Traveling across a continent, or an ocean, can lead to significant disruption. The use of a sunrise alarm clock may make this transition easier. The optimal timing of this light exposure will depend on the distance traveled, and whether preparation was made prior to departing on the trip.

Hearing impaired

Finally, those with a hearing impairment may benefit from using a light to wake, rather than an audible alarm. The deaf may otherwise need to rely on others to wake on time. The use of a sunrise alarm clock may provide a new degree of independence.

Alternatives to Sunrise Alarm Clocks

Many people will be attracted to the possibility of easing insomnia and waking and getting up easier. Not everyone may want to use a sunrise alarm clock, however. There may be a handful of alternatives to consider. Consider how these additional options may make it easier to wake in the morning:

Natural sunlight

Throw the window shades open in your bedroom before retiring for the evening. This will let in natural light. After sunrise, the light will be able to stream through the windows and promote wakefulness. Unfortunately, this may not be ideally timed certain times of the year.

Light box

Consider a light box with 10,000 lux of intensity. It is powerful enough to shift the circadian rhythm, benefiting seasonal affective disorder as well.

Light therapy glasses

For those with a little extra buying power, light therapy glasses are a convenient and effective option. With a lower amount of light, shone directly into the eyes, these glasses can make it easier to wake.

Caffeine

A cup of coffee or tea can make it easier to get the morning started. Caffeine blocks adenosine, a signal for sleep, within the brain. With a half-life of 4 to 6 hours, it can get you through the morning.

Get motivated

Consider ways to motivate yourself out of bed. Morning exercise, quickly hopping in the shower, a special breakfast, or stepping outside to enjoy the early light may be helpful. In some cases, scheduling something you really enjoy for first thing in the morning may do the trick. 

Conclusion

There are many effective ways to wake and feel refreshed. A sunrise alarm clock may help to ease the transition to wakefulness. If you consistently struggle to wake, or have sleep of poor quality, consider getting evaluate by a board-certified sleep physician. Sleep disorders can be effectively resolved to the benefit of your health and well-being.

Sources:

Follum JD, Catchpole JM. “Sunrise alarm clock for the hearing impaired.” Biomed Sci Instrum. 2011;47:18-23.

Viola AU et al. “Dawn simulation light: a potential cardiac events protector.” Sleep Med. 2015 Apr;16(4):457-61. doi: 10.1016/j.sleep.2014.12.016. Epub 2015 Feb 26.

Gabel V et al. “Dawn simulation light impacts on different cognitive domains under sleep restriction.” Behav Brain Res. 2015 Mar 15;281:258-66. doi: 10.1016/j.bbr.2014.12.043. Epub 2014 Dec 27.

Thompson A et al. “Effects of dawn simulation on markers of sleep inertia and post-waking performance in humans.” Eur J Appl Physiol. 2014 May;114(5):1049-56. doi: 10.1007/s00421-014.2831-z. Epub 2014 Feb 11.

Why Does Insomnia Happen?

By Brandon Peters, MD

There are few things more frustrating than an inability to sleep. Insomnia may undermine your night’s rest, leading to important daytime consequences. Why does insomnia happen? Learn about the factors that may lead to an inability to sleep at night and consider what you might do about them.

Insomnia is defined as the inability to fall or stay asleep or sleep that is unrefreshing in the absence of another sleep disorder (such as sleep apnea). It is the most common of all the various sleep disorders, and it may be a significant problem in about 1 in 4 people. Nearly everyone has experienced some degree of insomnia, even if only transiently, but why does this occur?

Spielman’s theoretical model of insomnia underpins our current understanding of the disorder. This theory suggests that three things contribute to the development of chronic insomnia, including: predisposing, precipitating, and perpetuating factors.

Predisposition: The Threshold for Insomnia

It is believed that everyone has the capacity to develop difficult sleeping at night. This predisposition is likely genetically determined. Some of the contributions to it likely include our individual circadian rhythm, homeostatic sleep drive, and level of arousal. The circadian rhythm directs the timing of our sleep, and it may be either advanced or delayed in some people. The homeostatic sleep drive is dependent on the build of sleep-promoting chemicals, including the compound called adenosine. The longer we stay awake, the sleepier we become, due in part to these chemicals. Finally, the baseline level of arousal also is factored in. Some people are more “wired” – also likely due to varying levels of neurotransmitters that promote wakefulness – and this may make sleep disruption more likely.

The predisposition towards insomnia can be thought of as a threshold. Below the threshold at which insomnia will develop, you sleep fine. Given the proper scenario, however, and the balance tips toward sleep disruption. The things that provoke the development of insomnia are known as the precipitating factors.

The Precipitating Factors for Insomnia

What might cause insomnia? There will be some variability in what provokes insomnia in you. Triggers for insomnia may not be the same for every person. Something that is particularly disruptive to your sleep may have no effect on someone else’s. This varying sensitivity is normal, and it shouldn’t be a source of additional distress.

Some of the most common triggers for insomnia include stress, mood disorders, pain, substance use, and poor sleep environment. Stress of every imaginable type is highly likely to make it difficult to sleep. The night before a big examination or presentation at work may be fitful. Major life events such as moving, the loss of a job, relationship problems including divorce, or the death of a close friend or relative may also lead to insomnia. If these problems lead to anxiety or depression, the risk of insomnia may be compounded.

There are other causes of insomnia as well. In particular, chronic medical conditions, especially those that cause pain, may disrupt sleep. Sleep is usually an anesthetic state, in which pain is not sensed, but nevertheless pain can make it hard to fall asleep. There are certain substances that may contribute to difficulty falling or staying asleep as well. The most common, caffeine, is notorious for sleep disruption. Nicotine is another stimulating substance that disrupts sleep. Alcohol may cause drowsiness initially, but when it starts to wear off, sleep becomes fragmented. Other medications and drugs can also undermine sleep.

Finally, the sleep environment can also make it hard to sleep. If your bedroom is too warm or too cold, too bright, or too noisy, sleep may be fleeting. An uncomfortable bed, or none at all, may also cause insomnia. If someone is snoring nearby, or a baby cries out to be fed, sleep becomes light and fragmented. Studies have also shown that environmental noise, such as may be present in a busy city, can also disrupt sleep.

It should also be noted that working against your natural ability to sleep can also cause insomnia. If you try to sleep at a time that your body expects you to be awake (contradicting your circadian rhythm), you will likely lie awake. If you took a prolonged nap in the afternoon, your desire for sleep will be diminished due to a weakened sleep drive. In addition, if you are wound up after a fight with your spouse (with increased arousal), insomnia will likewise result.

Perpetuating an Inability to Sleep

Once your threshold for insomnia has been crossed, incited by one of the precipitating factors, you will find yourself lying awake at night. This may quickly pass, as occurs in acute insomnia. If you had insomnia due to an examination that has come and gone, for example, the difficulty sleeping goes away with it. However, there are scenarios where insomnia will persist, and unintentional behavioral or cognitive changes may actually make things worse.

If the precipitating factor has not resolved, it is very likely that it will continue to disrupt your sleep. It is possible to adapt to some of these triggers, depending on the nature of the disruption, but this may not always happen. Therefore, it can be important to identify the cause of the insomnia and try to resolve it. This will require a careful self-assessment of the factors that are important to your situation.

Unfortunately, some triggers are not easily remedied. It may require a tincture of time to grieve a death. A mood disorder may require medication or psychotherapy. A new baby may take months to sleep through the night. Focus on what you have control over, and avoid making things worse.

Many people with insomnia unintentionally make their insomnia more sustained. Several bad nights of sleep (or dozens, for that matter) may lead you to change your pattern of sleep. This can be particularly true if you find yourself waking and lying awake in the night. You may think, “I am not sleeping well, so I am going to go to bed earlier to try to get enough sleep.” By extending your time in bed, you have introduced a new problem: you are now going to bed earlier than your body wants you to. If your body says you will get sleepy at 11 PM, but you crawl into bed at 9 PM, guess what happens? You will now have trouble falling asleep as well.

There can be a lot of emotions and thoughts that become associated with insomnia. Chronic insomnia is deeply frustrating. Feelings of distress, hopelessness, inadequacy, and failure become part of the scenario. People who sleep well do not wake in the morning and assess how well they slept. Insomniacs often do. Sleep becomes a focus in insomnia, and when it does, it becomes a challenge. There can also be an element of catastrophization, in which the worst possible scenario is imagined during the periods of wakefulness: “If I don’t get enough sleep, I’m going to get fired.” Many of these thoughts and feelings must be defused, and cognitive behavioral therapy for insomnia (CBTI) can be very helpful in this regard.

It is clear that insomnia can happen for multiple reasons, as detailed above. Everyone has a specific threshold at which insomnia will develop. The precipitating factors will vary for each person, but there are common triggers related to stress, mood, pain, and substance use. Acute insomnia becomes chronic when behaviors, thoughts, and emotions change surrounding sleep. If you find yourself stuck in the pattern of insomnia, it can be helpful to speak to a sleep specialist to begin to make changes that can correct the problem. Insomnia can be treated effectively, so reach out to get the help that you need.

Source:

Kryger, MH et al. “Principles and Practice of Sleep Medicine.” Elsevier, 5th edition. 2011.

The Science of Circadian Rhythms

By Brandon Peters, MD

Circadian rhythms may be the most difficult concept to understand in the world of sleep medicine. There is a lot of confusing language, and it relies on science that is not easily approached. Fortunately, a basic understanding of the science of circadian rhythms can be obtained and may help to explain some cases of insomnia and daytime sleepiness.

As the World Turns

The Earth’s 23 hour and 56 minute daily rotation provides predictable rhythms of light and temperature, food, and predator activity. Through adaptive evolution, our body’s metabolism and even our behaviors are programmed to respond to this precise timing. Franz Halberg coined the term circadian (from the Latin meaning “about a day”) in 1959. It describes numerous approximately 24-hour cycles that are generated within nearly every organism on the planet.

Within our body, there is a system in place that measures time and synchronizes many internal processes to daily events within the environment. Some of these important processes include:

• Sleep and wakefulness

• Metabolism

• Core body temperature

• Cortisol levels

• Melatonin levels

• Other hormones (growth hormone, thyroid hormone, etc.)

The control of these patterns is built into our genetic makeup; the machinery synchronizes rhythms that will persist independently of outside influences. The first mammalian gene, Clock, was identified in 1994. Multiple additional genes have been identified that constitute a core molecular clock that gives rise to other cellular, tissue, and organ function.

Every cell in our body follows a circadian pattern: an extraordinary symphony of biochemical reactions that are perfectly timed based on available resources and orchestrated by a small group of cells in the anterior part of the brain’s hypothalamus. Through hormones and other as yet undetermined influences, the central pacemaker coordinates peripheral clocks that are present in cells as diverse as cardiac, liver, and adipose tissues.

Light is perceived by the eyes and travels via the retina to the optic nerves. Above the optic chiasm, where the two optic nerves cross behind the eyes, sits the suprachiasmatic nucleus (SCN). This is the master clock of the body. It couples the numerous physiological processes described to the timing of light and darkness in the environment.

These patterns will persist without external time cues, but they may vary slightly from the geological day length. As a result, in isolation from resetting cues, the timing of these processes may gradually become desynchronized. The degree of shift may depend on our genetic program, or tau, with most people having an internal clock that runs longer than 24 hours. It is understood that our genetics and the interaction with other environmental factors – especially the exposure to morning sunlight – may have important effects on resetting the internal clock. These external influences are called zeitgebers, from the German for “time-givers”.

When the internal clock is misaligned to our environment, circadian disorders such as delayed and advanced sleep phase syndrome can occur. With a complete disconnect from light perception, as occurs in total blindness, a Non-24 rhythm occurs. These conditions are often associated with insomnia and excessive daytime sleepiness as well as irregularities in the sleep-wake rhythm that cause social and occupational dysfunction.

Fortunately, treatment of circadian disorders can be highly effective and a board-certified sleep physician can provide helpful guidance and resources.

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