A Harvard Medical School Special Health ReportImproving Sleep A guide to a good night’s rest In this report: Diagnosing sleep problems Practical tips for sounder sleep Sleep apnea solutions Special Bonus Section Dangers of sleep deprivation Price: $26 This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/ Harvard Health Publications Copyright Notice This report is copyrighted by Harvard University and is protected by U.S. and international copyright. All rights reserved. Here’s what you CAN do • Print out one copy and route this “original” to family. • You are permitted to have one copy of this publication on your computer at any time (you can’t put it on a network unless you purchased a license to do so). If you have paid for more copies, then you may have that many copies on computers at any time. • Copy, on an occasional basis, a couple of pages to give to friends, family members, or colleagues. • We are registered with the Copyright Clearance Center (CCC). You can comply with the copyright laws by paying a royalty on copies you make of passages. But not even the CCC can authorize cover-to-cover photocopying or wholesale electronic forwarding. • If you want to distribute copies of this publication, either in print or electronic form, to others on a regular basis, ask us about bulk discounts or licensing opportunities. You may be able to negotiate an agreement, for a single fee, that would enable you to legally distribute photocopies or electronic copies to others. Here’s what you CAN’T do (without prior permission) • Make or forward e-mail copies of an entire publication. The law provides for a very limited amount of copying, commonly referred to as “fair use.” However, cover-to-cover photocopy ing is forbidden. • Electronic transmission of a copyrighted work is the legal equivalent of photocopying it (and so is posting it on the Internet or in an electronic database), and is therefore not allowed. • Routinely copy and distribute portions. • Republish or repackage the contents. Some publishers must resort to lawsuits to protect their publications. Harvard Health Publications would like to eliminate the need for such suits by helping to educate customers. We hope this outline has helped explain what is legal, and what is not. For more information Copyright Clearance Center Telephone: 508-750-8400 www.copyright.com Permissions Requests Dawn Scott, Harvard Health Publications
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[email protected] Telephone: 888-456-1222 x31110 (toll-free) Harvard Health Publications Harvard Medical School 10 Shattuck Street, 2nd Floor Boston, MA 02115-6011 U.S.A. www.health.harvard.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/ improving sleep SPECIAL HEALTH REPORT Medical Editor Lawrence Epstein, M.D. Instructor in Medicine, Harvard Medical School Division of Sleep Medicine, Brigham and Women’s Hospital Medical Director, SleepHealth Centers, Brighton, Mass. Contents Sleep mechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Quiet sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dreaming (REM) sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sleep architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Your internal clock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 4 4 Sleep throughout life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Editor Julie Corliss Editor, Special Health Reports Kathleen Cahill Allison special bonus section: Dangers of sleep deprivation . . . . . . . . . . . . . . . . . . . . . . . 9 Art Director Heather Derocher General ways to improve sleep. . . . . . . . . . . . . . . . . . . . . 14 Production Editors Mary Kenda Allen Melissa Rico Illustrator Scott Leighton Michael Linkinhoker Published by Harvard Medical School Anthony L. Komaroff, M.D., Editor in Chief Edward Coburn, Publishing Director Copyright ©2010 by Harvard University. Written permission is required to reproduce, in any manner, in whole or in part, the material contained herein. Submit reprint requests in writing to: First-line strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Medical conditions and sleep problems. . . . . . . . . . . . . . 16 Illnesses that affect sleep. . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Types of insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . First-line treatment: Behavioral changes. . . . . . . . . . . . . . . . . . Prescription medications for insomnia . . . . . . . . . . . . . . . . . . Over-the-counter sleep aids. . . . . . . . . . . . . . . . . . . . . . . . . . . 20 20 22 25 Breathing disorders in sleep. . . . . . . . . . . . . . . . . . . . . . . 27 Harvard Health Publications 10 Shattuck St., 2nd Floor, Boston, MA 02115 617-432-1485 Fax: 617-432-4719 Snoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Sleep apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Web Site Movement disorders and parasomnias. . . . . . . . . . . . . . . 33 For the latest information and most up-to-date publication list, visit us online at www.health.harvard.edu. Customer Service Movement disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Parasomnias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 For all subscription questions or problems (rates, subscribing, address changes, billing problems) call 877-649-9457, send an e-mail to
[email protected], or write to Harvard Health Publications, P.O. Box 9308, Big Sandy, TX 75755-9308. Narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Ordering Special Health Reports Disturbances of sleep timing. . . . . . . . . . . . . . . . . . . . . . . 40 For multiple-copy discount rates, please write or call: StayWell Consumer Health Publishing, Attn: SR Bulk Orders, One Atlantic Street, Suite 604, Stamford, CT 06901 203-653-6270 (toll-free: 888-456-1222, ext. 31110). Delayed sleep phase syndrome. . . . . . . . . . . . . . . . . . . . . . . . Advanced sleep phase syndrome. . . . . . . . . . . . . . . . . . . . . . . Jet lag. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sunday insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seasonal affective disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . For corporate sales and licensing, please e-mail: jmitchell @ staywell.com. Evaluation of sleep disturbances . . . . . . . . . . . . . . . . . . . 43 Harvard Medical School publishes Special Health Reports on a wide range of topics. To order copies of this or other reports, please see the instructions at the back of this report, or go to our Web site: www.health.harvard.edu. ISBN 978-1-935555-18-6 The goal of materials provided by Harvard Health Publications is to interpret medical information for the general reader. This report is not intended as a substitute for personal medical advice, which should be obtained directly from a physician. Symptoms of narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Treatments for narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 40 40 40 41 41 42 When to seek help. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Sleep laboratory evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Home-based tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 The benefits of good sleep . . . . . . . . . . . . . . . . . . . . . . . . 47 Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/ Dear Reader, How do you feel 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. Sleep-related problems affect 50 million to 70 million Americans of all ages. Insomnia—trouble falling or staying asleep—is the most common complaint, but other chronic disorders, including sleep apnea, restless legs syndrome, or narcolepsy, can also contribute to a shut-eye shortfall. And some people simply stay up too late—usually because they’re watching late-night TV, according to a national time-use survey of more than 21,000 adults. Logging long hours on the computer is another common cause of sleep loss. Regardless of the reason, one in five Americans sleep less than six hours a night—a trend that can have serious personal and public health consequences. Insufficient sleep can make you too tired to work efficiently, to exercise, or to eat healthfully. Over time, sleep deprivation increases the risk for a number of chronic health problems, including obesity, diabetes, and heart disease (see “Special Section: Dangers of sleep deprivation,” page 9). What’s more, 54% of American adults—as many as 110 million licensed drivers—have driven when drowsy at least once in the past year. Drowsy driving is one of the most common causes of crashes in all modes of transportation, resulting in 8,000 deaths and 60,000 debilitating injuries each year. Even though many people acknowledge that sleep is important, few seek treatment for their sleep problems. If you aren’t getting your share of sleep, you needn’t fumble about in a fog of fatigue. This report describes the complex nature of sleep and the latest in sleep research, including the discovery of a genetic mutation that controls sleep duration. It also describes 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. Information about the diagnosis and treatment of sleep apnea, an under-recognized yet life-threatening sleep disorder, is also included. Most importantly, you’ll learn what you can do to get the sleep you need for optimal health, safety, and well-being. Sincerely, Lawrence Epstein, M.D. Medical Editor Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115 This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/ Sleep mechanics F or centuries, scientists scrutinized minute aspects of human activity, but showed little interest in the time that people spent in sleep. Sleep seemed inaccessible to medical probing and was perceived as an unvarying period of inactivity—a subject best suited to poets and dream interpreters who could conjure meaning out of the void. All that changed in the 1930s, when scientists learned to place sensitive electrodes on the scalp and record the signals produced by electrical activity in the brain. These brain waves can be seen on an electroencephalogram, or EEG (see Figure 1), which today is captured on a computer screen. Since then, researchers have gradually come to appreciate that sleep is a highly complex activity. Figure 1 EEG brain wave patterns during sleep Alpha waves Relaxed wakefulness Stage N1 Theta waves Stage N2 K-complex Sleep spindles Stage N3 Delta waves REM or dreaming sleep These brain waves, taken by electroencephalogram, are used by sleep experts to identify the stages of sleep. Close your eyes and your brain waves will look like the first band, “relaxed wakefulness.” Theta waves indicate stage N1 sleep. (The “N” designates non-REM sleep.) Stage N2 sleep shows brief bursts of activity as sleep spindles and K-complex waves. Deep sleep (stage N3) is represented by large, slow delta waves. 2 Improving Sleep Using electrodes to monitor sleepers’ eye movements, muscle tone, and brain wave patterns, they identified several discrete stages of sleep. And today, researchers continue to learn how certain stages of sleep help to maintain health, growth, and functioning. Scientists divide sleep into two major types: rapid eye movement (REM) sleep or dreaming sleep, and non-REM or quiet sleep. Surprisingly, they are as different from each other as either is from waking. Quiet sleep Sleep specialists have called non-REM or quiet sleep “an idling brain in a movable body.” During this phase, thinking and most physiological activities slow down, but movement can still occur, and a person often shifts position while sinking into deeper stages of sleep. To an extent, the convention of describing people “dropping” into sleep actually parallels changes in brain wave patterns at the onset of non-REM sleep. When you are awake, billions of brain cells receive and analyze sensory information, coordinate behavior, and maintain bodily functions by sending electrical impulses to one another. If you’re fully awake, the EEG will record a messy, irregular scribble of activity. Once your eyes are closed and your nerve cells no longer receive visual input, brain waves settle into a steady and rhythmic pattern of about 10 cycles per second. This is the alpha-wave pattern, characteristic of calm, relaxed wakefulness. The transition to quiet sleep is a quick one that might be likened to flipping a switch—that is, you are either awake (switch on) or asleep (switch off), according to research. Some brain centers and pathways stimulate the entire brain to wakefulness; others promote falling asleep. One chemical, hypocretin, seems to play an important role in regulating when the flip between states occurs and keeping you in the new state. Interestingly, people with narcolepsy (see page 38) often www.health.har vard.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/ Researchers have also detected increased blood levels of substances that activate your immune system.lack hypocretin. he or she will pass quickly through the lighter sleep stages into the deeper stages and spend a greater proportion of sleep time there. Normally. and pulse rate slows to about 20% to 30% below the waking rate. If they were prevented from having REM sleep. which creates the fight-or-flight response. Studies of students’ ability to solve a complex puzzle involving abstract shapes suggest the brain processes information overnight. Body temperature begins to drop. not everyone experiences stage N1 sleep in the same way: if awakened. and your heart rate and breathing are slower than when awake. as your eyes dart back and forth rapidly behind closed lids. e d u and muscle repair. breathing becomes more regular. you spend about five minutes in stage N1 sleep. h a r v a r d . the predominant brain waves slow to four to seven cycles per second. Blood flow is directed less toward your brain. Just as slow-wave sleep restores your body. These findings may help Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . students who got a good night’s sleep after seeing the puzzle fared much better than those asked to solve the puzzle immediately. In making the transition from wakefulness into light sleep. Your blood pressure increases. Eventually. which has been described as an “active brain in a paralyzed body. People tested to measure how well they had learned a new task improved their scores after a night’s sleep. muscles relax. Slow-wave sleep seems to be a time for your body to renew and repair itself.edu/ 3 . your body hardly moves. but slow-wave sleep is nearly absent in most people over age 65 (see “The later years. On the EEG. ■ Stage N1. known as deep sleep or slow-wave sleep.” page 8). large. and a K-complex will appear on the EEG. when brain waves speed up for roughly half a second or longer. This is stage N3. and your heart rate and breathing speed up to daytime levels. the pituitary gland releases a pulse of growth hormone that stimulates tissue growth www. When a sleep-deprived person gets some sleep. Earlier studies found that REM sleep facilitates learning and memory. suggesting that slow-wave sleep fills an essential role in a person’s optimal functioning. raising the possibility that slow-wave sleep helps the body defend itself against infection. K-complexes can also be provoked by certain sounds or other external or internal stimuli. Your body temperature rises. scientists believe that REM or dreaming sleep restores your mind. Someone whose slow-wave sleep is restricted will wake up feeling less refreshed. you will proceed smoothly through the three stages of quiet sleep. muscles not needed for breathing or eye movement are quiet. perhaps in part by helping clear out irrelevant information. thinking and dreaming. At the beginning of this stage. while another might describe having been asleep. the improvements were lost. and they consequently flip back and forth between sleep and wakefulness frequently. Whisper someone’s name during stage N2 sleep. Three stages of quiet sleep Unless something disturbs the process. Your eyes are still. People in stage N1 sleep lose awareness of their surroundings. is twice as active as when you’re awake. slow brain waves called delta waves become a major feature on the EEG. Dreaming (REM) sleep Dreaming occurs during REM sleep.” Your brain races. The brain becomes less responsive to external stimuli. the improvements in the scores were unaffected. You spend about half the night in stage N2 sleep. The sympathetic nervous system. but they are easily jarred awake.health. On the other hand. which scientists think represents a sort of built-in vigilance system that keeps you poised to awaken if necessary. The EEG tracings also show a pattern called a K-complex. Large. This first stage of true sleep lasts 10 to 25 minutes.h e a l t h . which cools measurably. ■ Stage N3.harvard. However. one person might recall being drowsy. ■ Stage N2. Despite all this activity. Blood pressure falls. During this stage. Your brain’s electrical activity is irregular. young people spend about 20% of their sleep time in stretches of slow-wave sleep lasting up to half an hour. if they were awakened an equal number of times from slow-wave sleep. except for intermittent twitches. and eyes often move slowly from side to side.Purchased at http://www. slow waves intermingle with brief bursts of activity called sleep spindles. a pattern called theta waves. making it difficult to wake the sleeper. The final period of REM sleep may last a half-hour. a pacemaker-like mechanism in the brain regulates circadian rhythm. 4 Improving Sleep Certain brain structures and chemicals produce the states of sleeping and waking. When the investigators plotted the times when unplanned naps occurred. and the release of hormones.m.to two-hour afternoon nap during the workday and a correspondingly shorter sleep at night. This pattern is known as sleep architecture. they found peaks between 2 a. alternating between REM and non-REM sleep. Not surprisingly. the different levels resemble a drawing of a city skyline. the brain center that regulates appetite. the different levels resemble a drawing of a city skyline. When these stages are charted on a diagram.harvard. many slipped into naps despite their best efforts not to. more stage N1 sleep.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . About three to five times a night. but REM time increases progressively over the course of the night. Most Americans sleep during the night as dictated by their circadian rhythms. In one study.”) This internal clock. and between 2 p. and 3 p.health. If someone who has been deprived of REM sleep is left undisturbed for a night. and to a lesser extent in midafternoon. and other biological states. controls the daily ups and downs of biological patterns. which gradually becomes established during the first months of life. blood pressure. For instance. people can respond to their bodies’ daily dips in alertness with a one. www. Sleep experts call this pattern sleep architecture.health. In societies where taking a siesta is the norm.m. As the night progresses. Altogether. (“Circadian” means “about a day. REM sleep makes up about 25% of total sleep in young adults. the sleep skyline will change. although many who work on weekdays nap in the afternoon on the weekends. Most deep sleep occurs in the first half of the night. including body temperature. or about every 90 minutes. and 4 a. with less stage N3 sleep. body temperature. researchers instructed a group of people to try to stay awake for 24 hours. The first such episode usually lasts only for a few minutes. a normal sleeper moves between different sleep stages in a fairly predictable pattern.har vard.m. In a young adult. explain why students who stay up all night cramming for an examination generally retain less information than classmates who get some sleep. periods of REM sleep get longer and alternate with stage N2 sleep. called a hypnogram (see Figure 2). Later in life.Purchased at http://www. and more awakenings.Your internal clock Figure 2 Sleep architecture Sleep stage Awake REM N1 N2 N3 0 1 2 3 4 5 6 7 Hours of sleep When experts chart sleep stages on a hypnogram. The circadian rhythm makes people’s desire for sleep strongest between midnight and dawn.m.edu/ . a sleeper enters REM sleep. The hypnogram above shows a typical night’s sleep of a healthy young adult. normal sleep architecture usually consists of four or five alternating non-REM and REM periods. Sleep architecture During the night. This cluster of cells is part of the hypothalamus. Figure 3 The sleep /wake control center Thalamus Hypothalamus Suprachiasmatic nucleus Cerebellum Brain stem The pacemaker-like mechanism in your brain that regulates the circadian rhythm of sleeping and waking is thought to be located in the suprachiasmatic nucleus. he or she enters this stage earlier and spends a higher proportion of sleep time in it—a phenomenon called REM rebound. Other researchers. Acetylcholine regulates REM sleep. albeit in disguised form. ■ Melatonin. and heartbeat. Post-Freudian theorists and psychoanalytic thinkers subsequently elaborated on and refined his ideas. h a r v a r d . which is located deep in the brain between the two hemispheres. and the 90-minute changeover between REM and non-REM sleep. studies in rats identified the suprachiasmatic nucleus as the location of the internal clock. the participants unconsciously reset their biological clocks to match the new light input. and fears. the area that controls breathing. its location allows it to respond to several types of external cues to keep it set at 24 hours.Mechanisms of your “sleep clock” In the 1970s. a hormone produced in a predictable daily rhythm by the pineal gland. Cells in the suprachiasmatic nucleus contain receptors for melatonin. who in 1900 proposed that dreams are meaningful representations of the unconscious mind in which we reveal our hidden conflicts. As a person reads clocks. e d u dreams occur upon activation of neurotransmitters in a portion of the brain. epinephrine. if any. Adenosine and gamma-aminobutyric acid are believed to promote sleep. attaching associations and emotions and helping to retain important events.h e a l t h . and appetites. there is cognitive pressure to stay on schedule. taking a physiological approach. are skeptical. Norepinephrine. Levels of melatonin begin climbing after dark and ebb after dawn. When researchers invited volunteers into the laboratory and exposed them to light at intervals that were at odds with the outside world. the brain center that regulates appetite and other biological states (see Figure 3).” ■ Light. Light striking your eyes is the most influential zeitgeber.Purchased at http://www. or when you’re chased through the streets of Paris by a giant turtle? Those who have studied dreaming fall into two general camps: those who say yes. Individuals vary greatly in their natural levels of neurotransmitters and in their sensitivity to these chemicals. our dreams can play in maintaining mental health. This timekeeper resides in a nugget of nerve cells within the brain stem. dopamine. Why do we dream? You’ve probably wondered whether your dreams serve any purpose. The circadian rhythm disturbances and sleep problems that affect up to 90% of blind people demonstrate the importance of light to sleep/wake patterns. Fluctuating activity in the nerve cells and the chemical messengers they produce seem to coordinate the timing of wakefulness. ■ Time. observed that patients who sustained injuries and lesions in the brain’s frontal lobe no longer dreamed. they’re not.” a German word meaning “time givers.edu/ 5 . Pointing to studies from the 1970s showing that www. One scientist. surely we’d remember them better. dreams are significant. The hormone induces drowsiness in some people. impulses. desires. the sleep/wake rhythm disappeared and the rats no longer slept on a normal schedule. This suggests that dreaming involves areas in the front of the brain that are connected to urges. and demands that the body remain alert for certain tasks and social events. Some research on the function of dreams has combined the psychological and neurochemical approaches. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh .harvard. This cluster of cells is part of the hypothalamus. Your clock’s hour hand As the circadian rhythm counts off the days. follows work and train schedules. Scientists call these cues “zeitgebers. they argue that dreams are merely aimless and chaotic images—essentially little more than the mind’s attempt to make meaning out of the random chemical signals sent up from the brain stem. Further study should offer important insights on why we dream and what role. When this tiny area was damaged. focusing on how dreams help the organization of thought and the consolidation and reinforcement of long-term memory. if they were significant. arousal. blood pressure. Several neurotransmitters (brain chemicals that neurons release to communicate with adjacent cells) play a role in arousal. What does it mean when you arrive at your senior prom in overalls.health. another part of the brain acts like the hour hand on a watch. Their actions help explain why medications that mimic or counteract their effects can influence sleep. Other research suggests that dreaming plays a role in helping consolidate the day’s memories. They also point out that we only remember a minute percentage of our dreams. and those who say no. for example. and scientists believe its daily light-sensitive cycles help keep the sleep/wake cycle on track. and hypocretin stimulate wakefulness. Followers of the first camp trace many of their ideas to Sigmund Freud. Although the clock is largely self-regulating. for example. requiring just six hours a night instead of the average of eight. and sleep at this age is deep and restorative.Sleep throughout life T o a certain extent. One study indicated that some adolescents might have delayed sleep phase syndrome.health. if a child is sleepy during the day. Except for infancy. During the preschool years. The discovery of a genetic mutation in two people who need far less sleep than average helps explain at least some of this variation. stage N3 sleep and REM A gene that controls sleep length Whether you’re a night owl or an early riser. scientists reported the discovery of a genetic mutation relating to sleep duration (see “A gene that controls sleep length. parents should be concerned. adolescence is the most rapid period of body growth and development.” below). many factors can affect how a person sleeps. suggests the potential to create a drug to enable humans to function on less sleep. Some people feel perky after just seven hours of sleep. most begin sleeping through the night and taking naps in the morning and afternoon. a newborn’s sleep periods get longer.edu/ .harvard. producing conflicts between parents and sleepy teenagers as well as with secondary schools. The mutations occurred in a mother and daughter who were naturally short sleepers. 6 Improving Sleep sleep decrease. you probably know roughly long you need to sleep to feel fully rested. it takes progressively longer to fall asleep. The mice not only slept less and stayed awake longer. But in 2009.health.har vard. You sleep less each night. until by age 6 most children are awake all day and sleep for about 10 hours a night. By contrast. A newborn may sleep eight times a day. and you awaken more often during the night (see Table 1). Parents often blame teenagers’ busy schedule of activities for their grogginess and difficulty awakening in the morning. Many Americans sleep just six hours nightly. which is known to affect circadian rhythms (see “Your internal clock. adolescents are known for their daytime drowsiness. and this does play a role. these two women awoke naturally after six hours. Nevertheless. daytime naps gradually shorten. But experts say that’s decades away. while others are groggy if they log less than nine hours. nocturnal melatonin production is at its lifetime peak. However. By 6 months. heredity determines how people sleep throughout their lives. REM periods occur more often. Although teenagers need about an hour more sleep each day than they did as young children. where they are not sleepy until well after the usual bedtime and cannot wake at the time required for school. caffeine. the problem is also partly biological. Aging is the most important influence on basic sleep rhythms—from age 20 on. Scientists found the mutation in a gene called DEC2. and power naps to awaken and stay awake during the day. accumulating 18 hours of sleep and spending about half of it in REM sleep. they also needed less sleep to recover following sleep deprivation. given the still-undiscovered genes and other factors that control the quantity and quality of sleep. Differences in sleeping and waking seem to be inborn. stages N1 and N2 sleep increase. Childhood For an adult to sleep like a baby is not only unrealistic but also undesirable. have much more similar sleep patterns than nonidentical twins or other sibling pairs. but most rely on alarms. Identical twins. At this age. Adolescence In contrast. The finding. most of them actually sleep an hour or so less. The scientists then created genetically engineered mice with the same mutation. although the genetic underpinnings aren’t fully understood.” page 4).Purchased at http://www. Between age 7 and puberty. infants spend longer and more regular periods in non-REM sleep. which usually www. described in a 2009 article in the journal Science. usually less than an hour apart.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . At about the age of 4 weeks. Between age 20 and age 30. which can lead to mood swings. pp. elevate your pillow or raise the head of your bed by placing blocks under the bedposts.h e a l t h . hormonal and anatomical changes reduce sleep efficiency so that less of a woman’s time in bed is actually spent sleeping. • If you feel drowsy. • Exercise regularly. The postpartum period usually brings dramatic sleepiness and fatigue—because the mother’s ability to sleep efficiently has not returned to normal.health.Purchased at http://www. During the second phase of the menstrual cycle. As a result. it takes longer to fall asleep. By age 40. During the first trimester of pregnancy. between ovulation and the next menses. cyclic changes in body temperature. behavioral problems. And sleep efficiency—the percentage of time spent asleep while in bed—decreases as well. h a r v a r d . www. slow-wave sleep is markedly reduced. take a midday nap. Age 20 Age 40 Age 60 Age 70 Age 80 Time to fall asleep 16 minutes 17 minutes 18 minutes 18. fried.5 hours 7 hours 6. Table 1 Sleep changes during adulthood As people age. • If you have heartburn. 1. some women fall asleep and enter REM sleep more quickly than usual. products). As pregnancy continues. many women are sleepy all the time and may log an extra two hours a night if their schedules permit. Researchers are probing whether sleep disturbances during pregnancy may contribute to postpartum depression and compromise the general physical and mental well-being of new mothers. or acidic foods (such as tomato Adulthood During young adulthood. • Prevent nausea by eating frequent snacks during the day.2 hours 6 hours 5.5% Time in REM sleep 22% 21% 20% 19% 17% Time asleep while in bed 95% 88% 84% 82% 79% Source: Sleep. which contribute to heartburn. and levels of the hormone progesterone to see whether these physiologic patterns also correlate with premenstrual mood changes. Other research indicates that early high school start times contribute to sleep deprivation among teens. • Use pillows or special pregnancy cushions to support your abdomen. because she is at the mercy of her newborn’s rapidly cycling shifts between sleeping and waking. and nighttime awakenings double. sleep patterns usually seem stable but in fact are slowly evolving. a phenomenon called increased sleep latency.harvard. nearly eight in 10 women reported disturbed sleep during pregnancy.5 minutes 19 minutes Total sleep time 7. fatigue increases (see “Getting a good night’s sleep during pregnancy. and because breast-feeding promotes sleepiness.8 hours Time in stage N2 sleep 47% 51% 53% 55% 57% Time in stage N3 sleep 20% 15% 10% 9% 7.edu/ 7 . which will help reduce leg cramps and improve sleep. Here are some tips to help you get a better night’s sleep when you’re expecting: • Avoid spicy. Getting a good night’s sleep during pregnancy In a National Sleep Foundation poll. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . and difficulties with concentration and learning. Investigators are studying the relationship between such sleep alterations. Women who aren’t pregnant may experience monthly shifts in sleep habits. • Cut down on fluids before bedtime to reduce nighttime trips to the bathroom. 2004. Nov. A few experience extreme sleepiness.start earlier than elementary schools. Women’s reproductive cycles can greatly influence sleep.” at right). 1255 –73. the amount of slow-wave sleep drops by about half. Obese people are more prone to nocturnal breathing problems. 70% of caregivers cited these problems as the decisive factor in seeking nursing home placement for a loved one. it’s best to take one midday nap.harvard. and the shallow quality of sleep results in dozens of awakenings during the night. The later years Like younger people. Falling asleep takes longer. During menopause.health.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . Doctors used to reassure older people that they needed less sleep than younger ones to function well. Since older people often have trouble attaining this much sleep at night. which often start during middle age. many women experience hot flashes that can interrupt sleep and lead to long-term insomnia.har vard. and in some people it is completely absent. 8 Improving Sleep they sleep differently. most adults need seven and a half to eight hours of sleep to function at their best.edu/ . Sleep disturbances in elderly people.Purchased at http://www. Slow-wave sleep accounts for less than 5% of sleep time. In one study. At any age. slow-wave sleep continues to diminish. older adults still spend about 20% of sleep time in REM sleep. but sleep experts now know that isn’t true. particularly in those who have Alzheimer’s disease or other forms of dementia. they frequently supplement nighttime sleep with daytime naps. Nighttime awakenings become more frequent and last longer. are very disruptive for caregivers. if you find that you need a nap. rather than several brief ones scattered throughout the day and evening. but other than that. www.health. This can be a successful strategy for accumulating sufficient total sleep over a 24-hour period. Middle age As men and women enter middle age. Men and women who are physically fit sleep more soundly as they grow older. compared with their sedentary peers. However. Waking after about three hours of sleep is particularly common.Snoozing news The average length of time Americans spend sleeping has dropped from about nine hours a night in 1910 to about seven hours today. h e a l t h . or even while talking on the telephone. people have difficulty completing tasks demanding a high attention level and often experience mood swings. but not 100% of what you need. Sleep deprivation is broadly categorized as complete or partial. and periodically took driving simulation tests. from weight gain to a heart attack (see Figure 4).10%. But during the peaks of sleepiness in the afternoon and overnight hours. When complete sleep deprivation extends for two or three days. They may not feel great.edu/ 9 . In one study. Experts refer to this as building up a sleep debt. A small percentage experience paranoia and hallucinations. h a r v a r d . a number of studies of hand-eye coordination and reaction time have shown that such sleep deprivation can be as debilitating as being intoxicated.10%—enough to be charged with driving while intoxicated in most states. An example would be when a person who needs seven or eight hours of sleep gets only four to six hours for several nights in a row. Partial sleep deprivation Partial sleep deprivation occurs when you get some sleep. At a different time. but they can usually get through the day without others noticing that anything is amiss. you go about 16 or 17 hours between sleep sessions. the volunteers’ driving ability was tested after drinking 10 to 15 grams of alcohol at 30-minute intervals www. which play a role in thousands of transportation accidents each year. based on duration and severity. microsleeps and automatic behavior (see page 12). By 2 or 3 a. For example. and increased feelings of tension. Complete sleep deprivation Normally.S p e c i a l S e c t ion Dangers of sleep deprivation M any people don’t realize that lack of sufficient sleep can lead to a range of ill effects. Sleep deprivation also leaves you prone to two potentially dangerous phenomena.health.Purchased at http://www. then exhausted. Sleep deprivation is so debilitating that it is sometimes used as a component of military interrogation. e d u until their blood alcohol content reached 0.. or eating. Complete sleep deprivation happens as the hours extend beyond this point. working on the computer. After a single night of short sleep. people usually show signs of irritability and sleepiness.. sitting. volunteers stayed awake for 28 hours. Simple tasks that you would normally have no trouble accomplishing start to become difficult. Performance is also highly influenced by fluctuations in circadian rhythms. The study concluded that 24 hours of wakefulness had the same deleterious effect on driving ability as that of a blood alcohol content of 0. many people have a hard time keeping their eyes open. people often literally cannot stay awake and may fall asleep while standing.m. most people function at or near their normal level. First you feel tired. sleepdeprived people may still function fairly well during the morning and evening. In fact. depression. After two or more nights of short sleep. triggering mild to potentially life-threatening consequences.m. Work Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . but the effects extend throughout the body.harvard. beginning at 8 a. scores for the four-hour and six-hour sleepers drew closer to those of the fourth group. 48 healthy men and women who had been averaging seven to eight hours of sleep nightly were divided into four groups. their self-rated sleepiness scores were leveling off. performance begins to suffer—particularly on complicated tasks—and people are more likely to complain of headaches. The six-hour sleepers performed adequately on the cognitive test but lost ground on reaction time and memory. Their memory scores and reaction times were about on par with those of the sleepless after their second consecutive all-nighter. and their scores on the memory and cognitive tasks rose steadily. At the end of the study. Long-term partial sleep deprivation occurs when someone gets less than the optimal amount of sleep for months or years on end—a common scenario for insomniacs and people with sleep disorders. One group slept eight hours. even as their performance scores continued to decline. and sore joints. www. people face a far higher risk of falling asleep on the job and while driving. and cognitive ability. The volunteers developed higher blood 10 Imp r ov i n g S l e e p pressure and higher levels of the stress hormone cortisol.Special Section | Dangers of sleep deprivation Figure 4 Health consequences of insufficient sleep Respiratory More likely to catch a cold Cardiovascular Boost in blood pressure Higher likelihood of a heart attack Metabolic Propensity for packing on pounds Increased risk of developing diabetes Mental More prone to depression and anxiety People who skimp on sleep face a higher risk of numerous health problems. memory. In another study. The fourth group went without sleep for three days. reaction times in the group that slept eight hours a night remained about the same.har vard. another slept six. and they produced only half the usual number of antibodies to a flu vaccine. whose scores had plummeted during their three days without sleep. and the third just four hours per night. the four-hour sleepers were cognitively in no better shape than the sleepless group after its first night awake. Meanwhile. logging scores that approximated those of the sleepless after their first night awake.edu/ . Every two hours during their waking periods. In a landmark study of human sleep deprivation. In addition. But even healthy people who can’t resist the round-theclock commerce.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . Over the course of two weeks. All the changes— which were reversed when the students made up the hours of lost sleep—help explain why ongoing sleep debt raises the risk of a number of health problems. How sleep loss harms your health A growing number of studies have linked long-term sleep deficits with significant health problems.Purchased at http://www.health. researchers followed a group of student volunteers who slept only four hours nightly for six consecutive days. The sleep-deprived students also showed signs of insulin resistance— a condition that is the precursor of type 2 diabetes. all the participants completed sleepiness evaluation questionnaires and took tests of reaction time. communication. Sleep loss exacts a toll on the mind as well as the body.health.harvard. the six-hour and the four-hour sleepers were failing to gauge reliably how sleepy they had become. In contrast. stomach problems. After two weeks. and entertainment opportunities our 24/7 society now offers may fall prey to this problem. in turn.edu/ 11 . People Leptin who Ghrelin slept an average of less than seven hours per night Sleepwere three times deprevation as likely to get sick as those who averaged at least eight hours.Purchased at http://www. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh .h e a l t h . then quarantined them for five days and exposed them to cold viruses. the underlying cause is thought to involve a disruption of the body’s normal hormonal regulation resulting from insufficient sleep. increases the risk of a number of health problems— Increased including some of those listed in hunger the following paragraphs. As described in a 2009 article in the journal Sleep.700 randomly chosen men and women from rural Pennsylvania. Excess weight. Lack of sufficient sleep tends to disrupt hormones that control hunger and appetite. March 2008. making you feel hungrier and slowing your metabolism. The link appears to be especially strong among children. Researchers tracked the sleep habits of 153 men and women for two weeks. High blood pressure Researchers involved in the diabetes study also evaluated risk of high blood pressure among the same Obesity group of people. the researchers found the risk of high blood pressure was three-and-ahalf times greater among insomniacs who routinely slept less than six hours per night compared with Figure 5 How sleep loss may lead to weight gain Greater hunger More opportunity to eat Altered ability to control body temperature Sleep deprivation Increased fatigue Increased caloric intake Reduced energy expenditure Obesity Staying up too late at night means you’ll have more opportunities to eat. according to a 2008 review article in the journal Obesity that analyzed findings from 36 different studies of sleep duration and body weight. You’ll also feel more tired during the day. People who fatigue had insomnia for a year or longer and who slept less than five hours per night had a threefold higher risk of type 2 diabetes compared with those who had no sleep complaints and who slept six or more hours nightly.harvard. Obesity. A 2009 study in Archives of Internal Medicine offers some proof. www. As with overweight and obesity (which are also closely linked to type 2 diabetes). which means you’re less likely to exercise. Increased Increased oportunity to eat caloric intake Diabetes A 2009 report in Diabetes Care Altered found a sharp increase in the risk thermoregulation Reduced of type 2 diabetes in people with energy expenditure Increased persistent insomnia.health. h a r v a r d . which included more than 1. Weight gain Not getting enough sleep makes you more likely to gain weight.Dangers of sleep deprivation | Special Section Viral infections Anecdotal evidence supports the notion that when you’re tired and run-down. Sleep deprivation can alter your body’s metabolism. and the resulting daytime fatigue often discourages you from exercising (see Figure 5). you’re more likely to get sick. but that’s not the only problem. 000 teenagers—found that sleep problems developed before a diagnosis of major depression and (to a lesser extent) anxiety. and higher blood pressure. sleep is not a luxury but a basic component of a healthy lifestyle. such as eating a healthy diet. In short. compared with normal sleepers. sleep apnea (see page 28). Just like purchasing healthy foods. included more than 98. and another including about 1. One common cause of poor sleep. Compared with women who snoozed for seven hours.Special Section | Dangers of sleep deprivation normal sleepers who slept six or more hours nightly. Sleep problems in the teenagers preceded depression 69% of the time and anxiety disorders 27% of the time.400 men and women whom researchers followed for an average of eight years. During this time. Brain wave monitoring by EEG of someone experiencing micro sleeps shows brief periods of stage N1 sleep intruding into wakefulness. Apnea spells can trigger arrhythmias (irregular heartbeats). the researchers found. the brain does not respond to noise or other sensory inputs.health. And Microsleeps and automatic behavior Microsleeps are brief episodes of sleep that occur in the midst of ongoing wakeful activity.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . women who got no more than four hours of shut-eye were twice as likely to die from heart disease.health.Purchased at http://www.000 adults ages 21 to 30 found that. according to a 2009 study of 6.3-fold increase in mortality compared with those who got sufficient sleep. Severe sleep apnea raises the risk of dying early by 46%.har vard. Mental illness A study of about 1.000 Japanese men and women ages 40 to 79 who were followed for just over 14 years.harvard. getting adequate sleep requires time www. 12 Imp r ov i n g S l e e p two studies in young people—one involving 300 pairs of young twins. or flossing your teeth. for example. They can occur in people who are sleep deprived. getting enough sleep is just as important as other vital elements of good health. Although only about 8% of the men in the study had severe apnea. getting regular exercise. and practicing good dental hygiene. Heart disease A number of studies have linked short-term sleep deprivation with several well-known risk factors for heart disease. When researchers excluded those who used a breathing machine (a common apnea treatment). One such report. those who did and who were between 40 and 70 years of age were twice as likely to die from any cause as healthy men in the same age group. short sleepers of both genders had a 1.edu/ . higher triglyceride levels. and you don’t react to things happening around you. published in a 2009 issue of Sleep. Examples include a driver who keeps the car on the road but misses an intended exit and a train engineer who can continue pressing a lever at regular intervals but doesn’t notice an obstruction on the track. Automatic behavior refers to a period of several minutes or more during which a person is awake and performing routine duties but not attending to his or her surroundings or responding to changes in the environment. Mortality In the Japanese heart disease study described above. Healthy sleep habits Clearly. those who reported a history of insomnia during an interview were four times as likely to develop major depression by the time of a second interview three years later. including higher cholesterol levels. and the condition also increases the risk of stroke and heart failure. They usually last just a few seconds but can go on for 10 or 15 seconds—and pose a grave danger if they happen when a person is driving. people with severe sleep apnea were three times more likely to die of heart disease during 18 years of follow-up than those without apnea. taking an after-dinner walk. also raises heart disease risk. In the Wisconsin Sleep Cohort study. the risk jumped to more than five times higher. These are the head nods some people experience when trying to stay awake during a lecture. e d u 365 days a year. getting enough sleep puts you in a better position to enjoy and achieve them. one night. you need to make sure you consistently get enough sleep. Seek a doctor’s help if conventional steps toward good sleep don’t work. If you don’t get to bed until 2 a.harvard. This doesn’t mean that you can’t have any fun.edu/ 13 . But over the long haul.h e a l t h . allow time over the next day or two to catch up on lost sleep.m. or that you need to beat yourself up if you don’t get eight hours of sleep www. or going to bed earlier. Mentally block off certain hours for sleep and then follow through on your intention.health. Sleep decisions are a qualityof-life issue. taking a short afternoon nap. you’d best forgo late-night talk shows—or record them to watch the next evening. avoid building up a sleep debt. h a r v a r d . to be at work by 9. and take steps to set up an ideal sleep environment. If you have to get up at 7 a. staying up a few extra hours for a party or to meet a deadline is perfectly acceptable—as long as you make plans to compensate the next day by sleeping in. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . Whatever your interests and goals.m.Purchased at http://www.Dangers of sleep deprivation | Special Section and discipline. Just as an occasional ice cream sundae won’t make you obese. If you don’t fall asleep within 15 minutes or if you wake up and can’t fall back to sleep within that amount of time.health. get out of bed and do something relaxing until you feel sleepy again. • Use relaxation techniques before bedtime.m. or at least do not smoke for one to two hours before turning in for the night. • Limit fluids before bedtime to minimize nighttime trips to the bathroom.health. especially close to bedtime. since its effects can endure for many hours. or noon if you’re caffeine-sensitive. raises blood pressure. ranging from anxiety to an unusual work schedule.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . That may be because caffeine blocks the effects of adenosine.Purchased at http://www. chocolate. If you continue to use tobacco.” because they represent scientific thinking about maintaining healthy sleep patterns. • Go to bed and wake up at the same time every day. or noon if they are especially caffeine-sensitive. M cause headache. For some people. Caffeine can also interrupt sleep by increasing the need to urinate during the night. • Don’t drink alcohol for at least two hours before bedtime. People who kick the habit fall asleep more quickly and wake less often during the night.edu/ . Sleep disturbance and daytime fatigue may occur during the initial withdrawal from nicotine.har vard. and as quiet as possible.. many teas. • Forgo naps. People who suffer from insomnia should avoid caffeine as much as possible.. avoid smoking or chewing it for at least one to two hours before bedtime. Before examining specific sleep problems. and extreme fatigue. • Exercise regularly (but not within two hours of bedtime). a few hours without it is enough to induce withdrawal symptoms. • Use the bed only for sleeping or sex. www. and stimulates fast brain wave activity that indicates wakefulness. a neurotransmitter thought to promote sleep. 14 Improving Sleep • Avoid eating foods that contribute to heartburn. a single cup of coffee in the morning means a sleepless night. Cut down on caffeine Caffeine drinkers may find it difficult to fall asleep. • Keep the bedroom cool. some people find it easier to cut back gradually than to go cold turkey.General ways to improve sleep any things can interfere with sleep. and cola drinks) after 2 p. many former users report improvements in sleep. These procedures are known as “sleep hygiene. • Replace a worn-out or uncomfortable mattress. their sleep is shorter and lighter. it makes sense to address some common enemies of sleep and tips for dealing with them.harvard. Once they drift off. In people addicted to nicotine. First-line strategies Stop smoking or chewing tobacco Nicotine is a central nervous system stimulant that can cause insomnia. Because caffeine withdrawal can Tips for a better night’s sleep Hygiene is the application of scientific knowledge to maintain good health. irritability. • Avoid caffeine-containing beverages (coffee. the craving can even wake a smoker at night. Turn in only when you’re sleepy.m. • Take a hot bath before bedtime. dark. • Stop smoking. even on weekends. People who have difficulty sleeping often discover that their daily routine holds the key to nighttime woes. Those who can’t or don’t want to give up caffeine should avoid it after 2 p. • Limit the time you spend in bed. This potent drug makes it harder to fall asleep because it speeds your heart rate. but even during this period. Exercise is the only known way for healthy adults to boost the amount of deep sleep they get. Removing the television. Research shows that older men and women who report sleeping normally can still increase the amount of time they spend in deep sleep if they do some form of aerobic activity. so a nightcap can help some people fall asleep. • Use a fan or other appliance that produces a steady “white noise. dark. a scheduled nap may be just the thing. Exercise seems to be of particular benefit to older people. and relatively cool. People who snooze later in the afternoon tend to fall into a deeper sleep. therefore. In an automobile. are available in stores. Alcohol suppresses REM sleep. with a comfortable bed and minimal clutter.Use alcohol cautiously Alcohol depresses the nervous system.” White noise devices. • Decorate with heavy curtains and rugs. naps take away from evening sleep. particularly among older adults. Here are some ways to reduce or disguise noises that can interfere with sleep: • Use earplugs. An ideal environment is quiet. People with the most regular sleep habits report the fewest problems with insomnia and the least depression. telephone. and they woke up less often during the night. nap shortly after lunch.to 20-minute nap has significant alertness benefits. e d u Stick to a regular schedule A regular sleep schedule keeps the circadian sleep/ wake cycle synchronized (see “Your internal clock. which causes greater disruption at night. Because your daily sleep requirement remains constant. the quality of this sleep is abnormal. ■ Keep a sleep diary. Drinkers have frequent awakenings and sometimes frightening dreams. Banish reminders or discussions of stressful issues to another room. are more easily awakened by noises. and even a 15. If your goal is to sleep longer at night. In one study. which absorb sounds. sometimes to a dangerous extent. If possible.health. but even a week’s worth of entries can be useful. running. But try to avoid exercise within two hours of bedtime because exercise is stimulating and can make it harder to fall asleep. h a r v a r d . Improve your sleep surroundings People respond to cues in their environment. If an insomniac is anxious about getting enough sleep.harvard. napping is a bad idea. Drinking during one of the body’s intrinsic sleepy times—midafternoon or at night—will induce more sleepiness than imbibing at other times of day. Napping during the day can also make it harder to get to sleep at night. you should do this for a month. However. Ways to control bedroom noise A quiet bedroom can help contribute to a good night’s sleep. But if your goal is to improve your alertness during the day. who spend less time in deep sleep and. Alcohol may be responsible for up to 10% of chronic insomnia cases. Even one drink can make a sleep-deprived person drowsy. Experts advise getting up at about the same time every day. An ideal nap lasts no longer than an hour.h e a l t h . www. • Install double-paned windows. attain a higher percentage of deep sleep. and awaken less often during the night.” page 4). even after a late-night party or fitful sleep. physically fit older men fell asleep in less than half the time it took for sedentary men. designed specifically to provide this kind of steady hum. the combination significantly increases a person’s chance of having an accident. then a scheduled nap may improve the quality of nighttime sleep by reducing anxiety.edu/ 15 . as are CDs that provide soothing sounds. Shorten or eliminate naps that produce lingering grogginess. it can worsen snoring and other nocturnal breathing problems. Also. and office equipment from the bedroom reinforces that this room is meant for sleeping. Be physically active Regular aerobic exercise like walking. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . ■ Use strategic naps. because alcohol relaxes throat muscles and interferes with brain control mechanisms. Keeping a sleep diary may help you uncover some clues about what’s disturbing your sleep.Purchased at http://www. If possible. or swimming provides three important sleep benefits: you fall asleep faster. and the soporific effects disappear after a few hours. Using pillows to elevate the upper body may help.health. Men with heart failure frequently have obstructive sleep apnea. respiratory problems.” page 29). a number of prescription and over-the-counter medications used to treat these and other health problems can impair sleep quality and quantity (see Table 2). You can also use gravity to your advantage by elevating your upper body with an under-mattress wedge or blocks placed under the bedposts. musculoskeletal disorders. the natural fluctuations in circadian rhythms may trigger angina (chest pain).” page 22) help some people to stay asleep despite this breathing disturbance. The stress of chronic illness can also cause insomnia and daytime drowsiness.har vard. cause daytime sleepiness. In addition. a frequent need to urinate. and thyroid disease. a series of increasingly deep breaths followed by a brief cessation of breathing. nighttime movements or pain may also disturb sleep.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . in which slow brain waves are mixed with waves usually associated with relaxed wakefulness. Heart disease Patients with heart failure may awaken during the 16 Improving Sleep night feeling short of breath because extra body fluid accumulates around their lungs when they’re lying down. You may find it helpful to take aspirin or a nonsteroidal anti-inflammatory drug (NSAID) just before bedtime to relieve pain and swelling in your joints during the night.harvard. If diabetes has damaged nerves in the legs. Benzodiazepine sleep medications (see “Prescription medications for insomnia.edu/ . treatment with corticosteroids frequently causes insomnia. which is caused by the backup of stomach acid into the esophagus. cardiovascular disease.health. People with fibromyalgia—a condition characterized by painful ligaments and tendons—are likely to wake in the morning still feeling fatigued and as stiff and achy as a person with arthritis. diabetes. Illnesses that affect sleep Common conditions often associated with sleep problems include heartburn. Diabetes Night sweats. Researchers who analyzed the sleep of fibromyalgia sufferers have found that at least half have abnormal deep sleep. which can disrupt sleep. Musculoskeletal disorders Arthritis pain can make it hard for people to fall asleep and to resettle when they shift positions.Medical conditions and sleep problems P eople who feel they sleep perfectly well may still be troubled by excessive daytime sleepiness because of a variety of underlying medical illnesses. These people can also be awakened just as they are falling asleep by a characteristic breathing pattern called Cheyne-Stokes respiration. kidney disease. but others may need to use supplementary oxygen or a device that increases pressure in the upper airway and chest cavity to help them breathe and sleep more normally (see “Positive airway pressure. A sleep disturbance may be a symptom of a health issue or an adverse effect of therapy to treat the problem. Over-the-counter and prescription drugs that suppress stomach acid secretion can also help.Purchased at http://www. Heartburn Lying down in bed often worsens heartburn. a pattern called www. or symptoms of hypoglycemia (low blood sugar) often rouse people with diabetes whose blood sugar levels are not well controlled. You may be able to avoid this problem by abstaining from heavy or fatty foods—as well as coffee and alcohol—in the evening. In addition. arrhythmia (irregular heartbeat). mental illness. and worsen heart failure. or even heart attack while asleep. In people with coronary artery disease. neurological disorders. If this is unsuccessful. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person’s everyday life. Common symptoms include trouble falling asleep. a person may get up as many as five or six times. Severe anxiety. persistent worry every day or almost every day for a period of six months or more. we produce more urine at night. insomnia or sleepiness may be the most prominent symptom. the bladder tends to lose holding capacity as we age. ■ Depression. in severe cases. both drugs.h e a l t h . In chronic.harvard. Disturbed sleep is a prominent feature of bipolar disorder (manic-depressive illness). other medical conditions (urinary tract infection.edu/ 17 . Laboratory studies have shown that people who are depressed spend less time in slow-wave sleep and may enter REM sleep more quickly at the beginning of the night. A mild case causes a person to wake up at least twice during the night. Panic attacks. especially among older adults. often strike at night. Almost half of those who took low doses of amitriptyline reported sleeping and feeling better. and older people are more likely to suffer from medical problems that affect the bladder. h a r v a r d . ■ General anxiety. and some depressed people have difficulty falling asleep or get fitful sleep throughout the whole night. Some cases are caused or exacerbated by excessive fluid intake after dinner. especially caffeine and alcohol. or uneasiness. With lower concentrations of this hormone. this can lead to significant sleep deprivation and daytime fatigue. Nocturia becomes more common with age. Also. sleep apnea).health. Mental illness Almost all people with anxiety or depression have trouble falling asleep and staying asleep. diabetes). which are intense fears related to a specific object or situation. People with the disorder typically experience excessive. In one study. Stimate). our bodies produce less of an antidiuretic hormone that enables us to retain fluid. Phobias. The most commonly used is desmopressin (DDAVP. cian evaluating a person with insomnia will consider depression as a possible cause. Sleep-related panic attacks do not occur during dreaming. multiple sclerosis. ■ Phobias and panic attacks. Therapies for nocturia fall into three categories: treatments to correct medical causes. low-grade depression. In many phobias and panic disorders. a physiwww. which mimics some of the action of the antidiuretic hormone. rarely cause sleep problems unless the phobia is itself sleep-related (such as fear of nightmares or of the bedroom). trouble staying asleep. If the nocturia persists. In fact. If the problem stems from increased contractions of the bladder. As we get older. try behavioral approaches such as cutting down on how much you drink in the two hours before bedtime. but rather in stage N2 and stage N3 sleep. and medication. The first step is to try to identify the cause and correct it. liver failure. an enlarged prostate. recognizing and treating the underlying problem—often with an anti-anxiety medication—may solve the sleep disturbance. kidney dialysis or transplant does not always return sleep to normal. Although researchers aren’t sure why. Sleep loss may exacerbate or induce manic symptoms Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . It affects nearly two-thirds of adults ages 55 to 84 at least a few nights per week. the tricyclic antidepressant amitriptyline. especially drinks containing alcohol or caffeine. and medication (especially diuretics). including some of the disorders mentioned in this report (heart failure.Purchased at http://www. nagging feelings of worry. your doctor may prescribe one of a growing number of medications approved to treat an overactive bladder. is a mental illness characterized by persistent. Kidney disease Kidney disease can cause waste products to build up in the blood and can result in insomnia or symptoms of restless legs syndrome (see page 33). formally known as generalized anxiety disorder. not being able to sleep may become a focus of some sufferers’ ongoing fear and tension. Nocturia has numerous possible other causes. or a placebo. which are free of psychological triggers. In turn. 62 people with fibromyalgia received treatment for six weeks with either the NSAID naproxen. e d u Coping with frequent nighttime urination Nocturia—the need to get up frequently to urinate during the night—is a common cause of sleep loss.alpha-delta sleep. the timing of nocturnal attacks helped convince psychiatrists that these episodes are biologically based. on the other hand. relaxant agents such as tol terodine (Detrol) and oxybutynin (Ditropan) can be effective. and not feeling rested after sleep. behavioral interventions. ■ Bipolar disorder. Waking up too early in the morning is a hallmark of depression. Because almost 90% of people with serious depression experience insomnia. Not surprisingly. apprehension. causing further sleep loss. quinidine (Cardioquin). sertraline (Zoloft). disrupted nighttime sleep Medications containing caffeine Decreased alertness NoDoz. less commonly. Synthroid. smoking cessation. daytime fatigue Beta blockers High blood pressure. sometimes prescribed off-label for alcohol withdrawal. Theraflu Warming Relief Suppressed REM sleep. Vivarin. Theo-Dur. chlorthalidone (Hygroton). nasal spray or inhalers (Nicotrol). decreased REM and non-REM deep sleep Theophylline Asthma theophylline (Slo-bid. 18 Improving Sleep www. heart rhythm problems. and flu Coricidin HBP.har vard. others) Increased nighttime urination. paroxetine (Paxil) Decreased REM sleep. Midol Nicotine replacement products Smoking nicotine patches (Nicoderm). restlessness. methamphetamine (Desoxyn). painful calf cramps during sleep Medications containing alcohol Cough. Between episodes. Some people with schizophre- nia sleep very little when they enter an acute phase of their illness. gum (Nicorette). others) Wakefullness similar to that caused by caffeine Thyroid hormone Hypothyroidism levothyroxine (Levoxyl. disrupted REM sleep. and lozenges (Commit) Insomnia. nightmares Clonidine High blood pressure. Excedrin. Nyquil Cough. HydroDIURIL.or temporarily alleviate depression. insomnia Diuretics High blood pressure chlorothiazide (Diuril). Your doctor may be able to suggest alternatives that do not disrupt sleep. Possible effect on sleep and daytime functioning Medication Used to treat Common examples Anti-arrhythmics Heart rhythm problems procainamide (Procanbid).health. their sleep patterns are likely to improve. During a manic episode. ■ Schizophrenia. hydrochlorothiazide (Esidrix. Table 2 Medications that may affect sleep A number of drugs steal sleep. asthma prednisone (Sterapred. chlorpheniramine (Chlor-Trimeton) Drowsiness Motion sickness dimenhydrinate (Dramamine) Depression. others) Daytime jitters.edu/ . nighttime awakenings. early morning awakening.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . others) Sleeping difficulties (at higher doses) Selective serotonin reuptake inhibitors (SSRIs) *These medications are also found in over-the-counter sleep aids (see page 25). Caffedrine Wakefulness that may last up to six to seven hours Headaches and other pain Anacin. cold. or other health problems clonidine (Catapres) Daytime drowsiness and fatigue. disturbing dreams Sedating antihistamines* Cold and allergy symptoms diphenhydramine (Benadryl). nightmares Corticosteroids Inflammation.health. methylphenidate (Ritalin) Difficulty falling asleep. angina atenolol (Tenormin). daytime fatigue Sympathomimetic stimulants Attention deficit disorder dextroamphetamine (Dexedrine).Purchased at http://www. a person may not sleep at all for several days. although many schizophrenics rarely obtain a normal amount of deep sleep. disopyramide (Norpace) Nighttime sleep difficulties. anxiety fluoxetine (Prozac). metoprolol (Lopressor). while others may cause unwanted drowsiness. Such occurrences are often followed by a “crash” during which the person spends most of the next few days in bed.harvard. propranolol (Inderal) Insomnia. Purchased at http://www. causing disturbed sleep and daytime sleepiness. Some patients who take drugs such as levodopa.health. similar to that of caffeine. Treatment with sleeping pills may be difficult because some drugs can worsen Parkinson’s symptoms. the use of these medications at night is important to maintain the mobility needed to change positions in bed. small doses of antipsychotic medications such as haloperidol (Haldol) and thioridazine (Mellaril) are more helpful than benzodiazepine drugs. shortness of breath. and the disease often dis- www. In such cases. People who have emphysema or bronchitis may also have difficulty falling and staying asleep because of excess sputum production. Feeling cold and sleepy is a hallmark of an underactive thyroid (hypothyroidism).Other neurological disorders Certain brain and nerve disorders can contribute to sleeplessness. Wandering. Brain wave disturbances that cause seizures can also cause deficits in slow-wave sleep or REM sleep. Headaches that awaken people are often migraines.edu/ 19 . Breathing difficulties or fear of having an attack may make it more difficult to fall asleep. and others seem to result from the disorder itself. ■ Headaches. leading to nighttime arousals. Alzheimer’s disease and other forms of dementia may disrupt sleep regulation and other brain functions. lead to better sleep. theophylline. as lack of sleep can promote headaches. headache. it spends more time in delta sleep. People with epilepsy are twice as likely as others to suffer from insomnia. but tend to correct these sleep disturbances when used for a long time. ■ Epilepsy. or other breathing medications that also have a stimulating effect. a phenomenon known as “sundowning. as can the use of steroids. when vessels are most constricted. Antiseizure drugs can cause similar changes at first. ask your doctor for a thyroid test. ■ Parkinson’s disease. Because thyroid function affects every organ and system in the body. About one in four people with epilepsy has seizures that occur mainly at night. which requires immediate medical attention. making the transition to REM sleep more dramatic and likely to induce a headache. but some migraines can be relieved by sleep. so if you notice a variety of unexplained symptoms. therefore. and coughing. h a r v a r d . as some students suffer their first seizures after staying up late to study. raising the potential for nocturnal asthma attacks that rouse the sleeper abruptly. and agitation during the evening and night. e d u rupts sleep. and tumors. or vision problems may signal a serious problem such as a brain tumor or stroke. weakness. People who are prone to headaches should try to avoid sleep deprivation. and it may cause night sweats. pain occurs when the walls of the blood vessels dilate.harvard. Both cluster headaches and migraines may be related to changes in the size of blood vessels leading to the cortex of the brain. Almost all people with Parkinson’s disease have insomnia. However. Respiratory problems Circadian-related changes in the tone of the muscles surrounding the airways can cause the airways to constrict during the night. As a result. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . the mainstay of Parkinson’s treatment. ■ Dementia. making it hard to fall asleep. daytime sleepiness is common. A bed rail or an overhead bar (known as a trapeze) may make it easier for people with Parkinson’s to move about and. Sleepiness coupled with dizziness. strokes. One study found that nearly 75% of people with asthma experienced frequent awakenings every week. Just getting in and out of bed can be a struggle. disorientation.” can require constant supervision and place great stress on caregivers. the symptoms can be wide-ranging and sometimes difficult to decipher. Sleep deprivation can also trigger a seizure. develop severe nightmares. The disorder overstimulates the nervous system. Researchers theorize that as the body catches up on missed sleep.h e a l t h . Some arousals are from the tremors and movements caused by the disorder. a phenomenon noted in college infirmaries during exam periods. Thyroid disease An overactive thyroid gland (hyperthyroidism) can cause sleep problems. others experience disruption of REM sleep. Checking thyroid function requires only a simple blood test. Purchased at http://www. One common form of persistent sleeplessness is conditioned (learned) insomnia. you must stay awake until 1 a.health. Taking steps to cope with sleep deprivation—napping. or an anxiety disorder can keep people awake at night. Nearly half of insomnia cases stem from psychological or emotional problems. drinking coffee. A careful evaluation can pinpoint habits that keep you up at night.health. having a nightcap. Some sleep experts suggest starting with six hours at first. Sleep restriction People with insomnia often tend to spend more time in bed. yet still be unable to nap. First-line treatment: Behavioral changes For chronic insomnia. If the alarm is set for 7 a. Setting a rigid early morning waking time often works best. If it doesn’t. or forgoing exercise—only fuels the problem.harvard. With proper treatment of the underlying cause. a sixhour restriction means that no matter how sleepy you are. A sleep specialist trained in behavioral medicine can help people with learned insomnia replace their bad habits with positive ones.m. As insomnia worsens. treating the condition or changing the medication may relieve the insomnia. spending less time in bed—a technique known as sleep restriction—promotes more restful sleep and helps make the bedroom a welcome sight instead of a torture chamber. are not included in this calculation. leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . In reality. but rather a general symptom like fever or pain. such as lost worker productivity and accidents. additional treatment focusing on sleep may help. They may experience daytime drowsiness. the treatment of choice is to change your lifestyle and habits. Types of insomnia One way doctors classify insomnia is by its duration. jet lag. Insomnia is considered transient if it lasts only a few days. In these instances. short-term if it continues for a few weeks. As you learn to fall asleep quickly and sleep soundly. sleep deprivation. Once you are www. and fitful sleep. After experiencing a few sleepless nights. Chronic insomnia may be caused by a number of medications or medical conditions (see Snoozing news The National Center on Sleep Disorders Research estimates that each year.Insomnia P eople with insomnia—the inability to sleep—may be plagued by trouble falling asleep. unwelcome awakenings during the night.edu/ . and sleepiness add $15. 20 Improving Sleep “Medical conditions and sleep problems. Although it’s the most common sleep disturbance.m. Stressful events. Finding a remedy requires uncovering the cause. insomnia is not a single disorder. and chronic if the problem persists.9 billion to the national health care bill. nervousness about an upcoming event (such as a wedding. some people learn to associate the bedroom with being awake. and are often anxious and irritable or forgetful and unable to concentrate. or discomfort from an illness or injury. mild depression. public speaking engagement. hoping this will lead to sleep. anxiety regarding the insomnia may also worsen. the time in bed is slowly extended until you obtain a full night’s sleep. or move).” page 16). or whatever amount of time you typically sleep at night. the insomnia usually recedes.har vard. Additional costs to society for related health problems. sleep disorders.. The causes of transient or short-term insomnia are usually apparent to the sufferer—the death of or separation from a loved one. and pelvic area. Immediate feedback helps you see how various thoughts or relaxation maneuvers affect tension. h a r v a r d . • Take several slow. If sleep does not follow quickly. Reconditioning Developed in the 1970s.Purchased at http://www. repeat. deep breaths through your nose. shoulders. your neck. Exhale with a long sigh to release tension. Techniques to quiet a racing mind—such as meditation. CBT for insomnia aims to change the negative thoughts and beliefs about sleep into positive ones. The idea is to train your body to associate your bed with sleep instead of sleeplessness and frustration. physical tension is to blame. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) teaches people new ways of thinking about and then doing things. then repeat the process until you’re getting a healthy amount of sleep. or place one under your knees to relax your back. • During the reconditioning process. enabling you to learn how to gain voluntary control over the process. phobias. a racing or worried mind is the enemy of sleep. your middle back. Progressive muscle relaxation. hips. Let them drop from your consciousness. Feel your shoulders relax. Biofeedback is usually done under professional supervision. with palms up. gently ignore them and return your attention to your breathing. • If thoughts distract you.sleeping well during the allotted six hours. and biofeedback—can be learned in behavior therapy sessions or from books. you can add another 15 or 30 minutes. and anxiety—as well as insomnia. • Go to bed only when you’re sleepy. is a tried-and-true. Relax any spots that are still tense. CBT has proved helpful in treating addictions.health. Put a pillow under your head if you like. forehead. jaw.edu/ 21 . get up at the same time every day and do not nap. drug-free technique for achieving both physical and mental relaxation.h e a l t h . arms. These are the rules: • Use the bed only for sleeping or sex. then return to bed. www. Feel your body relax and your lungs gently expand and contract. CDs. lower back. breathing exercises. Let your feet sink into the floor or the bed. upper back. People with insomnia tend to become preoccupied with sleep and apprehensive about the consequences of poor sleep. and scalp. This approach involves using equipment that monitors involuntary body states (such as muscle tension or hand temperature) and makes you aware of them. A typical approach is this: • Lie on your back in a comfortable position. abdomen. and hands. In others. The basic tenets of this therapy include setting realistic goals and learning to let go of inaccurate thoughts that can interfere with sleep. it’s always because I did not sleep well the night before”) • hopelessness (“I’ll never get a decent night’s rest”) • unrealistic expectations (“I need eight hours of sleep tonight” or “I have to fall asleep before my spouse does”) Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . If you’re unable to sleep. progressive muscle relaxation. Feel them getting heavy and becoming totally relaxed. Relaxation techniques For some people with insomnia. thighs. Are they painful or tense? Tighten the muscles briefly to feel the sensation. or classes. Rest your arms. this technique reconditions people with insomnia to associate the bedroom with sleep.harvard. Breathe softly. which involves progressively tensing and relaxing your muscles starting with your feet and working your way up your body. • Focus on your feet and ankles. Stay up until you are sleepy. tongue. move to another room and do something relaxing. e d u • Slowly move your attention through different parts of your body: your calves. This worry makes relaxing and falling asleep nearly impossible. Common types and examples of these thoughts include • misattributions (“When I feel nervous during the day. Your worries and thoughts will be there when you are ready to acknowledge them. Another way to release physical tension and relax more effectively is to use biofeedback. slightly apart from your body. ” page 48. newer. Subsequent research on people who did CBT alone or in combination with the drug zolpidem (see “Prescription medications for insomnia. just five sessions of CBT focusing on proper sleep techniques cut the average time it took people to fall asleep from 68 minutes to 34 minutes. Since behavioral therapies are as effective and may have longer-lasting beneficial effects. Those who received the six-week combined therapy followed by CBT alone for six months fared the best. I’ll embarrass myself at tomorrow’s meeting”) • performance anxiety (“It will take me at least an hour to fall asleep”). These medications enhance the activity of GABA. a neurotransmitter that calms brain activity. Also. suggest that shortterm medical therapy can help initially. benzodiazepines can lead to next-day drowsiness and sedation. related medications known as nonbenzodiazepines.harvard. which are also used to treat anxiety. which are typically prescribed in doses lower than those used to treat depression.” “I stand a good chance of getting a good night’s sleep tonight. Internet-based programs might help address that problem. helped long-term insomniacs boost their sleep efficiency compared with a control group. If your main problem is getting to sleep. Doctors prescribe several different types of medications to treat insomnia (see Table 3).health. CBT alone. If your problem is staying asleep. These medications should be discontinued www. the participants received no treatment. and other strategies can help insomniacs sleep better.edu/ . The newest sleep drug. ■ Benzodiazepines. Several small studies suggest that online CBT programs that teach people good sleep hygiene. usually for transient or short-term insomnia. or the combined therapy. such as triazolam (Halcion). One program. with 35% reporting that their sleep was “much improved” or 22 Improving Sleep “very much improved. and antidepressants. called SHUTi (Sleep Healthy Using the Internet). Another risk is that stopping the medication abruptly after long-term use can cause insomnia that’s even worse than the insomnia you had before you started taking the drug (a phenomenon known as rebound).Purchased at http://www. ramelteon. A cognitive behavioral therapist helps you replace these maladaptive thoughts with accurate and constructive ones. is classified as a melatonin-receptor agonist. Taken at night. see “Resources. After a few weeks.” (For more information about these programs. During the subsequent six months. In one study. described in a 2009 report in The Journal of the American Medical Association. they should be tried first when possible. One drawback of benzodiazepines is that they reduce how much deep sleep you get. but those who received the combined therapy had a larger increase in total sleep time. including older medications called benzodiazepines.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . But these drugs should be used at the lowest dose and for the shortest possible period of time.• exaggerating consequences (“If I don’t get to sleep soon. many people who use benzodiazepines develop tolerance—the need for more and more of the drug to obtain the same effect.har vard. Different benzodiazepines vary in how quickly they take effect and how long they remain active in the body. The findings.” The therapist also provides structure and support while you practice new thoughts and habits. a drug that lasts longer—such as estazolam (ProSom) or temazepam (Restoril)—may be necessary. the drugs may no longer promote sleep. These drugs are useful for patients with anxiety and insomnia that results from it.” at right) for six weeks found that both groups improved. but isn’t necessary for extended periods of time if you can learn and stick with good sleep habits. Another study documented at least mild improvements in about 80% of people who completed five weeks of online CBT. which selectively target sleep receptors in the brain.) Prescription medications for insomnia Prescription medications can be useful for some people with insomnia.” or “My job does not depend on how much sleep I get tonight. The biggest obstacle to successful treatment with CBT is patient commitment—some people fail to complete all the required sessions or to practice the techniques on their own. your doctor may prescribe one that begins working quickly and is short-acting. relaxation techniques.health. such as “All my problems do not stem from insomnia. weight gain Serotonin and norepinephrine reuptake inhibitor (SNRI) Upset stomach.under a doctor’s supervision because withdrawal may lead to muscle tension. dizziness. weight gain.harvard. dizziness. muscle relaxants. and zolpidem (Ambien)—in situations where they formerly prescribed benzodiazepines. or.health. drowsiness. physicians have found that they often help people with insomnia and therefore prescribe them. convulsions. headache Tetracyclic Dry mouth. venlafaxine (Effexor) mirtazapine (Remeron) amitriptyline (Elavil) doxepin (Sinequan) nortriptyline (Aventyl. sweating. Antidepressants* (for insomnia. restlessness. Nonbenzodiazepines (for insomnia) eszopiclone (Lunesta) zaleplon (Sonata) zolpidem (Ambien. zaleplon (Sonata). diarrhea. dizziness Tricyclics Dry mouth. the nonbenzodiazepines act only on the sleep receptors in your brain. nausea. Ambien CR) Headache. withdrawal symptoms occur if stopped abruptly.edu/ 23 . Many physicians now prescribe these drugs—which include eszopiclone (Lunesta). nonrestorative sleep. headache Should be used with caution by people with sleep apnea or other breathing difficulties. dry mouth. and sedatives). dry mouth. Pamelor) trimipramine (Surmontil) Melatonin receptor agonist (for insomnia at bedtime) ramelteon (Rozerem) Dizziness May exacerbate depression. nausea. faintness upon standing. h a r v a r d . constipation. sexual dysfunction. incomplete urination. constipation or diarrhea. Table 3 Prescription medications for insomnia Generic name (brand name) Side effects Comments Benzodiazepines (for short-term treatment of insomnia) alprazolam* (Xanax) clonazepam* (Klonopin) diazepam* (Valium) estazolam (ProSom) flurazepam (Dalmane) lorazepam* (Ativan) quazepam (Doral) temazepam (Restoril) triazolam (Halcion) Clumsiness or unsteadiness. in rare cases. excitement or anxiety. painful erections Selective serotonin reuptake inhibitors (SSRIs) Dry mouth. nausea. not to be used by people who have severe liver damage or who take fluvoxamine (Luvox). drugged feeling Avoid combining these medications with alcohol and certain depressants (including antihistamines. irritability. headache. skin sensitivity to sunlight. *Although the FDA has not approved these drugs for this use. Triazolam is a short-acting medication. sexual dysfunction trazodone (Desyrel) citalopram (Celexa) fluoxetine (Prozac) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft) Certain antidepressants should not be used with a monoamine oxidase inhibitor (MAOI) or during immediate recovery from a heart attack. weight gain.h e a l t h . jitteriness. headache. ■ Nonbenzodiazepines. dizziness. They also appear to have little or no effect on deep sleep. but they have a slightly different chemical composition. sweating. daytime drowsiness.Purchased at http://www. constipation. daytime drowsiness. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . tolerance may develop. sun sensitivity. lightheadedness. www. which means they cause fewer side effects. dizziness. not to be used with alcohol or other depressants. These medications also enhance the sleep-inducing activity of GABA. and depression) Serotonin modulator Dizziness. increased heart rate. insomnia. While benzodiazepines affect multiple brain recep- tors. weight gain. headache. If you experience any unusual occurrences. and avoid alcohol. The effect of antidepressants on sleep quality varies. they’re not perfect for everyone.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . In fact. antidepressants have fewer regulatory restrictions than benzodiazepines. Zaleplon and zolpidem act quickly (within 20 minutes) and. In addition. upset stomach. Although rare. talk to your doctor right away. Zaleplon wears off especially quickly. but only eszopiclone and zolpidem lengthen total sleep time. tolerance. some doctors believe antidepressants have fewer side effects and are safer for long-term use than benzodiazepines. These drugs also can increase leg movements during sleep. helps with problems with staying asleep as well as falling asleep. Ramelteon has a more potent effect than ingested melatonin. While nonbenzodiazepines have fewer drawbacks than benzodiazepines.edu/ . These medications are neither approved for insomnia nor proven effective for it. weight gain. wear off before your typical waking time. People who have severe liver damage or who use the www. Some people find the drugs aren’t powerful enough to put them to sleep. And the drugs may still cause morning grogginess. While zolpidem and zaleplon are both approved only to treat short-term insomnia (for up to 30 days).” at left). antidepressants do seem to help some people. The drug is approved to treat insomnia for people who have trouble falling asleep at bedtime. How they work isn’t clear. This does not mean eszopiclone is necessarily superior—just that its manufacturer took the time and expense to conduct studies to show the drug is safe and effective for longer use. ■ Antidepressants. It’s not clear if these medications lead to tolerance or rebound insomnia. dry mouth. The suprachiasmatic nucleus controls the circadian cycle of sleep and wakefulness. Several people even gained quite a lot of weight. Studies of depressed people who also have sleep problems show that the medication reduces the time it takes to fall asleep and nighttime arousals. nausea. so the medication can actually exacerbate insomnia. dizziness. but sleep may result from a sedative effect. ■ Melatonin-receptor agonist. 24 Improving Sleep well as headache. As a result of these incidents. in rare cases. Some people find certain antidepressants make them feel nervous or restless. The long-term effects of nonbenzodiazepines remain unknown. they reduce REM sleep but have little impact on deep sleep. use only as directed. sleepwalking and sleep eating (see “Sleeping pills and sleep eating. Eszopiclone takes a little longer to take effect and also lasts longer.har vard. but you can take one if you wake up in the middle of the night and can’t fall back asleep. as Sleeping pills and sleep eating Several news reports in 2006 drew attention to a strange side effect of zolpidem (Ambien): sleep eating. and. short-term amnesia. and that insomnia is often related to depression. Some of the driving cases occurred when people took sleep medication after drinking alcohol. A long-acting version of zolpidem.health. called Ambien CR. and.harvard. which helps some people fall asleep faster and can be used to change the circadian sleep phase. and sexual dysfunction—are common. However. Endep) and doxepin (Sinequan). eszopiclone is approved to treat insomnia for up to six months. in general.All three drugs make you fall asleep quicker. sleep driving. Ramelteon’s most common side effect is dizziness.Purchased at http://www. Those most commonly prescribed for insomnia include trazodone (Desyrel). Always allow enough time for sleep. for the most part. these incidents highlight the need for people who use sleep medication to be aware of the potential side effects and to use them properly. Ramelteon (Rozerem) works by attaching to the same receptors on the suprachiasmatic nucleus used by the body’s naturally produced melatonin (see page 5). amitriptyline (Elavil. and rebound insomnia.health. In addition. Other unusual side effects seen with Ambien and related drugs include sleepwalking. so they’re easier to prescribe. Side effects—namely dizziness. the drugs’ ability to ease anxiety and mild depression may make it easier for people with these problems to relax and fall asleep. in 2007 the FDA ordered the drugs’ manufacturers to issue strong new label warnings about the risks of unusual behavior and to produce brochures about safe use. or they reported finding evidence of a midnight feast with no recollection of the event. rarely. People were seen foraging for food at night but were unable to remember the episodes in the morning. and it may also worsen symptoms of depression. so it may not keep you asleep the whole night if you take it before bed. ” these products may contain biologically active substances that can have side effects or interact with other medications or supplements. or rebound insomnia. and others—contain 25 to 50 milligrams (mg) of the antihistamine diphenhydramine. largely because of their side effects but also because they are often ineffective in relieving sleep problems.health. Sominex. nor can they say Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . for example. fast or irregular heartbeat. which can also interact adversely with some drugs. Although marketed as “natural. since people produce less melatonin as they age. and there’s clearly a market for such products. the FDA does not regulate these products. quality. The drug may be more likely to benefit older rather than younger people. or heightened sensitivity to sunlight. which is essential for normal brain function. However. blurred vision. should you choose a sleeping pill. But do these products work? And if you try them.sea and. over the long term. But they can cause nauwww. a dietary supplement. be sure to ask your physician about the possibility of interactions with other medications. One small survey of people ages 60 and over found that more than a quarter had taken nonprescription sleeping aids in the preceding year—and that one in 12 did so daily. Over-the-counter antihistamines have a sedating effect and are generally safe. not falling asleep at the beginning of the night. or a mechanical device? Standard nonprescription sleeping pills Behind the riot of competing brands. more rarely. antidepressant fluvoxamine (Luvox) shouldn’t take it. Valerian root extract. A few. another antihistamine. Complications are generally more common in children and people over age 60. Even a single herb is a complex chemical stew. Researchers don’t know precisely which of these accounts for the herb’s effect. A study that pooled findings from 27 studies on the effect of medications like diphenhydramine found that elderly people who took these drugs faced a higher risk of cognitive problems. an herbal remedy. Each one— whether a tablet. Furthermore.h e a l t h . Over-the-counter sleep aids Drugstores carry a bewildering variety of over-the-counter sleep products. Many herbal products include a variety of active ingredients.edu/ 25 . or gelcap—contains an antihistamine as its primary active ingredient. such as Unisom SleepTabs. If you’re thinking about using such products (or already do so) be sure to tell your doctor.harvard. capsule.Purchased at http://www. so they aren’t tested for safety. contain 25 mg of doxylamine. dependence. As with other dietary supplements. contains more than 100 specifically identified substances. If you take nonprescription sleeping pills. More studies and clinical experience should help clarify the picture. Citing clinical studies that found ramelteon did not cause tolerance.4% of adult Americans had used some form of alternative medicine (mostly herbal supplements) for insomnia or trouble sleeping. But be aware that sleep experts generally advise against using these medications. this class of products is surprisingly straightforward. suggesting ramelteon’s usefulness may be limited. Diphenhydramine blocks the brain chemical acetylcholine. or accuracy of labeling. Alcohol heightens the effect of these medications. some of which might interact unfavorably with other medications you’re taking. effectiveness. older people’s primary sleep problem tends to be waking up during the night. e d u Dietary supplements A 2007 survey reported that about 1. Others—including AspirinFree Anacin PM and Extra Strength Tylenol PM— combine antihistamines with 500 mg of the pain reliever acetaminophen. Ramelteon has a short half-life of two to five hours. including delirium. h a r v a r d . there is no information about the safety of taking such medications Many nonprescription sleep aids contain antihistamines such as diphenhydramine. Most over-the-counter sleep aids—including Nytol. the drug’s manufacturer promotes it for long-term use. itching. Scientific understanding of these substances is limited. and many people who try them find they don’t work. A report by ConsumerLab—a commercial laboratory that periodically tests the quality of herbal remedies—found that nearly a quarter of valerian-based products appeared to contain no valerian whatsoever. the quality of valerian-containing products varies widely. including bronchial constriction. Chamomile is both mild and safe—although rare allergic reactions. and that even the positive studies showed only a mild effect. finding either minimal benefits or none at all. and what we know generally comes from small. Melatonin has a short half-life (one or two hours) and does not appear to pose any major health risks when taken for a short time.Mechanical devices Specially designed orthopedic pillows may help people with insomnia sleep better. Its long-term effects are unknown. www. A few studies suggest that valerian is mildly sedating and can help people fall asleep and improve their sleep quality. Despite some initial enthusiasm for synthetic melatonin. Finally. and gastrointestinal disturbances. and increase airflow. However.” However. exactly how they might interact with other medications. Readily available alternative sleep remedies include the following: ■ Valerian (Valeriana officinalis).har vard.harvard. But the market for such products is booming.edu/ . In Great Britain and Canada. can occur.Purchased at http://www. For people with sleep problems due to snoring or nasal congestion. Since the 1990s.health. ■ Synthetic melatonin. a synthetic version has been widely available in the United States as a supplement at health food stores and pharmacies. in conjunction with the onset of sleep.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . There are no scientific studies showing chamomile is effective in treating insomnia. a subset of people do appear to benefit: those whose insomnia results from delayed sleep phase syndrome (see page 40). may provide relief. short-term studies. is a traditional remedy long used to help people relax and become drowsy. 26 Improving Sleep ■ Chamomile. most subsequent research has been disappointing. headache. Thus. As with other unregulated remedies. a circadian rhythm disorder in which people don’t start to feel sleepy until hours after the traditional bedtime. The most common reported side effects are headaches. you should probably avoid this herb.health. dizziness. A 2004 review of the melatonin research by the federal Agency for Healthcare Research and Quality (AHRQ) concluded that the supplement “is not effective in treating most sleep disorders. thus improving sleep. reduce snoring. melatonin is classified as a medicine and available by prescription only. and dizziness. which includes ragweed. If you’re allergic to plants in the daisy family. and an equal number had less than half the amount claimed on their labels. a small plastic nasal support. adhesive-backed nasal strips (such as Breathe Right) or devices such as NoseWorks. Manufacturers contend that such products help keep nasal passages open. The brain’s production of the hormone melatonin peaks in the late evening. most doctors discourage the use of herbal medicines as sleep aids. Tea made from this flower. The AHRQ review found that melatonin enables people with this disorder to fall asleep an average of nearly 40 minutes faster than they would with a placebo. The most commonly reported side effects are nausea. the per-dose price of these remedies varies far more than that of standard sleeping pills. But little independent research has evaluated these claims. a member of the daisy family. a review in the Journal of Clinical Sleep Medicine pointed out that most of the studies were small and flawed. A particularly large uvula. Loud snoring may be a sign of sleep apnea. or a reaction to smoking. some people snore so loudly that they literally wake the neighbors. or tongue. In this surgery. people who snore only suffer from simple snoring produced when the muscles of the airways relax during sleep—a condition that doesn’t cause medical complications but may disrupt others sleeping nearby. and avoid sleeping pills or tranquilizers. Snoring With the onset of sleep. a life-threatening condition marked by frequent interruptions in breathing. Check with your physician before investing in such a breathing device. In most cases.Purchased at http://www. adenoids. Many women snore late in their pregnancies. a French physician reported successfully treating snoring with a type of laser surgery called laser-assisted uvulopalatoplasty (LAUP).edu/ 27 . tongue. before menopause. nose.harvard. which is done on an outpatient basis. or a very small jaw may also contribute to snoring. When a person’s nasal passages are swollen by a cold. Snoring occurs when the airway narrows too much. the physician uses a carbon dioxide laser to shorten the uvula and to make small cuts in the soft palate on either side of the uvula. and neck and may need to undergo sleep studies. Some encourage you to sleep on your side. muscles in the airway relax and the airway narrows. however. a phenomenon attributed to hormonerelated swelling of airway tissues. Doctors usually encourage overweight snorers to lose weight. The hormones progesterone and estrogen may play a protective role. Because snoring results from the flapping of loose tissue at the back of the soft palImproving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . women snore less than men. e d u Treatments for snoring Hundreds of devices are marketed as aids for people who wish to stop snoring or improve their nighttime breathing. For someone with a deviated septum.h e a l t h . h a r v a r d . and throat specialists in the United States use the procedure. similar to that used to treat sleep apnea. An operation may be necessary to correct a deviated septum or remove large tonsils and adenoids. the problem is ongoing. Some ear. As these nicks heal. but snoring increases among women later in life. physicians may recommend more extensive surgery. inexpensive ways to prevent snoring. a humidifier or medication may reduce swelling. Others keep air passages open by raising their heads with an extra pillow or by propping up the head of the bed a few inches. In 1990. ■ Laser surgery. Although snoring is rarely life-threatening. allergies. others are dental appliances that try to keep your airway open by preventing your tongue from falling back or by moving your jaw forward. For example. makes the surrounding tissue vibrate. sleep specialists take even simple snoring seriously. in turn. producing noise. In extreme cases. mouth. an elongated soft palate. the surrounding tissue pulls tighter and stiffens. It may also help to quit smoking. temporary snoring may occur.health. causing turbulent airflow. palate. A person who snores heavily deserves a thorough examination of the throat. which slow breathing and decrease muscle tone. This. www. If swollen nasal tissues are the problem. More than one-third of adults in one survey said they snored at least a few nights a week in the previous year. excess fat in the neck area may reduce the width of the air passage and promote snoring. forgo alcohol in the evening. In yet other people. enlarged tonsils. He or she may be able to recommend simple. some people snore only when lying on their backs and can be encouraged to lie on their sides by having a tennis ball or golf ball sewn into the back of their pajamas (which makes back sleeping uncomfortable).Breathing disorders in sleep A lthough relaxed and steady breathing is natural for most sleepers. the treatment may be repeated if snoring persists. fatty deposits in the airway walls. Also. A potentially life-threatening lack of oxygen and buildup of carbon dioxide. and throat specialists at Stanford University. over-the-counter painkillers can usually control any pain. and the incidence rises with age. developed by ear. while LAUP can be quite effective in stopping snoring. limiting obstruction of the back of the nose when a person falls asleep.ate. Sleep apnea used to be considered uncommon. causes little bleeding. it is less likely to occur when the tissue is smaller and stiffer. Sometimes the rods come out on their own. Another treatment for snoring is somnoplasty. and stroke. the FDA approved this procedure (also known as the Pillar procedure) in which up to three matchstick-sized stiffening rods made of polyester are implanted into the soft palate. or radiofrequency tissue volume reduction. it’s become a treatment option for obstructive sleep apnea. ■ Palatal implants.health. the tongue. LAUP is not considered an essential therapy and may not be covered by insurance. The disorder affects about one in 25 middle-aged men and one in 50 middle-aged women. but it may have to be repeated to achieve results. nose. If it causes pain or does not work. The doctor delivers radiofrequency waves through the tips of tiny needles inserted into the obstructive tissue to shrink it. since then. then the procedure may improve the symptoms. Although more than half of the estimated 18 million Americans who have sleep apnea are overweight. heart failure. The procedure. again under local anesthesia in the office. be sure you have a physician rule out sleep apnea before undergoing LAUP.Purchased at http://www. and automobile and workplace accidents. A New England Journal of Medicine study found sleep apnea doubles a person’s risk of stroke over a seven-year period. in which the airway becomes blocked during sleep. is reversible. the rods can be removed. done under local anesthesia. The relentless daytime fatigue that often results may lead to failed careers. Physicians rarely checked for it except in the stereotypical patient—an overweight. leading to the development of hypertension. At least one in 10 of those older than 65 has sleep apnea. By far the most common form is obstructive sleep apnea (OSA). It can even be life-threatening. the FDA approved this procedure as a treatment for snoring.edu/ . The rods help prevent collapse of the palate. or a floppy rim at the back of the palate. Obstructive sleep apnea Obstructive sleep apnea (OSA) occurs when the upper airway is blocked by excess tissue such as a large uvula. but without significant discomfort. In the mid-1990s. If palate collapse is the main reason for the snoring. Therefore. many are not. The procedure. A narrow airway makes obstruction all the more likely when airway muscles relax at the onset of sleep. broken marriages. middle-aged man who snored. Three or four procedures may be needed. nasal congestion. In 2004. Patients usually have a sore throat for about a week. People with OSA tend to have smaller airway openings than those who don’t.har vard. People typically experience some swelling immediately following the procedure.harvard. it has limited benefit if other anatomical problems are involved. After five weeks of healing. sleep apnea can have serious conse quences. At worst. Sleep apnea can wreak havoc on the cardiovascular system because the heart must work harder every time the person arouses to open his or her airway (see “Heart disease. the technique doesn’t appear to ease apnea. Somnoplasty is performed on an outpatient basis using a local anesthetic. as well as increasing efforts to breathe. cause the sleeper to wake and gasp loudly for air until blood oxygen levels return to normal. 28 Improving Sleep Sleep apnea Sleep apnea is a life-threatening condition in which breathing stops or becomes shallower hundreds of times each night.” page 12). In fact. a person with OSA cannot breathe and sleep at the same time.health. Untreated. and it often remained undiagnosed.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . Somnoplasty only takes a few minutes to perform and doesn’t cause bleeding. this procedure can be dangerous for people with apnea because it removes the warning signal of this breathing disorder. the tonsils. done under local anesthesia in an office. Some people with OSA repeat this cycle hundreds of times a night without being fully aware of what is www. ■ Somnoplasty. and moisturizing gels and sprays have not been shown to help. medication may be used along with these treatments. ■ Positive airway pressure. More than half of patients with OSA have high blood pressure. The snorer may choke. 5 points or less: Low probability of sleep apnea. In addition. Symptoms and signs of OSA are as follows: • S noring. and muscle relaxants. obesity is a major risk factor. Weight loss is the best treatment for weight-related OSA. additional treatments are often required. sedatives. air pressure devices. Because weight loss takes time and can be very hard to achieve and maintain. dental devices. but it doesn’t always cure the problem (see “Weight-loss surgery for apnea?” on page 32). David White.health. Men with a neck circumference of 17 inches or more and women with a neck circumference of 16 inches or more are at higher risk. the hallmark of OSA is frequent snoring that is loud enough to disturb a bed partner. Sleeping on one’s side instead of the back can work for people who have OSA only while sleeping on their back. or appear to hold his or her breath during sleep. • Do you snore on most nights (more than three times per week)? Yes–2 No–0 • Is your snoring loud (can it be heard through a door or wall)? Yes–2 No–0 • Has anyone ever told you that you stop breathing or gasp during sleep? Never–0 Occasionally–3 Frequently–5 • What is your collar size? Men: less than 17 inches–0 17 inches or greater–5 Women: less than 16 inches–0 16 inches or greater–5 • Have you had. high blood pressure? Yes–2 No–0 • Do you occasionally doze or fall asleep during the day when: You are not busy or active? Yes–2 No–0 You are driving or stopped at a light? Yes–2 No–0 Score 9 points or more: See your physician or a sleep specialist to assess the need for a sleep study. • Th ick neck. and sleepiness. www. Nasal strips. physician must use clinical judgment. The first-line therapy for most people with moderate to severe OSA is positive airway pressure (PAP). As with snoring. and some sleeping pills. Treatments for obstructive sleep apnea Treatments for OSA fall into four general categories— lifestyle changes. The condition can become even more perilous if a person with OSA uses substances that further relax airway muscles or suppress arousal or breathing. since fatty deposits surrounding the throat expand as people gain weight. Reprinted with permission from Dr. Research has shown that OSA is a cause of hypertension. In some cases. Boston. such as muscle relaxants. no problem) to a completely blocked airway (see Figure 6). Although many snorers have no medical problems. e d u ■ Lifestyle changes. • Hypertension. narrowing the airway. • Grogginess. they reason that insomnia—not a breathing problem—makes them sleepy during the day. or are you currently being treated for.happening.h e a l t h . 6–8 points: Uncertain. fatigue. Sleep Health Centers. and because other simple measures are usually not sufficient for more severe cases. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . alcohol. gasp. Others wake up after bouts of apnea and have difficulty getting back to sleep. and they may complain of insomnia or daytime sleepiness. They don’t realize how little sleep they’re actually getting and may routinely feel sleepy. People with OSA are excessively sleepy during the day and have two to six times as many traffic accidents as individuals without this condition.harvard. OSA occurs on a spectrum from a wide-open airway (that is. but people must work extra hard to inhale. Everyone with OSA should avoid alcohol. the airway is only slightly narrowed.edu/ 29 . mechanical dilators. although they have no significant drop in blood oxygen levels. This extra work wakes them up many times each night. The same treatments that help individuals with a fully closed airway are also effective for these cases. h a r v a r d . Mass.Purchased at http://www. and surgery. the use of an air-pressure device connected by a hose to a mask that covers the Screening for sleep apnea This six-question test can help you and your physician determine if you need to be tested for sleep apnea. They are less successful with severe OSA. CPAP generally leads to a great improvement in the amount of time spent in restorative deep sleep. which improves alertness the next day. air can’t enter the lungs. These pauses in breathing can last seconds to minutes and can occur up to 100 times per hour. Newer models are lighter and quieter. CPAP also reduces or eliminates hypertension. As a result. rather than staying at a fixed setting. Oral appliances that reposition the lower jaw and tongue. ■ Dental devices. a refinement called bilevel PAP (often referred to by the trademarked name BiPAP) may be more tolerable. preventing collapse when muscles relax during sleep and allowing the person to sleep normally and breathe regularly without interruption. and the resulting drop in oxygen signals the brain to send an emergency “Breathe now!” signal that briefly awakens the sleeper and makes him or her gasp for air. but they usually get used to it with time. allowing users to find the one that best fits the face and is most comfortable. CPAP is a lifelong treatment.nose. People usually try CPAP for the first time in a sleep laboratory.health. In many cases. It delivers air under higher pressure as the sleeper inhales and switches to a lower pressure during exhalation to make it easier to breathe out. mouth.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . For some people. which prevents the collapse of the airway when the muscles relax during sleep. permitting the airway to remain open. depending on your pressure needs at any particular moment. they can cause shifting of teeth and problems with the temporomandibular joint. excess fatty tissue around the palate and pharynx is the culprit. These devices are less cumbersome and easier to travel with than CPAP.harvard. 30 Improving Sleep The most common form of PAP is continuous positive airway pressure (CPAP). so be sure to get the device from a dentist trained in managing OSA patients and get regular folwww.edu/ . For people who have difficulty exhaling against the pressure of CPAP. From CPAP machine CPAP mask Restored air flow Opened airway A CPAP machine delivers continuous positive pressure via a mask that covers the nose.Purchased at http://www. and throat—is blocked. are fairly well tolerated and have a success rate of 50% to 70% for mild to moderate OSA. the upper airway— which includes the nose.health. Figure 6 Treating apnea with CPAP Nose Air flow Mouth Hard palate Soft palate Pharynx Blocked airway In a person with obstructive sleep apnea. but the blockage can occur anywhere along the airway. and dry mouth) and a timer that slowly builds up pressure to give you time to adapt and fall asleep more easily. In the example above. However. and many offer options such as warmed humidified air (which alleviates nasal congestion.har vard. so a technician can adjust the pressure during sleep. This allows the person to sleep normally without interruption. An important innovation (called AutoPAP) is the inclusion of an internal regulator that moves the pressure up and down. The air pressure delivered through the mask opens the airway. Others find it difficult at first to breathe out against a constant stream of air and to sleep with their mouth closed. skin dryness. in which the air pressure stays the same while breathing in and out. Many people adjust to it without any problem and report that their night in the laboratory is the best night’s sleep they’ve had in years. CPAP was once quite cumbersome but has become more comfortable. There are also a variety of mask styles. • Corrective jaw surgery. physicians have found that they sometimes help people with this condition and therefore prescribe them. If you have OSA. Surgery to move the upper or lower jaw forward may enlarge the upper airway for some people with OSA. Tricyclic antidepressants* amitriptyline (Elavil) clomipramine (Anafranil) desipramine (Norpramin) imipramine (Tofranil) nortriptyline (Aventyl. not to be used in conjunction with high doses of aspirin. find a surgeon who has a lot of experience with these procedures to improve your chances for success. Types of surgery for OSA include the following: • Uvulopalatopharyngoplasty (UPPP). if you decide on surgery. Pamelor) protriptyline (Vivactil) Blurred vision. vomiting. decreased sexual function Minimally effective. The procedure changes the facial appear- Table 4 Medications for sleep apnea Generic name (brand name) Side effects Comments Obstructive sleep apnea (medications are used with other therapies) SSRI antidepressants* fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) Upset stomach. What’s behind these poor success rates? Surgeons must deal with a long soft tube of tissue that can collapse at any point—or even at several points—and they can’t always predict exactly where it might collapse in the future. confusion. they have more episodes of apnea after the surgery than they had before. the procedure requires extensive training and experience. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . OSA can return. Uniphyl)* Heartburn. dry mouth. Although some patients improve. nausea. www. constipation. vomiting. Somnoplasty (see page 28) is sometimes used to treat mild OSA when other treatments have not helped. or diarrhea. and some patients’ symptoms actually worsen—that is. consult with a sleep specialist to review all your options. rash Should be used with caution by people with a history of convulsions. heart failure. h a r v a r d . including a sleep study done with the device in place to make sure it eliminates the OSA. does not treat apnea itself. There are limited data supporting its use. changes in hearing. • Somnoplasty. loss of appetite Not to be used if allergic to sulfa drugs.harvard. also used in obstructive sleep apnea. *Although the FDA has not approved drugs in this class for sleep apnea. Stimulants modafinil (Provigil) armodafinil (Nuvigil) Headache. nightmares. ■ Surgery. However. This procedure to remove throat tissue helps about 40% to 45% of people with OSA. a sizable percentage of patients don’t get better. should not be used by people with a history of kidney stones. Central sleep apnea (medications are first-line treatments) acetazolamide (Diamox)* Tingling in arms and legs. upset stomach.Purchased at http://www. Surgery corrects collapse at a single spot. or liver disease. theophylline (Theo-24. Centers with specialists in this procedure report success rates up to 90%.edu/ 31 .h e a l t h . That’s not to say surgery is always a bad idea. nervousness Approved to treat residual daytime sleepiness after treatment with positive airway pressure. decreased sexual function Minimally effective. Then. oxygen Nasal dryness and irritation Eliminates apnea in some patients. The rest may need to have further upper airway surgery or use PAP.low-ups. Most surgical procedures for sleep apnea do not have good success rates.health. so if a collapse later occurs at a different spot or in several spots. A related drug. was Weight-loss surgery for apnea? Bariatric surgery helps extremely obese people lose weight by reducing the size of the stomach. others will still have sleep apnea following surgery and likely need continued treatment. the FDA approved the use of the drug modafinil (Provigil) for this post-treatment sleepiness. In 2004. if the CSA is caused by heart failure. triggering the person to resume breathing (and often waking him or her as a result). CSA doesn’t cause snoring. the diaphragm and chest muscles stop moving. While both drugs can help people with OSA who have trouble staying alert in the day. Certain antidepressants slightly improve airway muscle tone and are helpful for a small percentage of people with mild OSA. ■ Medications.ance and teeth alignment and requires an extensive recovery period. falling blood oxygen and rising carbon dioxide levels set off an internal alarm. Initial reports suggested that the extreme weight loss following the surgery could effectively “cure” sleep apnea. which in turn guides treatment. Some specialists have started using palatal implants (see page 28) to treat people whose OSA results from an elongated soft palate. Central sleep apnea Central sleep apnea. to establish the underlying cause. Some patients use PAP and may also receive added oxygen. Shortly. • Stimulants. Medications for OSA (see Table 4) are used primarily in conjunction with other treatments. 32 Improving Sleep originally approved in 1999 to treat sleepiness from narcolepsy. medications to treat the heart failure may eliminate the CSA. can prevent the drops in blood oxygen that accompany airway collapse. Two classes of antidepressants are used: tricyclics and SSRIs. or CSA. or neurological damage. shift work. • Oxygen.edu/ . but people with this problem are usually aware of waking up during the night and often complain of daytime sleepiness. not in place of them. and OSA. • Antidepressants.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . oxygen does not prevent an airway collapse or sleep fragmentation. www.health. CSA becomes more common as people age and is more frequent and severe in those with heart failure. Although the airway isn’t blocked. including a sleep study. For example. It’s not yet clear what percentage of patients benefit or how long improvements last. which seems to temporarily stop the brain from making neurotransmitters that promote sleep. For people who have CSA only as they begin to fall asleep. solving the breathing problem. Some people with OSA still feel sleepy during the day even after successful treatment.har vard. However. was approved in 2007 for sleepiness resulting from narcolepsy. a mild sleeping pill may help them fall asleep and stay asleep.Purchased at http://www. Uniphyl) benefit some people (see Table 4).health. Therapy usually involves treating the underlying medical condition that has disrupted breathing.harvard. This rare condition warrants a thorough evaluation. bear in mind that the drug does not address the source of the problem and is therefore used with other treatments. Supplemental oxygen. •P alatal implants. Medications such as acetazolamide (Diamox) and theophylline (Theo-24. so it’s used in addition to other treatments. chronic lung disease. occurs when respiratory centers in the brain fail to send the necessary messages to initiate breathing. But subsequent research revealed that while surgical weight loss can reduce the severity of sleep apnea and eliminate the condition in some people. administered through tubing in the nose. The drug. armodafinil (Nuvigil). only occur at night.Purchased at http://www. Some people report that their symptoms started in adolescence and that adults attributed the problem to growing pains or back trouble.edu/ 33 . enjoy a movie. such as pacing. accompanied by an uncomfortable urge to move the limbs. 2005. h a r v a r d . symptoms are worse when sitting still. Sleep deprivation is a major problem for individuals with RLS. Restless legs syndrome Restless legs syndrome (RLS) is a neurological disorder characterized by strange sensations in the lower legs. in many cases. RLS usually worsens with age (see Figure 7). In 2007. and it’s normal for muscles to jerk at the onset of sleep. or a stress-related disorder. 1286–92. two research teams identified specific genes linked to the development of RLS that may account for up to half of all cases of the disorder. rocking. Adapted from Archives of Internal Medicine. or stretching the leg muscles. people with RLS are frequently thought to have psychiatric problems. But people with certain neurological disorders that trigger excessive limb movements may find it impossible to obtain a restful night’s sleep. Motion may relieve the discomfort temporarily. doing knee bends. manicdepressive illness. In recognition of the restless nights suffered by people with RLS. Women may find that symptoms flare up during men- Figure 7 Prevalence of restless legs syndrome by age 6 4 Percentage S leep is not always as quiet and peaceful as we’d like it to be. they were often misdiagnosed as having hypochondria. June 13. as the symptoms are most prominent at night—or. the nonprofit Restless Legs Syndrome Foundation titled its newsletter NightWalkers (see “Resources. or applying cold or warm compresses. As many as half of people with RLS note that other members of their family have similar symptoms.” page 48). pp. and the irresistible urge to move can make it difficult for some people with RLS to take car or plane www. e d u trips. Because the symptoms sound bizarre or vague. People develop a variety of coping strategies. two-thirds of them women. Some people are troubled by uncontrollable limb movements. During the day. and the need to be constantly mobile seems like nervousness.Movement disorders and parasomnias Movement disorders Sleepers typically shift position every 15 to 30 minutes. but it tends to be more common and severe in people over 50. Children who have RLS are often diagnosed as having attention deficit hyperactivity disorder. and occasionally the arms.health. Some people get temporary relief by rubbing or squeezing their leg muscles. or even hold a desk job. RLS symptoms may compel the person to get in and out of bed many times. while others experience parasomnias (unusual behaviors during sleep). knees. or even years.h e a l t h . wrapping their legs in bandages. and each child of an affected person has a 50% chance of inheriting the condition. days.harvard. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . 2 0 20–29 30–39 40–49 50–59 60–69 70–79 80+ Age (years) RLS can occur at any age. The daytime symptoms sometimes abate for a few hours. Many people don’t seek medical attention until their late 30s. RLS affects about 10% of people ages 30 to 70. In the past. or stretching—performed to relieve uncomfortable sensations in the lower legs and knees. Restless legs can be a complication of alcoholism. diabetes. Periodic limb movement disorder A neurological condition called periodic limb movement disorder (PLMD) causes people to kick and jerk their arms and legs throughout the night. knee. so the same movement— involving the hip. burning. are good choices. Finally. Some people find that cold showers are beneficial. stress. but the reverse is not true. heart failure. typically occurring every 20 to 40 seconds. Several small studies suggest that exercise can ease both RLS and PLMD. Although the drugs used to treat RLS and PLMD are the same as those used in treating Parkinson’s disease.health. pregnancy. some people with mild RLS may be able to get to sleep by simply massaging their calves or stretching their legs in bed. Drugs that ease the tremors of Parkinson’s disease also reduce the number of leg movements and thus improve quality of life for people with RLS and PLMD (see Table 5). www. or prolonged exposure to a cold or very warm environment worsens the symptoms. causing partial arousals that disrupt sleep. But most people with moderate to severe RLS need medication. These include bromocriptine (Parlodel). Involves voluntary movements— pacing. in some cases. pramipexole (Mirapex). people with these sleep disorders are no more likely to develop Parkinson’s disease than other individuals. People with RLS are aware of their symptoms.Purchased at http://www. Treatments for movement disorders Doctors diagnose RLS and PLMD based on the individual’s description of symptoms and. caffeine. PLMD results when the movements disrupt sleep enough to produce daytime sleepiness. However. antidepressants. Occurs during sleep. unconscious awakenings that disrupt sleep. people with PLMD awaken for a few seconds at a time (generally without realizing it) and frequently skip back to the lighter stages of sleep. In some people. Diagnosis usually requires a sleep study. These repetitive movements are called periodic limb movements of sleep and can cause brief arousals. which in 2005 became the first drug approved by the FDA to treat RLS.har vard. such as biking or swimming. Standard neurological examinations often reveal no abnormality.harvard. knee. fatigue. or lithium—can exacerbate RLS. or kidney failure. and not all of these people experience the brief. 34 Improving Sleep According to some estimates. but instead cluster in the first half of the night and occur mainly during non-REM sleep. iron-deficiency anemia. Their leg and arm muscles involuntarily contract about every 20 to 40 seconds. or ankle—may be repeated hundreds of times a night. Certain medications—including antihistamines. with intervals of sound sleep in between. observations during an overnight sleep study. and hip. or they may continue for hours. as many as 30% to 50% of people ages 65 and older have PLMD. rocking. tingling.edu/ . that figure is based on observations of leg twitches alone. usually repetitive flexing of the big toe. and ropinirole (Requip). Most people with RLS also have PLMD. Episodes of PLMS may last only a few minutes. and “creepy. They usually don’t occur continuously throughout the night. walking or other moderate exercise. Instead of proceeding smoothly through all the sleep stages in regular cycles. ankle.health. levodopa-carbidopa (Sinemet). Involves involuntary movements. people with PLMD are often oblivious to the movements and may wake up baffled at why they feel exhausted despite getting what they thought was a full night’s rest. RLS and PLMD What’s the difference? Restless leg syndrome (RLS) Periodic limb movement disorder (PLMD) Occurs while awake.struation. which include aching. Unless a bed partner complains. knee bends. Often worse after periods of inactivity and at bedtime. but others prefer heat. Diagnosis is based on a patient’s description of symptoms. Episodes last anywhere from a few minutes to several hours. nicotine. Affected people usually aren’t aware of their symptoms unless a bed partner complains. At least one in four pregnant women experiences restless legs. the two disorders have several key distinctions (see “RLS and PLMD: What’s the difference?” below). In fact.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . crawly” sensations in the legs. sometimes preventing sleep. or menopause. constipation. h a r v a r d . nausea. Scientists used to believe that sleepwalkers were acting out their dreams. nausea. most physicians are reluctant to treat sleep disturbances with these drugs. Opiates (opium-derived drugs) such as oxycodone (OxyContin) may be used to treat people with severe RLS symptoms who don’t respond to other treatments. Abnormal movements. The tendency seems to be inherited. next-day sedation. for some. who take monoamine oxidase inhibitors (MAOIs). depression. but experts have determined that sleepwalking does not occur during dreaming. congestion Tegretol may reduce the number of blood cells produced by your body. body aches. dramatically reduce leg movements at night. Parasomnias People with parasomnias may wake up enough to carry out complex behaviors. headache Should be used with caution by people with sleep apnea or other breathing difficulties. Sometimes sleepwalkers carry out complex actions. Most people who take these medications for insomnia develop a tolerance to them after a few weeks. there is Table 5 Medications for movement disorders Generic name (brand name) Side effects Comment Clumsiness or unsteadiness. occurs during partial awakening from deep sleep. They can be difficult to awaken and typically have no memory of the episode in the morning. with few people endangering themselves or others. among others. which may help them stay asleep during leg movements. but not enough to realize what they are doing. withdrawal symptoms may occur if stopped abruptly. lightheadedness. Episodes of sleepwalking are usually brief and benign. at other times they simply pace or sit on the edge of the bed performing repetitive behaviors. or who have glaucoma. Somnambulism and somniloquy Somnambulism. There have been reports of somnambulists committing murder. Percocet) Anticonvulsants carbamazepine (Tegretol) gabapentin (Neurontin) valproic acid (Depakene) *Ropinirole and pramipexole are FDA-approved to treat RLS. or sleepwalking.Purchased at http://www. not to be used by persons with sleep apnea. but this doesn’t seem to happen when such drugs are taken for RLS. Depressed breathing and circulation. although this is extremely rare. But because of the potential for addiction. dizziness. when properly used. Other medications in this chart are not approved to treat RLS or PLMD.health. However. and night terrors.People with mild movement disorders may be prescribed clonazepam (Klonopin) or temazepam (Restoril). Opiates decrease the discomfort of RLS and. but physicians have found that they help people with these conditions. www. These sleep-disrupting behaviors include sleepwalking.harvard. Sleepwalking is common in children and probably occurs because their brains have not yet mastered regulation of sleep and waking. habit-forming. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . who have hypertension. Benzodiazepines clonazepam (Klonopin) temazepam (Restoril) Dopamine agents bromocriptine (Parlodel) levodopa-carbidopa (Sinemet) pramipexole* (Mirapex) ropinirole* (Requip) Opiate oxycodone (OxyContin.h e a l t h . mental changes. sleep eating. should not be used with alcohol or other depressants. Unsteadiness. Although people are more likely to sleepwalk when they’re anxious or fatigued. daytime drowsiness. vision problems. not to be used with alcohol or other depressants. dizziness or lightheadedness. they may provide long-term benefit with little risk of addiction. vomiting Risk of addiction. dizziness Certain drugs in this class should not be used by people who are sensitive to ergot drugs.edu/ 35 . Sleep-related eating disorder occurs more frequently in people with eating disorders and depression. but results have been mixed. children have little control over bedwetting and that admonishments and punishments won’t solve the problem. ■ Sleep-related eating disorder is a combination of a sleep disorder and an eating disorder. Almost all bedwetting children eventually stay dry at night. Occasionally. people who talk in their sleep rarely remember what they said. or a nervous system defect leads to bedwetting.health. is common among children. ■ Nocturnal eating syndrome occurs most commonly in people with daytime eating disorders or depression. is usually due to slow maturation of bladder control. When a specific physical problem such as a structural abnormality of the urinary tract. even without treatment.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . Consult your pediatrician for further details.health. A number of medicines have been tried to treat these disorders. Don’t show disgust or disappointment. it results from psychological stress. or a sleep problem such as narcolepsy.harvard. and only 1% to 2% of children still wet the bed by the time they’re 15. and opiates. Nocturnal eating disorders The two types of nighttime eating disorders are nocturnal eating syndrome and sleep-related eating disorder. a urinary tract infection. However. Parents should remain calm as they change the bed sheets and underpants. if it’s still occurring by age six. such as cookie dough. however. The person is awake and fully alert during the episode and can recall it the next day. but respond by eating. as a last resort. Statistically.little correlation between somnambulism and psychological problems. anticonvulsants. Sleep-related eating disorder occurs in children and adults and sometimes can be traced to an illness 36 Improving Sleep or traumatic event. Often they consume unhealthful. Bedwetting. Only occasionally can someone who talks in his or her sleep hear and respond to what someone else says. a doctor may prescribe medications such as benzodiazepines. they can’t go back to sleep without eating. extreme stress. Bedwetting occurs in a very small percentage of adults and is often due to an underlying medical problem or excessive caffeine or beer consumption. They are usually light sleepers and wake frequently. medications. If the condition presents a risk of injury. sleep apnea. Within minutes after getting out of bed. and. 80% to 85% of children are consistently dry throughout the night by age 5. the individual should be evaluated to determine whether sleepwalking is the result of nighttime epilepsy or a reaction to medication. Talking can occur during any or all stages of sleep. They report being half-awake or asleep during the episodes and have very poor memory of the events or no recollection at all. Other options include setting up a token-and-reward system to motivate the child to stop wetting the bed. is nothing to worry about. Sometimes medications prescribed for depression or insomnia can cause this disorder. known medically as sleep enuresis. treatment should address both the sleep disorder and the existing eating disorder. or talking in one’s sleep. not during the daytime. diabetes. It’s important for adults to understand that. In www. antidepressants. or periodic limb movement disorder. If the condition continues beyond puberty. It’s considered a problem. the number of children who continue to wet the bed decreases by about 15% per year. Although they aren’t really hungry. sleepwalking. bulimia. After that. Nocturnal eating syndrome should be treated as an eating disorder.Purchased at http://www. including dopaminergic agents. which occurs more frequently among boys than girls. initially. the child will also have difficulty with daytime bladder control. people with this condition raid the refrigerator and begin wolfing down food. using an alarm that wakes the child upon the first sign of wetness. overeating occurs only during sleep hours. In some people with this disorder.har vard. A medical evaluation may reveal an ulcer. Reminding the child to urinate before going to bed and limiting liquids in the last two hours before bedtime may reduce or eliminate the problem. high-calorie food. Somniloquy. bladder training exercises. People with this disorder experience partial arousals similar to sleepwalking. or another sleep disorder. a history of strict dieting. People are more likely to talk in their sleep during times of stress or illness.edu/ . When awakened. Bedwetting Bedwetting. a medium-acting benzodiazepine may help suppress symptoms. a person may seem confused and agitated. people can protect themselves and loved ones by sleeping in a separate room and putting sharp or breakable objects out of reach. breathlessness. trembling. and attempt to fight or flee. If you experience frequent nightmares that aren’t linked to medication use. The sleeper may let out a bloodcurdling scream.health. e d u rates. REM sleep behavior disorder Most people make subtle twitching movements during REM sleep. h a r v a r d . helping you imagine confronting or driving off a pursuer. such as antidepressants. Alcoholics who stop drinking often experience dream disturbances and nightmares. Nightmares can be a side effect of certain medications. They appear to run in families and occur most often in children. but there are occasional reports of it occurring in younger adults and children. Until the problem is under control. People with this condition awaken suddenly because of episodes of intense panic characterized by a racing heartbeat. and nine out of 10 people who have it are men. medical treatment may be recommended. sleep terrors occur during non-REM sleep. but occasionally sleepers shout. It’s estimated to occur in one in 200 people (0.edu/ 37 . Bedwetting may be a side effect of diuretic pills or a sign of diabetes. ■ Sleep-related panic attacks. sit bolt upright. Nightmares. Approximately 70% of people with REM sleep behavior disorder go on to develop Parkinson’s disease. Some doctors prescribe medications such as benzodiazepines that suppress deep sleep. an enlarged prostate gland that presses against the bladder may be to blame. A sleep terror can be quite dramatic to witness. narcotics. or the feeling that they may be dying. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . are bad dreams that become so threatening that a person wakes in a state of fear and agitation. The disorder nearly always arises after age 50. The therapist may guide you through typical dream sequences—for example. The most common approach is a type of behavioral therapy known as desensitization. Adults with sleep terrors tend to be more agitated. epilepsy. This phenomenon— known as REM sleep behavior disorder—was identified in the 1980s. on the other hand. During an episode. suggesting that similar brain structures are involved in both conditions. or otherwise act out their dreams. If the person is at risk of harming himself or others or is having daytime sleepiness from the sleep disruption. Nightmares can also occur when a person stops taking drugs that temporarily reduce REM sleep. he or she is likely to go right back to sleep and later may not remember what happened. counseling may help. or serious obstructive sleep apnea. sleep terrors.harvard. Nightmares occur mainly during REM sleep. may focus on identifying and resolving past and present emotional issues that play themselves out in nightmares. Unlike nightmares. a bladder or kidney problem. and aggressive than children who have this problem.Purchased at http://www.h e a l t h . Treatment for adult bedwetting depends on the cause. sweating. which may last as long as 15 minutes. in which the sufferer recalls the details of the nightmare and uses relaxation techniques to overcome fear. Hypnosis or a relaxation technique known as guided imagery may also be helpful.men. and barbitu- www. such as benzodiazepines.5%). punch. which usually occur early in the morning. ■ Nightmares. A psychoanalytically oriented therapist. Anti-anxiety drugs are often useful for both daytime and nighttime attacks. ■ Sleep terrors. and panic attacks Nightmares. usually in the first hour or so after going to bed. when the body barely moves. anxious. When the episodes involve violent or injurious behavior. After the spell is over. sleep terrors. and sleep-related panic attacks can interrupt sleep. Nightmares. Other medications in this chart are not. improve nighttime sleep. Should not be used with MAOIs. trouble urinating.edu/ . headache. it takes five years of symptoms and visits to five physicians before a diagnosis of narcolepsy is made.har vard. insomnia. To prevent cataplexy and other REM-related symptoms Dizziness. diarrhea or constipation. chills. sweating. In the late 1990s. but physicians have found they often help people with narcolepsy and therefore prescribe them. Concerta) To counter daytime sleepiness Nervousness. or cataplectic attacks (see “Cataplexy. nausea. A variety of other symptoms may also be present. It affects both sexes and all races equally. Less potential for abuse than other stimulants. To prevent cataplexy.000 people has this condition. headaches. researchers Table 6 Medications for narcolepsy Generic name (brand name) Use Side effects. Should not be used by people who take monoamine oxidase inhibitors (MAOIs) or who have glaucoma. armodafinil. drowsiness.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . dizziness. stomach discomfort. Potential for abuse. researchers discovered that many cases of narcolepsy result from the lack of a brain chemical called hypocretin (sometimes called orexin) that normally maintains wakefulness and helps regulate sleep. dizziness. irregular heartbeat. and sexual problems. weight loss. Metadate. About one in 2. headache. Instead of occurring normally—after a steady progression through the other stages of sleep—REM sleep or features of REM sleep intrude at unusual and unwelcome times. This is because sleepiness may be the only symptom. nervousness. although symptoms sometimes appear in early childhood or middle age. Narcolepsy usually becomes apparent during adolescence or young adulthood. On average. Potential for abuse. and it has a genetic component. Must be taken at bedtime and again during the middle of the night. The discovery of the gene that makes hypocretin and the location of its production in the brain has spurred research focused on new ways to diagnose and treat this disorder. nausea.Purchased at http://www.harvard. 38 Improving Sleep www. insomnia. Should not be used with MAOIs or during immediate recovery from heart attack. drowsiness. dry mouth. People with narcolepsy lose the cells that make hypocretin. Stimulants Tricyclic antidepressants clomipramine (Anafranil) desipramine (Norpramin) imipramine (Tofranil) protriptyline (Vivactil) SSRI antidepressants fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) Anticataplectic sodium oxybate (Xyrem)* *Modafinil. and reduce daytime sleepiness Abdominal pain. or even in the midst of daytime activities.Narcolepsy N arcolepsy is a disorder of sleep/wake regulation whose hallmark is daytime sleepiness.health. dry mouth. as soon as a person lies down. changes in blood pressure and pulse. having a close relative makes a person 20 to 40 times more likely to have it. constipation. and sodium oxybate are FDA-approved to treat narcolepsy symptoms. disturbance of heart rhythm. but abnormalities of REM sleep seem to underlie each one. comments dextroamphetamine (Dexedrine. Adderall) methylphenidate (Ritalin. blurred vision. such as immediately after sleep begins. loss of appetite. To prevent cataplexy and other REM-related symptoms Nausea. nervousness. abnormal dreams.” page 39) may be misdiagnosed as epilepsy or fainting. modafinil* (Provigil) armodafinil* (Nuvigil) To counter daytime sleepiness Anxiety. In 2009. loss of appetite. weight gain.health. it must be taken at bedtime and again during the middle of the night. Because of its chemical properties. known as hypnagogic hallucinations. and often have great trouble completing tasks.reported a link between narcolepsy and variations in a gene that controls immune function. depriving narcoleptics of restorative rest and www. also known as gamma hydroxybutyrate (GHB). however. Just as sleep intrudes during the day. A person may suddenly lose muscle tone while awake. A person may suddenly fall asleep for five to 10 minutes when relaxing or even while carrying on a conversation. which occurs when the brain mechanism that paralyzes muscles during REM sleep becomes activated. ■ Disturbed nighttime sleep. people are never as alert as they would be if they didn’t have this condition. For example. are difficult to distinguish from reality. Even with medication. one man washed and dried the dishes and then stacked them in the refrigerator. People with narcolepsy struggle to stay awake during the day. ■ Automatic behavior. causing the head to fall forward and the knees to buckle. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . or other strong emotions often trigger cataplexy.Purchased at http://www. This usually happens just at sleep onset or upon awakening. ■ Cataplexy. Some feel as if they have hardly slept at all. Xyrem is tightly regulated because of its potential for misuse. but in severe cases. sertraline (Zoloft). but they aren’t as potent as the older stimulants. When REM dreaming occurs during wakefulness. Modafinil (Provigil) and armodafinil (Nuvigil) are once-a-day medications to promote wakefulness that have a different mechanism of action. Because of their profound sleepiness. They speculate that the loss of hypocretin-producing cells may stem from an autoimmune process. A person may see prowlers or believe that his or her house is on fire. unwelcome awakenings can occur at night.h e a l t h .health. the person sometimes makes conversation that is appropriate to the dream instead of the actual situation. Most attacks last for less than 30 seconds and may go unnoticed. A terrifying feeling of paralysis may occur during the transition between wakefulness and sleep if the REM stage begins before a person is fully asleep. ■ Hypnagogic hallucinations. so there’s less concern about misuse or abuse. people with narcolepsy perform many routine tasks without being fully aware of what they are doing. ■ Sleep attacks. in which the body mistakenly attacks itself.harvard. paroxetine (Paxil). Treatments for narcolepsy Treatment for narcolepsy is geared toward improving wakefulness during the day and preventing REMrelated symptoms. Laughter. Because these medications have been abused as recreational drugs and misused as diet pills. it has been associated with criminal acts such as date rape. clomipramine (Anafranil). This condition can be confused with mental illness because its symptoms resemble those of some psychotic disorders. drug enforcement agencies often require physicians to provide extensive documentation when they prescribe them. anger. e d u exacerbating daytime drowsiness.edu/ 39 . antidepressants that suppress REM sleep—such as fluoxetine (Prozac). the vivid and often frightening images. This medication helps decrease the number of cataplexy episodes and may improve nighttime sleep and reduce daytime sleepiness as well. ■ Sleep paralysis. Symptoms of narcolepsy Narcolepsy may manifest in any of several ways: ■ Excessive sleepiness. such episodes can cause great anxiety. the person may fall and stay paralyzed for as long as several minutes. but had no recollection of doing so. h a r v a r d . If REM sleep and dreaming occur immediately. Most people require stimulant medications such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) to counter sleep attacks and drowsiness (see Table 6). Although muscle control usually returns within a few minutes. They don’t cause such side effects as euphoria or weight loss. In most people. or venlafaxine (Effexor)—can also prevent cataplexy and other REM-related symptoms. Another medication for cataplexy is sodium oxybate (Xyrem). Treatments being studied include bright light therapy in the evening. and carefully timed doses of melatonin.Purchased at http://www. In addition to having headaches.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . A delayed sleep phase also can be reset in a single weekend. and eventually can’t stay awake past early evening. They may be able to gradually synchronize their schedule with others by going to bed and getting up at the same time every day. You can also gradually adjust your sleep time prior to leaving www. or a weekend of latenight parties—can throw them off kilter unless they force themselves to get up at the same time every day. wake up in the early morning. and difficulty concentrating. stomach upset. get up at 7 a. a coast-to-coast trip. which contains the entire spectrum of light wavelengths. patients typically sit for 30 minutes facing a specially manufactured box that emits bright light with a minimal amount of ultraviolet light. called advanced sleep phase syndrome. This condition. Melatonin may also have a role in treating delayed sleep phase syndrome.edu/ . they would generally go to sleep and wake up much later each day. wake yourself up at the same time each day. From then on. such as alarm clocks.m. taking 1 to 3 milligrams at your desired bedtime may help advance your sleep schedule. it’s easy for their sleep patterns to go awry when they go on vacation or retire. adhere closely to the same bedtime and waking time seven days a week. Younger people usually adapt more quickly to time changes than older people. people may long for sleep when they need to be awake or may stay up until the wee hours of the morning without feeling tired. Only by relying on external cues. The standard way to handle jet lag is to try to sleep only at night upon arrival and to get up early in the morning. More recent studies suggest that blue light is the most potent part of the spectrum for resetting the circadian clock. although it may be difficult the first few days. It takes about a day to adjust for every time zone crossed. do they manage to stay in sync with a more conventional schedule. On Sunday. Night owls have trouble getting anything done in the morning.Disturbances of sleep timing W hen their internal clocks are disturbed. which helps reset the body’s clock.harvard. Delayed sleep phase syndrome Almost everyone is programmed for a day that lasts slightly longer than 24 hours. Left to their own devices.har vard. Jet lag Many people find that crossing several time zones makes their internal clocks go haywire.m. go to bed three hours later each night. Night owls often find that a minor shift in sleep/wake cycles—such as the onset of daylight savings time. but “night owls” are less sensitive to the environmental cues that help most people maintain the usual 24-hour cycle. This requires staying up all night on Friday and all day Saturday. Resetting your internal clock Exposure to bright light as directed by a sleep specialist—a technique known as light therapy—may be useful in treating delayed sleep phase syndrome.health. To do this. Initial studies used white light. they may suffer from fitful sleep. is more common among older people. Once you have synchronized your schedule to match that of the other people around you.health. Upon awakening. Another option is to move your bedtime progressively later until you’ve shifted around the clock and 40 Improving Sleep are back in sync. Many people have more difficulty traveling eastward. Advanced sleep phase syndrome People whose body rhythm cycles are shifted much earlier go to bed earlier. However. then going to bed around 10 p. but older people may have more symptoms traveling westward. This way your body can start adjusting to the new time zone as soon as possible. If you need to wake up earlier in the new setting (flying west to east). make it 90 minutes. The next night. On a brief trip just one or two time zones away. get out in the early morning sun. often the most important factor is weekend changes in sleep habits. The day before you travel. spend as much time outdoors as possible to let daylight reset your internal clock. don’t turn in until it’s bedtime in the new time zone. Sunday insomnia People often have trouble falling asleep on Sunday nights. go to bed half an hour earlier than usual. For example. as when flying coast to coast. For the first day or two.h e a l t h . you are primed to stay up even later Saturday night and sleep in the next day. police officers. www. and get up half an hour earlier the next morning. Short-term use of timed doses of melatonin or ramelteon to shift circadian rhythms or over-the-counter or prescription sleep aids to help you sleep at night also can be helpful.(see Figure 8). People who have devel- oped a pattern of Sunday insomnia may feel their anxiety mount as they anticipate a difficult night ahead. expose yourself to late afternoon sunlight. • Drink plenty of fluids. three days before you plan to travel from the West Coast to the East Coast. Figure 8 Reset your biological clock Day 1 Day 2 Day 3 9:30pm 9:00pm Usual bedtime 10:00pm Day 4 8:30pm • Switch as rapidly as possible upon arrival. Shift work More than 20% of American workers—including health care workers.Purchased at http://www. Even a partial switch may make the trip easier.harvard. move mealtimes and bedtime incrementally closer to the schedule of your destination. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . e d u Traveling west to east Help reset your biological clock when you travel through time zones. Caffeine and alcohol promote dehydration. h a r v a r d . and sleep on home time.health. • Use the sun. If you need to wake up later (flying east to west). you maintain the same wake-up time while still compensating for your sleep deprivation. The best way to avoid the Sunday blues is to maintain the same wake-up time and bedtime on the weekends as during weekdays. go to bed an hour earlier than usual and get up an hour earlier. your body’s clock is programmed to stay up late. eat. but not caf- feine or alcohol. security guards.edu/ 41 . While anxiety about work or school on Monday is a potential cause. Schedule appointments for times when you would be alert at home. For several days before you leave. it may be possible to wake up. the next best thing is to force yourself to get up at your weekday wake-up time and take an early afternoon nap on Saturday and Sunday. When you stay up later Friday night and sleep in Saturday morning. By Sunday evening. which worsens the physical symptoms of jet lag. • Gradually switch before the trip. you can gradually adjust your sleep time. If you’ll be traveling through several time zones. This way. By the fourth day—the day of your trip—you’ll find it easier to adjust to your new time zone. On a long trip. If this isn’t possible and you end up staying up later than usual on Friday and Saturday. They can also disturb sleep. Ways to avoid jet lag • Don’t time-shift. Dark curtains or eyeshades can keep daylight out. These people fall asleep on the job two to five times more often than day-shift workers do. or by maintaining the same schedule seven days a week. by rotating shifts from day to evening to night rather than the other way around. Shift workers need to enlist the help of family members to get enough sleep while maintaining a schedule at odds with the rest of the world. plane. which may induce the craving for carbohydrates. Researchers speculate that people who suffer from this condition.edu/ .harvard. Sleep-deprived physicians. as is the short-term use of sleep medications. and drawn to high-carbohydrate foods.har vard. Shift workers can also benefit from practicing good sleep hygiene (see “Tips for a better night’s sleep. As the days get shorter. Shift workers’ sleep disruption can be eased somewhat by incorporating scheduled breaks. called seasonal affective disorder (SAD). truck.health. The most successful shift workers are those 42 Improving Sleep who block out time for sleep in advance and then are vigilant about protecting their sleep time from outside intrusions. Light therapy is sometimes recommended to help people get used to a new schedule. Antidepressants can also be helpful. Sleepiness can be catastrophic for people in these vital roles. Seasonal affective disorder In some parts of North America. and running a fan can help block external noise.Purchased at http://www. make a greater number of errors than their better-rested colleagues. About 60% to 70% of shift workers experience sleep disturbances. sleepy.health. and it’s common for fatigue to play a role in overnight rail.and transit workers—are on the evening or night shift. Exposure to bright light in the morning for 30 minutes may alleviate the symptoms of SAD and help people wake up in the mornings. some people find themselves depressed.” page 14).edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . and maritime accidents. winter means less exposure to sunlight. produce too much melatonin (or are extra-sensitive to normal amounts of this drowsiness-inducing hormone) and don’t make enough serotonin. for example. www. particularly insomnia.harvard. Your physician may ask how likely you are to doze off in certain situations. more than half did not consult with an expert in sleep medicine. on the job. the vast majority of people with sleep disturbances suffer in silence. may actually be displaying signs of abnormal sleepiness. A bedroom partner may be able to help answer some of these questions and should contribute to the discussion.” page 29).Purchased at http://www.” able to drop off quickly and sleep through anything. For this procedure. Physicians may screen problem sleepers for symptoms of depression. They enjoy life less. Don’t hesitate to ask for help when you’re sleeping badly following a death in the family or other stressful event. h a r v a r d . or other psychological problems or traumatic experi- Figure 9 Undergoing a sleep study Polysomnography is commonly done in sleep labs to monitor patients’ sleep. are less productive. e d u Some people are so used to sleep deprivation that they don’t realize they’re tired. A physician may suggest the shortterm use of a sedative to help you sleep at night and thus cope better during the day and prevent development of a long-term sleep disorder. and endure more illnesses and accidents at home.” page 44. Lab staff examine the readings from a nearby control room.edu/ 43 . childhood physical or sexual abuse. lethargic. or not very motivated.h e a l t h . www. Doctors trained in the United States receive just over three hours of instruction on this topic during four years of medical school. instead. It’s not always easy for people to get evaluation and treatment for a sleep problem. and on the road. the more dangerously sleepy you are considered to be. small electrodes placed on the scalp and other parts of the body take readings during the night. The psychiatric interview Sleep disturbances. When to seek help The American Academy of Sleep Medicine recommends seeking medical advice if sleep deprivation has compromised your daytime functioning for more than a month. Your sleep history A sleep disturbance cannot be accurately diagnosed unless your physician is familiar with your sleep habits and history.health. they may see themselves as lazy. anxiety. And while most of the physicians who took part in the survey admitted they had limited knowledge about sleep-related matters. most primary care physicians do not routinely ask their patients about sleep. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . Or they may not think it is unusual to fall asleep at a movie or while sitting at dinner with friends. So it’s in your best interest to seek out the help you need. and “Screening for sleep apnea. are often related to psychological difficulties that respond well to treatment once they’ve been identified. This information may be gleaned from an interview or from written questionnaires that you review and discuss with your doctor (see “A sample sleep history questionnaire. Someone considered by family members to be a “good napper. The less appropriate the circumstances (such as waiting in traffic while driving or having a conversation).Evaluation of sleep disturbances A lthough two-thirds of Americans have sleep problems. According to a National Sleep Foundation survey. or one of the parasomnias. periodic limb movement disorder. and when do you wake up? • What medications or drugs (including alcohol and nico- tine) do you use? Have you ever taken sleep medications? If so.ences (see “Discovering the cause of sleeplessness. or do you awaken because it’s hard to breathe? • Does your bed partner or roommate mention that you snore loudly or gasp for air at night? • Do you ever awaken with a choking sensation or a sour taste in your mouth? • Do you wake up with a headache or with cramps in your legs? • How have you been feeling emotionally? Does your life seem to be going as well as you would like? www. do you sleep through the night or • Do you ever feel discomfort or a fidgety sensation in your wake up frequently? • What’s your bedroom like? • What do you do in the few hours before bedtime? • Do you follow the same sleep pattern during the week and on weekends? If not. However. can be diagnosed by a thorough history and physical examination. he or she may recommend formal sleep testing. do you sleep better in your bedroom or in another room in the house? • Do you often feel sleepy during the day? • Do you fall asleep at inappropriate times or places? • Have you ever been in a car accident or had a close call because you nodded off at the wheel? 44 with sleep? Improving Sleep legs and feet when you lie down? Do you have to get up and walk around to relieve the feeling? • Do you kick or thrash around at night? • Do you ever have trouble breathing when you lie down.Purchased at http://www. you’ll wear your own nightclothes and you can use a pillow from home. Overnight sleep tests When you spend the night in a sleep laboratory. Insomnia and circadian rhythm disorders. • What bothers you most about your sleep habits? • Do allergies or nasal congestion bother you at night? • How long have you had trouble sleeping. Sometimes these changes alone correct the problem. Some centers allow you to make an appointment directly. for example. how are weekends different? • How well do you sleep on the first few nights when you’re away from home? At home.500. The American Academy of Sleep Medicine has a listing of more than 1. You may also be asked to change your sleep habits in certain ways before scheduling the visit. Staying overnight in a sleep laboratory costs between $800 and $1. Sleep laboratory evaluation Most people with sleep problems don’t need to visit a sleep laboratory. The center will request medical records and may send you a sleep questionnaire or diary to use before your visit. You may find it helpful to write down your answers to these questions and bring the completed questionnaire to the exam so you and your doctor can discuss it. which ones? • How long does it take you to fall asleep? • Do you often have indigestion at night? • Once you’re asleep. when a doctor suspects a sleep disorder such as narcolepsy. Some people require a one-time consultation with a sleep specialist. A sample sleep history questionnaire Your physician may ask you some of the following questions during an evaluation for a sleep problem. Check with your insurance company in advance because reimbursement varies and may depend on your diagnosis.edu/ .” page 48).health.800 accredited sleep disorder centers and more than 3.” page 45).000 board-certified sleep specialists (see “Resources.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . while others require a physician referral. your primary care physician may refer you to a psychologist or psychiatrist for treatment.harvard. sleep apnea. which may run a few hundred dollars.health. You can take your regular medications. Fees depend on the level of testing required. and what do you • Do you have physical aches and pains that interfere think started the problem? Did it come on suddenly? • How would you describe your usual night’s sleep? • What time do you go to bed. If one of these conditions is diagnosed.har vard. for example.D. and sad. on your legs to record twitches or jerks. 5. Throughout the night. Do you often feel ill at ease? 8. 4. Do you often feel tired without any reason? 9. Ph. near your nostrils to measure airflow. I don’t enjoy the things I used to. you are probably more anxious or tense than other people.harvard. Do you often feel insecure or anxious? 7. Ph. even over things that you realize don’t matter? 11. They may be placed on your scalp to track brain waves. 6. and these symptoms have persisted for at least two weeks. and over your rib muscles or around the rib cage and abdomen to monitor breathing (see Figure 9). or high-strung? 13.health. After a technician sets up the sleep-monitoring equipment. I have trouble sleeping through the night. you’ll be left alone to relax until bedtime. Do you often have a lump in your throat? 5. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . If your doctor suspects that you have a seizure disorder. jittery. ■ Daytime sleep tests. I have felt so low I’ve thought of suicide. The lab usually provides a regular bed in a private room with a bathroom attached. I am restless and can’t keep still. 2. The multiwww. Readings are collected on a single printout (called a polysomnogram) and analyzed by a technician and physician.. The room is kept as quiet as possible. or EMG). Signs of movement disorders (such as periodic limb movement disorder) or parasomnias will probably be apparent on the video. 7. such as PAP. on your earlobe or finger to measure the amount of oxygen in your blood (using a device called an oximeter). maybe without even knowing why? 2. This may show. Reprinted with permission from No More Sleepless Nights by Peter Hauri. A video may also be taken to compare with the polysomnogram. you may be awakened and given treatment. Are your hands often sweaty. I feel that I’m not useful or needed. ■ Audio and video recording. Do you often worry about things you’ve said that might have hurt somebody’s feelings? 10. you answered yes to either question 1 or question 2.D. clammy. Are you presently worrying over a possible misfortune? 12. and Shirley Linde. Do you have difficulty slowing down or relaxing? 6. on your chest or back to record heart rate and rhythm.but the clinicians will need to know what they are. small waferthin electrodes and other sensors are pasted on specific body sites to take a variety of readings during the night. and daytime sleep tests. Procedures used may include polysomnography. This allows the sleep experts to monitor how well the treatment works for you. 10. Daytime sleep tests may be administered after a night in the sleep lab. Sometimes this process requires two nights. blue. or extremely cold? 4. 8. My mind isn’t as clear as it used to be. ■ Polysomnography.h e a l t h . If a breathing problem is detected early on. 9. Audio equipment may be used to record snoring. Do you tend to worry. h a r v a r d . audio and video recording. Do you often feel nervous. I feel hopeless about the future. Do you feel upset or tense. I notice that I’m losing/gaining weight. talking during sleep. laboratory staff will monitor the instruments in a nearby control room. e d u Discovering the cause of sleeplessness Are you depressed? Yes No 1. during the second half of the night. Are you anxious? Yes No 1. 3. under your chin to measure fluctuations in muscle tension (called an electromyogram. and you may need to seek professional help. Are you more apprehensive about the future than other people are? If you answered yes to five or more of these questions. or other sounds. near your eyes to measure eye movements. that you snore only when in a certain position. You should seek professional help immediately if you answered yes to question 3.edu/ 45 . you may undergo a full electroencephalogram (EEG) during the night. I get tired for no reason.Purchased at http://www. I feel downhearted. You may be suffering from depression if you answered yes to at least five of these questions. Does your heart often race uncontrollably? 3. In this procedure. A standard polysomnogram cannot diagnose sleep-related epilepsy. Accordingly. Portable home recording devices also may be useful when polysomnography is not available and the person’s symptoms suggest a need for immediate treatment. snoring sounds. Home-based tests For people who.har vard. ■ Wrist actigraphy. called the Epworth Sleepiness Scale. Add up these numbers. the information may not be sufficient to diagnose and devise a treatment plan. Although it cannot determine the stage of sleep. done in a sleep lab. Imagine yourself in the following situations. they should only be used when the patient’s physician is familiar with the devices’ benefits and limitations and has experience interpreting the results. Home-based tests may also be used when a physician wishes to evaluate the effectiveness of treatment. nasal airflow. as the best method for diagnosing sleep apnea and determining its severity. home sleep monitoring may be helpful. wrist actigraphy accurately determined whether a person was asleep almost 90% of the time. and then select your likelihood of dozing using the 0–3 scale below. body position.Purchased at http://www. consider seeing a physician for an evaluation.harvard. The American Academy of Sleep Medicine recommends polysomnography. there is no technician to monitor the device and patient. ■ Apnea detectors.edu/ . which is less commonly used. based on their symptoms. Falling asleep within five minutes each time indicates extreme sleepiness.health. The procedure is usually repeated four or more times during the day at two-hour intervals.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh . it can help clarify ambiguous aspects of a sleep diary—such as entries reporting long hours of sleep but exhaustion the next day— or assess the effectiveness of medical treatment. a patient can be equipped with apnea detectors that measure heart rate. to gauge a patient’s level of daytime sleepiness. People are sometimes given both tests at different times. This test measures sleepiness and looks for signs of narcolepsy. www. Although these devices have been used to estimate how many people suffer from breathing disturbances. like a theater or meeting As a passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (when you’ve had no alcohol) In a car while stopped in traffic TOTAL ple sleep latency test measures how long it takes you to fall asleep while lying down in a quiet room and what stages of sleep occur during a brief nap. Unlike in a sleep lab. In the maintenance of wakefulness test. you’re given the opposite instructions: try to stay awake.health. Scale: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Score Sitting and reading Watching TV Sitting inactive in a public place. and there is a higher rate of problems associated with the home-based devices. The actigraphy device may reveal that brief awakenings during the night are unknowingly disturbing sleep. probably have sleep apnea (see page 28) and who have no 46 Improving Sleep other significant other medical problems. This ability is also affected by the degree of sleepiness. If you score 10 points or more. or when a patient is bedridden or medically unstable and cannot be moved. Portable home devices can miss mild apnea and other sleep disruptions. the information they provide isn’t as accurate as a sleep lab evaluation. and they don’t provide the sleep stage information needed to rule out other sleep disturbances. As a result. How sleepy are you? Sleep specialists often use this measure. To detect breathing disturbances during sleep. A wristwatch-sized monitoring device that automatically records arm or leg movements can be used to track periods of sleep and wakefulness at night. In some studies. and the amount of oxygen in the blood. avoiding caffeine and alcohol before bedtime. • Make sure your primary care physician is aware of any over-the-counter or alternative medicines you take to help you sleep. and social satisfaction) that brought them to the same level as the general population. While there’s no guarantee you’ll always get eight hours of uninterrupted sleep. and going to bed and waking up at the same time every day (see “Tips for a better night’s sleep. • People with narcolepsy treated with modafinil for six weeks reported significant improvements in energy and a significant reduction in daytime fatigue.” page 14). • Make sure you’re getting proper treatment for any underlying illnesses. h a r v a r d . sleep is the source of much anxiety.The benefits of good sleep B y now. that may interfere with sleep (see “Medical conditions and sleep problems. con- sider seeing a sleep specialist for a thorough sleep evaluation (see “Evaluation of sleep disturbances.” page 43).h e a l t h . with proper treatment you can reasonably expect improvements in both your nighttime sleep and your overall quality of life.” page 22). mental health. • People with sleep apnea who used CPAP for one year reported quality-of-life improvements (such as better energy. some patients report feeling like a “whole new person. people with sleep disorders function without sufficient sleep for so long that they come to accept their constant fatigue as normal and assume they will always feel tired.” page 16). such people are able to accomplish things they’ve always put off attempting.Purchased at http://www.edu/ 47 . Here is a review of the basic steps to follow if you’re having trouble maintaining normal. and follow your doctor’s recommendations about taking prescription sleep aids (see “Prescription medications for insomnia. The researchers also showed that people who underwent CBT increased their total time in slow-wave (deep) sleep. • If sleep problems persist despite your own efforts. the encouraging news is that if you successfully conquer whatever is preventing you from sleeping soundly— either on your own or with a sleep specialist’s assistance—you have a lot to look forward to. Here. • Keep a sleep diary to look for patterns you may not be aware of and to track progress. Patients treated by sleep specialists gain a number of benefits.health. such as cardiovascular disease or diabetes. switching careers. Often.” with newfound energy and an improved out- www. Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . you should have a solid understanding of the various sleep problems and their consequences. In some cases. such as making sure your bedroom is sleep-friendly. Research documents the improvements that can come with treatment: • People with chronic insomnia who participated in six 50-minute sessions of cognitive behavioral therapy (CBT) improved their sleep efficiency (the percentage of time spent asleep while in bed) more than people who took a prescription sleeping pill. e d u look on life. After a few weeks of healthy sleep.harvard. healthy sleep patterns: • Practice good sleep hygiene. So if you’re struggling to get a good night’s rest. such as completing college or getting an advanced degree. there is much cause for optimism. or finding a life partner. Sleep review For such a natural and necessary thing. It’s worth taking a moment to look at the flip side: the benefits of routinely getting a good night’s rest. D. It also publishes the quarterly newsletter NightWalkers and maintains a list of support groups located throughout the country. this organization also provides the public with information on sleep disorders as well as contact information for accredited sleep centers.org Restless Legs Syndrome Foundation. MD 20892 301-435-0199 www.cbtforinsomnia. NW. co-written by the medical editor of this report.edu/ . American Sleep Apnea Association 6856 Eastern Ave. childhood sleep problems.Purchased at http://www. Sleep Healthy Using the Internet www.harvard. training.com This cognitive behavior therapy program.health.sleepapnea.harvard. and videos.shuti. and Blood Institute. sleep disorders such as insomnia. NIH 6701 Rockledge Drive Bethesda. Suite 500 Washington. this site aims to help the general public understand sleep and to get the sleep they need. Book The Harvard Medical School Guide to a Good Night’s Sleep Lawrence J. National Sleep Foundation 1522 K St. Web sites Conquering Insomnia Program www. developed at Harvard Medical School and the University of Massachusetts Medical Center. Suite 920 Westchester. M. IL 60154 708-492-0930 www.sleepfoundation.med. Sleep and Health Education Program http://healthysleep. MN 55901 507-287-6465 www.nih. NW. a newsletter.nhlbi. and coping with jet lag. as well help in finding support groups. Narcolepsy Network 110 Ripple Lane North Kingston. DC 20012 202-293-3650 www. developed at the University of Virginia Center for Behavioral Medicine Research.Resources Organizations American Academy of Sleep Medicine 1 Westbrook Corporate Center. The book includes a six-step plan for getting a good night’s sleep. and education and offers a number of free publications about sleep disorders. Suite 203 Washington.org This nonprofit foundation distributes brochures and provides information on restless legs syndrome. and narcolepsy. part of the National Institutes of Health. sleep apnea. 48 Improving Sleep www.sleepeducation. Suite 300 Rochester. the program is available only to participants in a research study.net This interactive Web-based program. Lung. This nonprofit foundation helps consumers locate sleep centers and provides information on a variety of sleep topics. National Center on Sleep Disorders Research National Heart.edu Created by Harvard Medical School’s Division of Sleep Medicine and the WGBH Educational Foundation.gov/about/ncsdr This federal center.narcolepsynetwork.har vard. is available for purchase as either an online program or in CD format.org This organization offers educational materials on narcolepsy.edu This Harvard Health Publication was prepared exclusively for Helen McIntosh .com Dedicated to the advancement of sleep medicine and related research.aasmnet. NW.rls.. At this writing. provides cognitive behavior therapy for insomnia. 2007) This book. Epstein. It also operates a network of support groups throughout the country.org www. RI 02852 888-292-6522 (toll-free) www. and Steven Mardon (McGraw-Hill. DC 20005 202-347-3471 www. coordinates government-supported sleep research. 1610 14th St. covers sleep physiology. sleep medications. Inc.health.org This nonprofit organization provides information on sleep apnea via brochures. brought on by laughter. somniloquy: Talking in one’s sleep. periodic limb movement disorder (PLMD): Syndrome characterized by periodic jerking of the limbs during sleep and daytime sleepiness. central sleep apnea: Sleep apnea caused when respiratory control centers in the brain fail to activate breathing muscles. h a r v a r d . thinking and most physiological activities slow. In the quiet phase of sleep. electroencephalogram (EEG): A recording of brain waves obtained by attaching flat metal discs (electrodes) to the scalp. melatonin: A hormone that helps regulate circadian rhythms. Also called dreaming sleep. deep sleep: See slow-wave sleep. rapid eye movement (REM) sleep: A period of intense brain activity often associated with dreams. narcolepsy: A sleep disorder marked by excessive sleepiness or sudden sleep attacks. blood pressure. positive airway pressure (PAP): A treatment for sleep apnea in which a continuous stream of air is delivered through a mask worn over the nose to keep the sleeper’s airway open.health. or sleep that is nonrestorative. the person tends to go to bed later and get up later each day. e d u Improving Sleep This Harvard Health Publication was prepared exclusively for Helen McIntosh . including body temperature. parasomnias: Episodic disruptive behaviors occurring during sleep. somnambulism: Sleepwalking. or strong emotions. hypnagogic hallucinations: Often terrifying dreamlike sounds or images occurring just before sleep.harvard. resulting from blockage of the airway. delayed sleep phase syndrome: A daily sleep/wake rhythm in which the onset of sleep and wake times are later than desired. Most prominent at night. named for the rapid eye movements that occur during this time. obstructive sleep apnea: Disordered breathing during sleep. lasting at least 10 seconds and associated with a fall in blood oxygen or arousal from sleep. but movement can still occur. a hallmark of narcolepsy. indicating abnormal or partial arousal. and the release of hormones. polysomnography: Simultaneous recording of brain waves and other measures of physiological functioning to assess sleep. the person wakes up earlier and wants to retire earlier each day. making it hard to fall asleep or stay asleep. sleep architecture: The pattern made when sleep stages are charted on a hypnogram. produced in a predictable daily rhythm by the pineal gland. cataplexy: Sudden paralysis of some or all muscles. insomnia: A condition marked by trouble falling asleep or staying asleep. quiet sleep: All sleep except REM sleep.h e a l t h .edu/ 49 .Purchased at http://www. restless legs syndrome (RLS): Achy or unpleasant feelings in the legs associated with a need to move. a symptom of narcolepsy that can be mistaken for psychosis. circadian rhythm: The innate biological clock that regulates sleep and waking and controls the daily ups and downs of physiologic processes. anger. www. hypnogram: A diagram that summarizes the stages of sleep recorded in the sleep laboratory. it shows changes in brain waves. Also called non-REM sleep.Glossary advanced sleep phase syndrome: A daily sleep/wake rhythm in which the onset of sleep and the time of awakening are earlier than desired. apnea: Cessation of breathing during sleep. harvard.harvard.harvard.health.com www.649-9457 (toll-free) Harvard Health Publications P.edu phone 877.edu/ IS10 . TX 75755-9306 mail bulk rate 203-653-6270
[email protected] 877-649-9457 (toll-free) Other publications from Harvard Medical School Special Health Reports Harvard Medical School publishes in-depth reports on a wide range of health topics. Box 9306 Big Sandy.Purchased at http://www.Order this report and other publications from Harvard Medical School online www.health. including: Addiction Alcohol Allergies Alzheimer’s Disease Anxiety and Phobias Arthritis Back Pain Caregivers Cholesterol Depression Diabetes Diabetes & Food Energy/Fatigue Erectile Dysfunction Exercise Eye Disease Foot Care Grief and Loss Hair Loss Hands Headache Hearing Loss Heart Disease Heart Disease & Diet High Blood Pressure Incontinence Knees and Hips Living Independently Living Longer Memory Neck & Shoulder Pain Nutrition Osteoporosis Positive Psychology Prostate Disease Sensitive Gut Sexuality Skin Care Sleep Strength Training Stress Management Stroke Thyroid Disease Virus Vitamins & Minerals Weight Loss Workout Workbook Periodicals Monthly Newsletters and Quarterlies including: Harvard Health Letter Harvard Women’s Health Watch Harvard Men’s Health Watch Harvard Heart Letter Harvard Mental Health Letter Perspectives on Prostate Disease ISBN 978-1-935555-18-6 SU11000 This Harvard Health Publication was prepared exclusively for Helen McIntosh .