Use OTC Sleep Aids With Caution

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Sleeping pill users should read the label of OTC sleep medicationsIt annoys me when people dismiss sleeping pills as categorically harmful. Yes, they can be used inappropriately and it’s important to be informed about their downsides. But the existence of downsides doesn’t necessarily mean the risks associated with using them outweigh the benefits.

The sleeping pill of choice for many Americans with insomnia can be purchased over the counter at drug and grocery stores. But a new study shows that many older adults who use OTC sleep aids know little about them and may be using them in ways that do more harm than good.

Older Americans Use Them and Like Them

Participants in the new study were adults in the United States aged 60 and older who were managing their sleep problems with nonprescription sleep aids. University of Pittsburgh investigators interviewed 116 by telephone and found that well over half were satisfied with their medication and felt it improved their sleep.

Asked about her satisfaction with one such drug, an interviewee replied that she was “pretty satisfied. It does help me fall asleep and stay asleep, and go back to sleep when I invariably get up once or twice a night.”

“There is a dramatic difference when I use it versus when I don’t,” another explained.

This jibes with the results of other, quantitative research. The prevalence of insomnia and other sleep problems among older adults is high and OTC sleep aids are widely available. About 17% of older adults in the United States turn for relief to antihistamine-containing sleep aids like Unisom and Simply Sleep.

How OTC Sleep Aids Work

Diphenhydramine and doxylamine are the active ingredients in antihistamine sleep aids. They block the action of histamine neurons, which are generally active when we’re awake and inactive when we’re asleep.

“Marked drowsiness may occur,” is the type of warning that usually appears on the label. This propensity to cause sedation is likely why, despite few controlled trials supporting their efficacy for insomnia, these drugs are seen as effective by many older adults. The trials that have been conducted suggest these antihistamine sleep aids may have more to offer sleep maintenance insomniacs than people who need help falling asleep at the beginning of the night.

Side Effects of OTC Sleep Aids

But like most prescription medications, OTC sleep aids are not intended for nightly or long-term use. Continuous use has been found to lead to the development of tolerance, tempting users to take more of the drug to get the same sedative effect. Yet in the Pittsburgh study, nearly half of the participants reported using OTC sleep meds daily or very often. Over half reported using them for more than a year.

Fewer than a quarter of the study participants had studied the label on their medication to find out about the recommended dosage or about warnings and possible side effects.

“I never really paid any attention to the directions,” an interviewee said. “I take a couple before I go to bed, about twenty minutes before I go to sleep, I go upstairs and go to bed. That’s it.”

Common side effects to be aware of are morning grogginess (our bodies process drugs more slowly as we age) and blurred vision, constipation, and trouble urinating (for more on this, see my post on OTC sleep aids and anticholinergic effects).

Drug-Drug Interactions

Possible drug-drug interactions is another factor to take into account, given that almost 40% of older Americans are taking five or more prescription medications. Studies have shown that diphenhydramine (the main ingredient in many OTC sleep aids, including Benadryl, Sominex, Nytol, ZzzQuil, and Simply Sleep) interferes with the body’s metabolizing of at least three commonly prescribed drugs:

  1. tamoxifen, an anti-estrogen drug used to treat breast cancer and lower breast cancer risk
  2. metoprolol (Lopressor), a beta blocker used to treat high blood pressure and heart problems
  3. venlafaxine (Effexor), a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) used to treat depression

Reducing the effectiveness of a drug taken to manage a serious health condition isn’t something most of us would want to do. But information about all possible drug-drug interactions isn’t necessarily listed on the label of OTC sleep aids.

Americans seem to have the attitude that OTC meds are harmless—but that isn’t necessarily true. If you’re going to use an OTC sleeping pill, read the label for information about the proper dosage and potential side effects. Take concerns about possible drug-drug interactions to your doctor or pharmacist.

Traveling With Insomnia: Don’t Let Jet Lag Spoil the Trip!

Do your summer plans include eastbound, transatlantic travel? If so, take precautions to avoid jet lag—the sleepy, sluggish, headachy feeling and insomnia that can seriously curtail your enjoyment of the first few days.

Here’s advice on how to prevent severe jet lag and hit the ground ready for action.

Managing light exposure and use of melatonin can curb travel-related insomnia & jet lagDo your summer plans include eastbound, transatlantic travel? If so, take precautions to avoid jet lag—the sleepy, sluggish, headachy feeling and insomnia that can seriously curtail your enjoyment of the first few days.

Here’s advice on how to prevent severe jet lag and hit the ground ready for action.

Why Jet Lag Occurs

Body processes occur in a 24-hour cycle tuned to daylight and darkness in the time zone where you live. Eastbound travel over multiple zones is a challenge. To adapt to time in the new zone, your body clock has to advance by several hours. For many people, achieving this phase advance is harder than the delay that occurs with westward travel.

Symptoms of jet lag are more pronounced in some people than in others. But the more time zones crossed, the more severe the symptoms usually are. Jet lag symptoms also seem to grow worse with age. And although I have no hard evidence, I think people with insomnia, who have to be careful about scheduling their sleep anyway, may have more trouble adjusting to changes in distant time zones. I know I do.

Exposure to Light: Get It Right

Your biggest help or hindrance to adjusting to the new time will be the sun. To calculate whether to step right out into the sunlight when you deplane or wear dark glasses during the first few hours of the trip, consider these things:

  • Time of arrival at your destination
  • Time difference between where you live and where you’re going
  • Time you normally get up in the morning

Your habitual rise time matters because of what it implies about daily changes in your core body temperature. Your temperature reaches a low point about 2 hours before you normally get up. Light exposure after your normal temperature low is going to advance your sleep cycle, which is what you want if you’re traveling east. Light exposure before that normal temperature low is going to delay your sleep cycle, making it even harder to adjust to time in a distant eastward zone.

Two Examples

Let’s say you live in the eastern time zone of the U.S., which is 5 hours behind London time. You book a night flight, leaving at 11 p.m. Eastern Daylight Time (EDT) and arriving in London at 11 a.m. British Summer Time (BST). Let’s say you typically get up 6:30 a.m., so your body temperature low would fall around 4:30 a.m. Your arrival time—11 a.m. BST, which is 6 a.m. EDT—occurs after your normal temperature low. Immediate exposure to sunlight upon landing will help adjust your body clock to British Summer Time.

But let’s say you book an earlier flight, leaving at 8 p.m. EDT and arriving at 8 a.m. BST—which is 3 a.m. EDT. This flight would get you into Heathrow before your normal body temperature low of 4:30 a.m. Immediate exposure to daylight upon arrival will push your sleep–wake cycle even further out of sync with the new time than it would otherwise be. This will make your jet lag worse.

If your flight arrives before your core body temperature low, keep plane shades drawn and wear dark glasses until you’re past the time of your normal temperature low. Only then is it going to work to your advantage to expose yourself fully to daylight.

Melatonin Supplements Can Help

Taking a melatonin supplement (sold over the counter in the U.S.) is another jet lag remedy, especially for travel across 5 or more time zones. Your body itself produces melatonin starting a few hours before your normal bedtime in physiological levels of about 0.3 mg. According to a 2015 review in Current Sports Medicine Reports, both low (0.5 mg) and high (3 to 5 mg) doses of supplemental melatonin—taken 1 to 4 hours before the desired bedtime at your destination—can advance the sleep cycle, which should help to prevent jet lag symptoms associated with eastbound travel.

Higher doses may put you to sleep sooner. They may also result in a “hangover” the next day. Melatonin has not been found to have other side effects in healthy human beings. But it is not recommended for people with epilepsy or those taking warfarin.

Comfort During Your Trip

No diet has been scientifically proven to reduce jet lag. Caffeinated beverages can of course perk you up when you’re flagging, but if you want to avoid some of the stomach upset associated with travel, remember in general to (a) stay well hydrated with nonalcoholic, noncaffeinated beverages on the plane and (b) eat plenty of fruit and vegetables. Anecdotal evidence coming out of Harvard suggests that fasting immediately prior to and during a flight, and then eating at the soonest mealtime after landing, may reduce symptoms of jet lag.

With that, I’ll wish you bon voyage and plenty of restorative sleep to power you through your trip!

9 Ways to Keep Worry From Sabotaging Sleep

These days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Insomnia sufferers should incorporate a bath into their bedtime routineThese days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Worrying Around the Clock

Worry and sleep don’t mix. Like anxiety, which is more intense, worry—or repetitive thinking about issues of concern—triggers the release of neurochemicals that prepare the body for action rather than for rest.

Some people are by nature inclined to worry day and night. Allison Harvey, in her cognitive model of insomnia (2002), hypothesized that round-the-clock worry about sleep led to arousal, resulting in the sleep problems experienced by insomniacs at night.

Worrying at Night

More recently, research has suggested that it’s worry in bed—rather than worry day and night, or trait-level worry—that is connected to trouble sleeping, and a new study published in Behavioral Sleep Medicine supports this conclusion. Researchers administered a series of questionnaires to 139 insomnia sufferers and had them complete sleep diaries every day for 10 days. Neither trait-level worry nor trait-level rumination (repetitive thinking about negative emotions) was shown to have a relationship with any aspect of sleep.

The researchers then conducted a similar study with another group of insomniacs. Sixty-four participants were asked to fill out two diaries: one at 6 a.m., to record the sleep-related worries experienced during the night, and the other at 7 p.m., to record sleep-related worry and stress experienced during the day.

The results? Nighttime sleep-related worry had a significant and negative effect on every aspect of sleep, including trouble falling asleep, being awake longer during the night, and sleeping less efficiently. In contrast, daytime sleep-related worry had a negative impact on sleep quality only.

“Cognitive activity during the day is relatively benign,” the study authors concluded, “but cognitive activity in bed plays an important role in development and persistence of sleep problems in insomnia.”

The Take-Away

Do your worrying during the daytime rather than at night!

Because that’s easier said than done, here are nine ways to check your worries—sleep-related or not—at the bedroom door.

  1. Write your worries down early in the evening. Preempt nighttime worrying by taking 10 or 15 minutes to write down the issues you’re worried about, whether or not they’re related to sleep. Beside each concern, write what action you’ve taken/you’re taking/you will take to deal with the problem. Some problems may be clearly outside your control (or feel that way), yet resolving to take some small action to manage the problem can afford relief.
  2. Share your worries with an empathic listener at dinner. Sharing your concerns with an empathic partner or friend over the evening meal can also help to preempt worry at night. And when it comes to figuring out how to deal with a problem, two heads are often better than one. Further, research suggests that regardless of who’s talking and who’s listening, interactions with friends and supportive family members help tone down stress.
  3. Create a pre-sleep routine. It’s important to end the day with a wind-down period (ideally, at least an hour) in the run-up to bedtime. Think of it as a time to indulge in self-care, incorporating activities that make you feel good—such as listening to slow jazz and bathing by candlelight. The aim is to create an end-of-day ritual that’s worry free. Doing the activities in the same sequence every night will establish a clear association between your wind-down routine and sleep.
  4. Train your attention on something outside yourself. Watch a movie or a sit-com. Read or listen to a novel with complex, interesting characters. Do a crossword puzzle or play a word game such as Scattergories (Pick a category: Food. Pick a letter of the alphabet: L. Think of all the foods that begin with the letter L.) If you can do so without disturbing others at home, play a musical instrument. Engaging your mind will free it from repetitive thinking and enable you to go to bed feeling more relaxed.
  5. Adjust your perspective with cognitive restructuring. Confront your worries head on by asking a series of questions to find out how realistic your repetitive thoughts about a worrisome situation really are. In the process you’ll often find your anxiety level going down. Click on cognitive restructuring to find out more.
  6. Do a low-key physical activity. Underlying worry and anxiety are neurochemicals that trigger the urge to fight or flee. Low-key physical activity, such as walking outside or around the house, enables you to work the stress out.
  7. Do a deep breathing exercise. Deep diaphragmatic breathing triggers the relaxation response, enabling the body to move out of fight-or-flight mode and into a relaxed and restful state. Sitting in a chair, slowly inhale to a count of 4, pause briefly, and exhale to a count of 4. Focus on your breathing. If you find your mind wandering, gently guide your attention back to your breathing. Repeat this cycle as many times as needed.
  8. Do progressive relaxation. Sitting or lying down, one by one, tense and release every group of muscles in your body. Start with the muscles in your toes and move upward through your trunk to your head. Then move downward through the arms to the fingers.
  9. Do a guided meditation. Allow someone else to lead you through meditations designed to quiet your mind and relax your body. Jon Kabat-Zinn, whose guided meditations are available on the internet, is a master at this.

Please share any strategies you’ve found to cut down on worry at night.

Tai Chi When Insomnia Isn’t the Only Problem

Insomnia combined with other health problems is bound to cause distress.

But help is at hand. New research shows that tai chi reduced insomnia symptoms in breast cancer survivors, suggesting that it may help with insomnia linked to other health problems, too.

Tai chi may improve sleep for insomnia sufferers with other health problemsA reader wrote yesterday asking for advice: “I’ve been reading through your website but have yet to see an article on how to manage sleep with chronic illness. I’m currently experiencing health challenges that are keeping me awake at night. What would you recommend for people experiencing health issues, especially moderate to severe ones?”

Insomnia combined with other health problems is bound to cause distress. But help is at hand. New research shows that tai chi reduced insomnia symptoms in breast cancer survivors, suggesting that it may help with insomnia linked to other health problems, too.

When Insomnia Is Not the Only Problem

Sometimes insomnia is the only health problem a person has. But insomnia more commonly occurs in conjunction with other health issues—everything from mood disorders and chronic pain to gastrointestinal problems and heart disease.

Part of the solution when you’re in this situation (sometimes referred to as comorbid insomnia) lies in getting treatment for the associated health problem. This will involve consulting a medical or psychiatric specialist.

But even when treatment is successful at controlling other health problems, trouble sleeping often persists. Women successfully treated for breast cancer have twice the rate of insomnia as occurs in the general population, as well as depression and fatigue. This is hardly surprising: A diagnosis of breast cancer is distressing in and of itself, never mind the invasive (although often effective) treatment options. But then you never know if or when the cancer might come back. Such chronic health concerns take an emotional toll that can interfere with sleep.

CBT for Insomnia Can Help

Cognitive behavioral therapy (CBT) is the gold standard in treatment for insomnia these days. This combination of sleep restriction, stimulus control, and talk therapy has been shown to be an effective treatment for insomnia in cancer survivors. Research shows it’s also effective in relieving insomnia in people with depression and people with other psychiatric and medical conditions.

But CBT for insomnia is not widely available nor can everyone afford it. Besides, it can be challenging to adhere to the protocol. CBT does not suit everyone.

UCLA investigators wanted to find a more accessible, less expensive type of therapy for breast cancer survivors experiencing insomnia that would equal CBT in efficacy. So they conducted a randomized, partially blinded study pitting CBT against tai chi.

Why Tai Chi?

Tai chi, a practice involving slow, flowing movement combined with meditation and deep breathing, is said to alleviate stress and anxiety and promote energy and stamina. In the words of the study’s authors, tai chi emphasizes “control over physical function and arousal-related responsiveness . . . through the mindful performance of repetitious, nonstrenuous, slow-paced movement.”

This type of activity might have an effect on sleep. And in fact a handful of studies have shown that tai chi does indeed relieve insomnia symptoms.

So investigators recruited 90 breast cancer survivors, aged 42 to 83 years, who were experiencing insomnia, depression, and fatigue. Half of them then received three months of weekly instruction in CBT for insomnia. The other half received three months of weekly instruction in a westernized form of tai chi called tai chi chih.

Impressive Results

At 15 months following the start of treatment (one year after treatment ended), nearly half of the participants in both groups showed marked improvement in their sleep, or complete or nearly complete remission of their insomnia symptoms. Both groups also experienced a robust reduction in fatigue severity and depression.

The novelty of this result is that for these survivors of breast cancer, the practice of tai chi chih resulted in sleep improvements equivalent to those obtained with CBT. Tai chi may be similarly useful for insomnia sufferers with other distressing health problems.

Lowering Arousal, Reducing Inflammation

The mechanisms by which tai chi relieves insomnia symptoms aren’t understood. But research has shown that tai chi:

  • Cuts down on arousal of the sympathetic nervous system. The sympathetic nervous system becomes active when you detect a threat, increasing vigilance and triggering bodily preparations to fight or flee.
  • Reduces inflammation. Inflammation is part of the body’s response to infection and tissue damage and is necessary to the healing process. But when inflammation becomes chronic it leads to disease.

Both arousal and inflammation have a negative effect on sleep. So it follows that a practice such as tai chi, which reduces them, might help.

Tai chi is worth checking into for people with comorbid insomnia and other distressing health conditions. Classes are offered in many locales. You can even learn tai chi by watching YouTube videos or using a smartphone app.

If you’ve practiced tai chi, what effect, if any, did it have on your sleep?

11+ Nighttime Activities for Sleep Restriction

Here’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

Sleep restriction less difficult with enjoyable activities that keep you awakeHere’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

A Trivial Topic? Think Again

Sleep restriction therapy involves first restricting your time in bed to just the number of hours you’re actually sleeping. Then you gradually add time in bed until you find your ideal sleep window. Normally, this means starting therapy with a later-than-usual bedtime, an earlier-than-usual rise time, or both.

If you’re new to sleep restriction, planning what to do in the run-up to a later bedtime may seem unnecessary.

“I’ll read,” you say, “I’ll watch TV, I’ll catch up with friends on Facebook. I’ll do what I always do at night, only I’ll stay up longer.”

Sticking to the familiar may not work and here’s why:

The first week you’re restricting your sleep you’ll probably feel somewhat sleep deprived. If even mild sleep deprivation is involved, passive activities like watching TV and reading can lead to nodding off well before the prescribed bedtime. This interferes with establishing a regular sleep schedule, which is one thing you’re trying to accomplish. The more you stick to your prescribed bed and wake times, the quicker the therapy will take effect.

Devices with screens (computers, iPads, iPhones) emit blue light, which blocks secretion of the sleep-friendly hormone melatonin. It’s helpful to install an app called f.lux or wear blue-blocker glasses if you use devices at night. Even so, being wedded to the screen in the hour leading up to bedtime is not a good idea, especially for people with sleep onset insomnia (people whose insomnia occurs at the beginning of the night).

Other Constraints on Nighttime Activities

Evening activities have to be quiet unless you live alone. Playing the saxophone may be fun for you but obviously not for other members of the household.

Evening activities can’t require a lot of physical or mental stamina. By then you’re usually low in the tank.

A walk outside might have appeal. But depending on who you are and where you live, it may not be safe to leave home after dark.

The Special Challenge of Sleep Anxiety

What to do in the run-up to bedtime can be especially challenging for sleep onset insomniacs, whose anxiety about sleep tends to escalate the later it gets. Clock watching adds to (or is a part of) that sleep-related anxiety. When undergoing sleep restriction there’s no getting around use of the clock for information about when it’s OK to go to bed.

Waiting until anxiety sets in to decide what to do can be risky. A glass of wine? A sleeping pill? You’re off the rails before you’ve even begun. Why add stress to the sleep restriction process by waiting too long to decide what you’re going to do in the extra time you’re up?

Take it from one who’s been there twice and who, knowing what she knows now, would do it somewhat differently. In the week before you start restricting your sleep (as you’re collecting information about your sleep and recording it in your sleep diary), come up with a list of activities you’re going to do when restriction begins, acquiring any supplies you’ll need in advance. Ideally, these activities should (a) be somewhat enjoyable (or at least tolerable), (b) offer mild mental stimulation, and/or (c) involve some movement.

This list of activities is hardly comprehensive. But maybe it will motivate you to come up with other activities that would suit you as well or better.

  1. Do (or Take Up) an Art or Craft:

  • Needlework (quilting, knitting, crocheting, embroidery).
  • Jewelry or beadwork.
  • Woodworking or leatherworking
  • Calligraphy.
  • Origami.
  • Sewing. Lay out a pattern and cut the fabric.
  • Any artistic activity, such as sketching or watercolor painting, as long as it doesn’t require much clean up.
  1. Make Lists:

  • To-do lists and grocery lists.
  • Travel checklists for different kinds of trips (road trips, air travel [overseas and domestic], business trips, camping.) Printed out before each trip, they make packing a lot easier.
  • Gift lists. Avoid panic during the holidays and at birthdays and other special occasions.
  • A bucket list. Think of everything you’d like to see and do while you’re still able to do it.
  1. Organize or Reorganize:

  • Your tool bench.
  • Your jewelry box(es).
  • Your music. If you have CDs, tapes, albums, or sheet music, arrange them by style, period, composer, or instrument.
  • Your herbs and spices. Group them as powders, whole spices, and herbs, or arrange them alphabetically.
  • The garage or the basement.
  1. Sort and Discard:

  • Books. Do one shelf at a time, separating them into keepers, throw-aways, and give-aways.
  • Clothing in closets and drawers.
  • Old photos. Put the ones you want to keep into albums or photo boxes.
  1. Redecorate:

  • Your walls. Take down wall art and replace it with other paintings, photos, prints, or posters.
  • Your shelves. Replace pottery and art objects with others.
  1. Bake Cookies or a Coffeecake.

  2. Do Light Housework:

  • Dust furniture.
  • Fold or iron clothes.
  1. Prepare for the Day Ahead:

  • Set the breakfast table.
  • Pack lunches.
  • Do prep work for the evening meal.
  1. Do Things You Enjoyed in the Past:

  • Play Solitaire.
  • Do a thousand-piece jigsaw puzzle.
  • Get out a telescope, look at the stars, and identify constellations.
  • Gather every small thing you’ve collected outdoors—flowers, nuts, leaves, shells, stones, feathers, pine cones—and look at them under a microscope.

The following two categories of activities may be too passive for some people but could work if combined:

  1. Look at Publications with Images:

  • Art books.
  • Coffee table books.
  • Catalogs.
  • Family albums.
  • Cookbooks. Use a post-it note to mark every recipe you want to try out.
  1. Using Headphones, Listen to:

  • Music.
  • Books on CD.
  • A podcast. (But avoid looking at screens.)

Before you start to restrict your sleep, make a list of activities you’re going to do in the run-up to bedtime. And who knows? You might even enjoy some of that extra time awake.

If you’ve gone through sleep restriction, what activity did you find was most helpful in keeping you awake till bedtime?

A Different Pathway to Chronic Insomnia

Let’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

Stress and poor sleep can lead to chronic insomnniaLet’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

How Insomnia Develops

For decades sleep scientists have been trying to work out how chronic insomnia develops. The main model they’ve proposed looks something like this:

  1. Predisposing factors are presumed to exist in everyone who develops chronic insomnia. They include such observable factors as (a) parental history of insomnia, (b) high sleep reactivity (a tendency to sleep poorly before and after stressful events such as giving a speech or having an argument; and to be highly reactive to caffeine, jet lag, and interpersonal stressors), and (c) poor health—all associated with biological challenges to sleep.
  2. Precipitating factors come next: major life stressors that often trigger an episode of insomnia such as a job loss, marriage, or relocation to a different town.
  3. Perpetuating factors are the habits some people then adopt for insomnia relief—taking naps, going to bed early, sleeping in on weekends—that actually make their sleep worse.
  4. Conditioned arousal of the cerebral cortex is the final step in in the process. Lying awake for long stretches of the night opens the door to worry and rumination. This brain activity can spill over into sleep and keep insomnia going indefinitely.

This may be how chronic insomnia develops in some people. There may also be alternative pathways to insomnia. A large community-based study (Evolution of Pathways to Insomnia Cohort) was recently conducted to figure out what those alternative pathways might be. Working with data from that study, Michigan researchers have concluded that even people who have no evident predisposition to insomnia may develop chronic insomnia through a process involving sleep system sensitization. Here’s more on what they found.

From Normal Sleep to Insomnia in Just One Year

In this prospective study, thousands of participants filled out a series of questionnaires at the start of the study and one and two years later. The Michigan researchers looked at the 262 participants who did not have insomnia at the start of the study but who, by year 1, had developed it.

These participants might be expected to have characteristics predisposing poor sleep from the start (a mother with insomnia, for example, or high sleep reactivity). But not all of them did. A total of 60 participants tested low for sleep reactivity at the start of the study (on the Ford Insomnia Response to Stress Test, or FIRST). But by year 1, these 60 people had jumped an average of 4 points on the FIRST, indicating a significant increase in sleep reactivity. Over two-thirds went from low sleep reactivity to very high sleep reactivity following major life stress and the onset of insomnia in the space of just one year. At year 2, the high sleep reactivity persisted regardless of whether their insomnia was chronic or not.

A Different Path to Chronic Insomnia

In a nutshell, here’s the take-away:

  • People with apparently low vulnerability to insomnia (like the person described at the beginning of this blog post) can develop high sleep reactivity in conjunction with major life stress and an episode of insomnia.
  • Stress exposure leading up to insomnia appears to sensitize the sleep system. This lends support to the idea that insomnia itself may be a perpetuating factor in chronic insomnia. Every episode may trigger neurobiological changes that increase the risk of subsequent bouts of insomnia, just as every experience of depression increases the risk of future depression.
  • High sleep reactivity, once it develops, is persistent.

No matter how or why your insomnia develops, don’t wait to look for help. Take action right away.

Q&A: Can’t Sleep Due to Temperature Sensitivity

A reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia sufferers may have increased temperature sensitivity at nightA reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia and Thermosensitivity

Insomnia may have something to do with compromised thermoregulation, but the issue has not been fully investigated, say authors of a paper on sleep and thermosensitivity. Evidence shows that older adults may have an impaired ability to recognize the most comfortable temperature for sleep, and this may relate to abnormalities in the area of the brain that evaluates comfort. Not much else is known.

But I’m never surprised when people complain of trouble sleeping related to temperature sensitivity. I have the problem myself. I’ve gone to bed in very hot and very cold situations and lain awake for a good chunk of the night. Like Gunjan, I regularly have to make small temperature-related adjustments in the middle of the night. Now, with some nights warm and others cool, is the season when it’s trickiest to get it right.

Temperature Changes at Night

Core body temperature varies by about 1.5 degrees Fahrenheit over the course of the 24-hour day. From a temperature high in the evening, it descends and reaches its low point some 1 to 3 hours before normal wake-up time. If you keep the bedroom windows open at night (a cool bedroom is good for sleep), the room temperature will likely drop as well. The combination of internal and environmental temperatures falling could easily explain why you might wake up feeling cold at night.

Covering yourself with a blanket or a bed sheet is the obvious way to make yourself comfortable enough to get back to sleep. But what if, like Gunjan, you then feel too hot?

Covering up can create a closed system where, once the skin temperature has risen enough to dilate the blood vessels close to the skin, the body heat then released has no place to go. It’s similar to the situation created by an electric blanket. The blanket continues to add heat to the body, increasing skin and core body temperatures. The heat the body would normally throw off is then trapped underneath the blanket. You wake up feeling too hot to sleep.

Here are two ways to keep from overheating at night:

  • Use sheets and blankets made of a breathable fabric such as cotton. Fabrics like polyester are more likely to trap heat rather than allow for its release.
  • When you cover up, see if keeping your feet outside the covers helps. You lose lots of heat through your extremities, so keeping them uncovered, or partially covered, may make you comfortable enough to sleep through the night.

Help for Sleep Onset Insomnia

It’s easier to go to sleep when core body temperature is falling, and people who have problems falling asleep—sleep onset insomnia—may have trouble cooling down at night.

Ideally, the temperature in the bedroom should be a little lower than is comfortable during the day. But there are also ways to facilitate internal heat loss. Activities that increase skin temperature eventually help to cool you down. Warming the skin dilates blood vessels close to the skin. This enables the release of body heat and a lowering of core body temperature to occur for a few hours after the activity ends, in turn facilitating sleep.

Early in the evening these activities may trigger processes that help you fall asleep:

  • Take a hot shower or bath
  • Spend time in a sauna
  • Do a resistance workout or aerobic exercise

As you’re winding down on cooler nights, mild heating of the hands and feet may dilate the blood vessels enough to facilitate heat loss, lowering your core body temperature and inducing sleep. But this is a losing strategy on the warmer nights. Lightly clad and barefoot is the way you want to be.

If you’re sensitive to temperature changes at night, what have you found that helps?

Exercise Improves Sleep, Preserves Mental Fitness

You may have been a couch potato for most of your life, but now, if you’re middle-aged and envisioning a healthy retirement, you’d better change your ways.

Moderate-to-vigorous exercise can mitigate some effects of aging, including poor sleep quality and cognitive decline. Research generally supports this claim, so especially if you’re prone to insomnia, you’ll want to check this out.

Insomnia and mental decline can be alleviated with exercise
Me, returning from my first bike ride this year

You may have been a couch potato for most of your life, but now, if you’re middle-aged and envisioning a healthy retirement, you’d better change your ways.

Moderate-to-vigorous exercise can mitigate some effects of aging, including poor sleep quality and cognitive decline. Research generally supports this claim, so especially if you’re prone to insomnia, you’ll want to check this out.

Age-Related Sleep Problems and Exercise

Sleep tends to be less robust as we age. Middle-aged and older adults get less deep sleep (the restorative stuff) than younger people. Our sleep is less efficient, too, peppered with wake-ups during the night. In the morning, we wake up feeling less rested, with fewer resources to meet the demands of the day.

Investigators are now looking at lifestyle factors that might alleviate aged-related sleep problems. A majority of studies suggest that both male and female exercisers tend to experience better sleep quality and fall asleep more quickly than people who don’t exercise.

Newer Data From Objective Tests

The majority of such studies are based on reports from participants rather than objective tests. In two more recent studies, investigators used objective measures to assess the relationship between participants’ level of physical activity and their sleep.

The SWAN Sleep Study was an observational study involving 339 middle-aged women. Over 6 years, investigators collected data on their activity level in three domains: (1) Active Living (activities like watching TV and walking to work), (2) Household/Caregiving (housework and childcare), and (3) Sports/Exercise (recreational activities and sports).

Toward the end of the 6-year period, the women underwent in-home polysomnography (a sleep study) every night during one entire menstrual cycle or 35 days, whichever was shorter. They also kept sleep diaries and filled out sleep-related questionnaires.

Altogether this made for a lot of data on a lot of women. The findings reported here are both significant and clinically important:

  • Activities in the Active Living and Household/Caregiving categories had little impact on women’s sleep. Women typically spend a lot of time doing these activities, yet they may not be vigorous enough to affect our sleep.
  • Women with high Sports/Exercise activity over the 6-year period experienced better sleep, especially on measures of sleep quality and sleep continuity.
  • Greater recent Sports/Exercise activity was associated with better sleep quality and better sleep continuity—and more deep sleep (insomnia sufferers, take note!).

What About Men?

Routine exercise has similar benefits for men, a small exercise intervention study showed. Via polysomnography, the sleep of 13 men aged 60 to 67 was assessed 3 nights before and 3 nights after they participated in a 16-week exercise program. The program consisted of regular 60-minute workouts on the treadmill. The workouts were fairly rigorous and the results, impressive. Compared with their sleep before starting the exercise program, by the end of the program the men’s sleep

  • had significantly greater continuity. Acute exercise reduced their nighttime wakefulness by 30%.
  • was significantly deeper. On nights following exercise, they experienced a 71% increase in slow-wave (deep) sleep. (That 71% is not a typo, by the way!)

Exercise Protects Mental Fitness

If the sleep benefits of exercise don’t move you to action, maybe the high cost of inactivity to your brain will. Regular exercise helps improve cognitive function and protects against cognitive decline. How it does so has yet to be worked out, but one theory holds that exercise has a beneficial effect on the brain due to its positive effect on cerebral blood flow. For optimal functioning the brain has to have adequate blood flow. Moderate-intensity exercise increases blood flow to the brain in healthy adults.

But blood vessels may lose their ability to respond normally in the brain and elsewhere, a situation called vascular dysfunction, which is associated with cardiovascular disease. Systemic vascular dysfunction will likely reduce blood flow to the brain and manifest as cognitive impairment.

“Vascular dysfunction and altered blood flow regulation may be a key link between cardiovascular disease and cognitive decline,” writes Jill N. Barnes in a paper titled Exercise, Cognitive Function, and Aging.

Protecting vascular health—which typically declines with age—may also protect against cognitive decline. Barnes cites a few studies that suggest that exercise is the key to protecting vascular functioning. A few other human studies show that both aerobic exercise and strength training help maintain cognitive fitness. In addition, animal studies have shown that sustained aerobic exercise promotes the growth of new nerve cells in the hippocampus, a part of the brain associated with memory.

So particularly if you’re middle aged or older and prone to inactivity, check into starting an exercise program now. It will improve your physical and mental health and—perhaps more relevant if you’re looking for help with insomnia—it will likely improve your sleep.