We’re increasingly realising it’s not simply how much you sleep that’s important: it’s when you sleep. Recently, scientists identified a new photoreceptor in the eye that specifically responds to sunlight and helps set your body clock and regulate your circadian rhythm. In other words, it determines when you feel awake and when you feel sleepy. That’s why nearly all people who are blind from birth have disruptive sleep/wake patterns. Shift workers also suffer.
What to do: Rotating shifts are the real killer as your body can’t set a pattern. So if there’s any flexibility, make your shifts as fixed as possible. If you’re naturally a night owl, you’re much better picking the evenings, lates and night shifts, and vice versa. Ensure you factor in the wind-down period – if you finished work at 5pm, you wouldn’t climb into bed at 6pm, would you? Make your sleeping environment as much like night as possible: use blackout blinds and earplugs. At the other end of the day, sitting in front of a light box for half an hour before you start your night shift will wake you up and reset the clock.
2. Sleep more
A US study by the National Commission on Sleep Disorders revealed that the average American male is now in bed for seven to seven and a half hours a day, compared with nine hours a night in 1910. That’s a 20 per cent reduction in total sleep-time and that pattern is evident throughout Western society. Chronic sleep restriction is a side effect of the electronic age and 24/7 lifestyles, and research has shown it’s at the expense of memory and learning.
What to do: Keep a sleep diary for a week or ideally two. Write down when you get up, the time you get into bed and your estimate of how much sleep you’ve had. Often there’s a real penny-drop moment when it’s all added up and the permanently fuddled patient realises they’re subsisting on five or six hours sleep a night. At that point, I’ll say: you need to reassess how productive you’re really being and what’s important in life. People think they can sacrifice a couple of hours’ sleep because it’s the least important part of the day. It isn’t.
3. Stop clock-watching
A common sleep disorder, insomnia, is defined as: persistent difficulty falling asleep and staying asleep; perception of impaired sleep quality; and not getting enough sleep despite having enough time in bed. It can cause distress or a degree of functional impairment. Usually this is fatigue, decreased mood or irritability and/or general malaise. Many insomnia patients are preoccupied with sleep so the harder they try to fall asleep, the more difficult it becomes.
What to do: Sleeping tablets are effective, although there’s concern about long-term use of benzodiazepine increasing the risk of hip fracture (possibly even dementia) in the elderly. Cognitive behavioural therapy (CBT) works for 50 to 70 per cent of insomniacs. It’s not the same as the talking therapies for anxiety and depression; it’s a fairly rigid structure entailing sleep diaries, sleep scheduling and sleep restriction. If CBT for insomniacs isn’t available locally, there are effective online programmes such as Sleepio (www.sleepio.com).
And if it’s just the odd all-nighter… Everyone has an occasional bad night for no special reason. Don’t take your work and the rest of your life into your bedroom: the bed should only be used for sleeping or sex. It sounds obvious but don’t get into bed until you’re sleepy, and don’t go to bed really early because you had a bad night yesterday. Instead take time to wind down properly. If you’re lying there wide awake, get up, go into another, softly lit room and do something else until you actually feel sleepy. Paying attention to sleep is its Achilles’ heel: you can’t chase it.
4. Sort our snoring
Lots of people snore, which is usually only a problem for their nearest and dearest. But five to ten per cent of people who are really loud, chronic snorers – snoring you can hear in another room – will have associated pauses in their breathing. Basically, the weight on the soft tissues at the back of the neck presses down and closes off your airway. So you stop breathing, your oxygen level drops and your brain wakes you up as an emergency response. The result: a very bad night’s sleep. People with obstructive sleep apnoea are symptomatically sleepy. The question I always ask is: can you get through the day without taking a nap?
What to do: Nasal strips and tennis balls sewn to your pyjama top don’t work; you’ll need medical help. Obstructive sleep apnoea is by far the commonest problem we see in sleep clinics and there are plenty of good treatments being trialled. The reason for this absolute epidemic is increasing obesity rates across the Western world; obstructive sleep apnoea is a neck circumference and body fat issue for 70 per cent of people. So of course another thing that can help is losing weight.
And if it’s just plain old snoring… Cut down on booze and sleeping tablets, which worsen snoring because they decrease muscle tone. Again, there’s the boring advice about losing weight. Some people find a sort of brace called a mandibular advancement device helps – you can order them bespoke online. Think carefully about surgery because it can be quite complex and there isn’t evidence that it always works. It might also be worth investigating whether you have a nasal blockage or allergy.
5. Don’t dream on
I see many patients who have to sleep in the spare bedroom because they have been lashing out and hurting their spouse. When we dream, everything is still apart from our diaphragm and rapid eye movements (REM) because there’s a switch within the brain stem that turns off skeletal muscles. If you’re flailing around, that switch isn’t working as it should. Seventy per cent of people who act out their dreams (REM sleep behaviour disorder or RBD) will injure themselves or someone else at some stage so it can be a real problem.
What to do: Ask your GP to refer you to a sleep clinic where a sleep study will be done to rule out other disorders. Even if someone only does it three or four nights a week and doesn’t flail around in the sleep lab, there will be increased muscle activity during the dream-sleep. Once diagnosed, medication is effective in 80 to 90 per cent of cases. There’s a huge amount of research into RBD as it can be a hint of trouble to come: elderly males in particular are at risk of developing some form of Parkinson’s disease and neuro-degeneracy.
6. Tame night terrors
Isolated sleep-talking is near universal and is rarely anything to be concerned about. Twenty per cent of children have night terrors or sleepwalk and five per cent of adults walk. Again, this is nothing to worry about if it’s very occasional and you aren’t getting into trouble. Far more serious is more complicated behaviour: eating, trying to have sex during sleep, violence.
What to do: You can buy window and door alarms and locks to make your environment safe. Some people prefer a short course of tablets while on holiday as you’re more at risk of sleepwalking in a new environment. If you’re exhibiting more extreme behaviour, seek help. There’s surprisingly little research into treatments so I try a range: tablets, behavioural therapies, hypnotherapy. We also know that bad days lead to bad nights. So if someone has associated anxiety or depression, we treat those symptoms as well.
7. Beat jet lag
The natural catch-up is about an hour a day for every hour of time difference. However, we become worse at rapid clock-setting as we get older. So if you take your kids to Australia, they will be bouncing around at the wrong time of day for three or four days, whereas you might feel the effect for several days longer.
What to do: Some people use melatonin to combat jet lag, although it’s unlicensed for this use in the UK. It’s important not to mess up the timing and dosage: it depends which direction you’re flying and how many hours out-of-sync you are. The more abrupt method is simply to keep yourself awake until the normal bedtime of the new country. That’s what I would do. For my children I’d be less bothered because I know they’d adapt much more quickly.