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

JUL 2010

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Sleep-maintenance insomnia is a common complaint among women at midlife.

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.

For many reasons, women transitioning through midlife may be more vulnerable to sleep disturbances. 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. (Depression is strongly associated with chronic early morning awakening and inability to get back to sleep.) And though their role in awakenings and sleep arousals is still controversial, hot flashes may compound a woman's difficulty in staying or falling back asleep.

Another problem is that as we grow older, the normal sleep cycle becomes shorter, and we spend less time in deep sleep. According to Dr. Karen Carlson, who conducts classes on improving women's sleep quality at Boston's Massachusetts General Hospital, "What sometimes happens is that women are going to bed early trying to sleep and then they wake up at 3 or 4 a.m. — and they're not really meant to sleep more than six or seven hours, but they're in bed early trying, and they awaken early."

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. Cognitive and behavioral techniques have proven effective, and you should usually try them before considering medications. It's especially important to develop habits that promote healthful sleep, a collection of practices called sleep hygiene. (See "Sleep hygiene tips.")

Sleep hygiene tips

Stay away from stimulants. Avoid caffeinated beverages (coffee, many teas, chocolate, and some soft drinks) after 1 or 2 p.m. — or altogether, if you're especially caffeine-sensitive. Caffeine blocks the effects of adenosine, a brain chemical thought to promote sleep. Limit alcohol to no more than one drink a day, preferably taken at least two hours before bedtime. Alcohol interferes with deep sleep and can interfere with breathing. Stop smoking, and avoid secondhand smoke. 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. Don't nap at all in the evening before you go to bed. (And no falling asleep in front of the television!)

Exercise. Getting regular aerobic exercise such as walking, jogging, or swimming 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. A regular sleep schedule helps synchronize your sleep/wake cycle. 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. To block out noises, use a fan or other appliance that produces a steady "white noise." Make sure your mattress is comfortable.

Eat sensibly. Finish dinner several hours before bedtime. If you need a snack in the evening, eat a small serving of something you know won't disturb your digestion, such as applesauce, yogurt, cereal and milk, or toast and jam.

Don't watch the clock. Watching the sleepless minutes pass makes it harder to fall back to sleep in the wee hours. Turn the clock face so you can't see it.

Establish a relaxing routine before bedtime. Consider meditation, a warm shower, listening to quiet music, or some simple stretches to loosen muscles. Avoid activities that might cause stress, such as work or emotional discussions.

Limit fluids before bedtime. To minimize nighttime trips to the bathroom, don't drink anything during the two or three hours before bedtime.

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. (For a list of medications that can interfere with sleep, go to www.health.harvard.edu/womenextra.) Or if life events are distressing you, seeing a mental health professional could help.

But sleep-maintenance insomnia is usually a primary insomnia — meaning that there's no obvious medical or psychiatric cause. Your clinician (or a sleep specialist, if you've been referred to one) will ask about your lifestyle, your habits, and when, where, and how you sleep. She or he may also inquire about your thoughts on sleep and sleep loss, because people who sleep poorly often have ideas about sleep that contribute to insomnia. A 2010 study published in the Journal of Psychosomatic Research found that compared with good sleepers, poor sleepers were more likely to believe, for example, that they needed eight hours of sleep to function; that they couldn't function the next day if they didn't have enough sleep; and that they couldn't cope with the consequences of disturbed sleep. Cognitive techniques (see "Cognitive behavioral therapy") can help change such beliefs.

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. "This gets into the whole concept of sleep efficiency," says Dr. Carlson. "If you're spending less than 80% of your time in bed asleep, you're probably spending too much time in bed."

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. And don't nap during the day. 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 listed below. If you find that you're falling asleep too early in the evening, keep the lights up bright where you're sitting or working. This can slow the release of the hormone melatonin, which rises when it's dark, promoting sleep, and falls when it's light, promoting wakefulness.

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. For biofeedback, which monitors physiological states such as muscle tension and hand temperature, you need special equipment and the aid of a specialist. During biofeedback, you learn how to control tension by sensing how it is affected by various thoughts and relaxation techniques.

Progressive muscle relaxation involves alternately tensing and relaxing muscles throughout your body, starting with your feet and working your way up. The purpose of deep breathing (also known as diaphragmatic breathing) is to replicate the way you breathe during sleep (slow and from the diaphragm), as opposed to the faster and shallower way you breathe when you're awake. Meditation typically involves sitting quietly and using an image, a repeated phrase, or rhythmic breathing to focus attention and quiet the mind. A form of meditation called visualization helps you mentally distance yourself from stress by imagining a place that makes you feel at peace — say, a seaside retreat or a quiet garden — and thinking about what you see, hear, feel, smell, and taste there.

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. (For instructions on how to perform these relaxation techniques, go to www.health.harvard.edu/womenextra.)

Selected resources

"Conquering Insomnia"
www.cbtforinsomnia.com

This cognitive behavioral therapy program, developed by Dr. Gregg Jacobs at Harvard Medical School and the University of Massachusetts Medical Center, can be purchased as an online program or in CD format ($29.95).

"Healthy Sleep"
healthysleep.med.harvard.edu

Created by Harvard Medical School's Division of Sleep Medicine and the WGBH Educational Foundation, this Web site discusses the science of sleep and ways to get the sleep you need.

American Academy of Sleep Medicine
www.aasmnet.org
www.sleepeducation.com
708-492-0930

National Sleep Foundation
www.sleepfoundation.org
202-347-3471

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.

People with insomnia often become preoccupied with sleep and the consequences of poor sleep, replaying unproductive thoughts as they lie awake. These thoughts may include misattributions ("When I feel nervous during the day, it's because I didn't sleep well the night before"), unrealistic expectations ("I must get eight hours of sleep tonight"), and exaggerated fears ("If I don't get to sleep soon, I'll mess up at work tomorrow"). A cognitive behavioral therapist will work with you to substitute more accurate and constructive thoughts ("My job doesn't depend on how much sleep I get tonight"; "I'll probably sleep better tonight").

The biggest obstacle to successful CBT treatment is failure to stick with it. Some people don't complete all the required sessions (usually one session per week for four to six weeks); others stop practicing the techniques after having used them for a time. Internet-based programs, which people can practice on their own and at their own pace, might help address this problem. Several small studies suggest online CBT programs that teach good sleep hygiene, relaxation techniques, and other strategies can help people with insomnia sleep better. (For two online programs, see "Selected resources.")