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Too early to get up, too late to get back to sleep

You wake up and look at the clock: it’s 3 a.m. You tell yourself you’ve got to get back to sleep, but thoughts about yesterday’s troubles, the coming day’s challenges, and all those “must-do’s” race through your mind. You toss and turn and worry about not getting enough sleep. Maybe you doze off for an hour or so, but when the alarm clock gets you up for the day, you’re far from rested.

Insomnia — inability to get the sleep you need to wake up refreshed — is the most common sleep complaint in the United States. It often takes the form of sleep-maintenance insomnia — that is, difficulty staying asleep, and in particular, waking too early and struggling to get back to sleep. Like difficulty falling asleep at the beginning of the night, called sleep-onset insomnia, sleep-maintenance insomnia is more common in women than in men.

Midlife is often a time of psychological stress: children may be leaving home, a partner may be lost through death or divorce, and roles may be changing at home and work. Health problems — pain, depression, or a sleep disorder such as sleep apnea — may be part of the picture as well. Another problem is that as we grow older, the normal sleep cycle becomes shorter, and we spend less time in deep sleep.

Whatever the original cause, difficulty staying asleep often gives rise to worry over not getting enough sleep, and a vicious cycle develops in which this worry itself becomes the main source of insomnia.

Fortunately, there are many things you can do to remedy sleep-maintenance insomnia. It’s especially important to develop habits that promote healthful sleep, through a collection of practices called sleep hygiene.

Sleep hygiene tips

Stay away from stimulants. Avoid caffeinated beverages  after 1 or 2 p.m. — or altogether. Caffeine blocks the effects of adenosine, a brain chemical thought to promote sleep.

Limit alcohol to no more than one drink a day. Alcohol interferes with deep sleep and can interfere with breathing.

Stop smoking. Nicotine makes it harder to fall asleep and harder to stay asleep.

Don’t nap if you can avoid it. If you can’t stay awake in the afternoon, take a 15- to 20-minute nap — that’s usually long enough to improve alertness but not so long that you feel groggy afterward.

Exercise. Getting regular aerobic exercise can help you fall asleep faster, get more deep sleep, and awaken less often during the night. But avoid exercise within a few hours of bedtime.

Set a sleep schedule. Once you determine how much time in bed you need, go to bed each night and get up each morning at the same time.

Make your bedroom a sleep sanctuary. Reserve it for sleep, intimacy, and restful activities such as meditation and reading for pleasure. Keep it cool, dark, and quiet.

Establish a relaxing routine before bedtime. Consider meditation, a warm shower, listening to quiet music, or some simple stretches to loosen muscles.

Relaxation techniques

You can’t get back to sleep if your mind is racing or your muscles are tense. To calm the mind and relax the muscles, consider meditation, deep breathing, progressive muscle relaxation, or biofeedback. You can learn most of these techniques by taking classes or on your own from books, CDs, or DVDs.

Practicing relaxation techniques during the day for 15 or 20 minutes not only offers many health benefits, it also establishes a routine that you can invoke when you wake up in the middle of the night.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) teaches you new ways to think about problems in your life and better strategies for dealing with those problems. Research has shown that CBT provides better long-term relief for insomnia, especially primary insomnia, than sleep medications.

First steps

If you have any ongoing sleep problem, especially if it results in daytime sleepiness, see your primary care provider to investigate the possible causes. You may need a change in medications or treatment for an underlying medical condition.

One of the best aids in figuring out sleep problems is a sleep diary. For a week or two, keep track of your sleep patterns — especially how much time you spend in bed and how much of that time you’re awake.

To establish a more restorative sleep pattern, try going to bed later. Estimate from your diary how much sleep you actually get each night. If you get six hours and you need to wake up at 6 a.m., then don’t go to bed until midnight — even if you feel sleepy before then. When you’ve been able to sleep most of your allotted six hours for five to seven days, go to bed 15 minutes earlier, repeating the process until you reach optimal sleep efficiency: 85% or more of your time in bed spent sleeping. This technique, called sleep restriction, may at first make you feel sleep-deprived, but it can be very effective if you stick with it, while also continuing other efforts to improve sleep, including sleep hygiene and the relaxation and cognitive behavioral strategies.

August 2010 update

Improving Sleep: A guide to a good night's rest

When you wake up in the morning, are you refreshed and ready to go, or groggy and grumpy? For many people, the second scenario is all too common. This report describes the latest in sleep research, including information about the numerous health conditions and medications that can interfere with normal sleep, as well as prescription and over-the-counter medications used to treat sleep disorders. Most importantly, you’ll learn what you can do to get the sleep you need for optimal health,... Learn more »