Integrative approach to sleep and sleep disorders


December 2011

“Health is the first muse and sleep is the condition to produce it.” Ralph Waldo Emerson,

Our society doesn’t really contribute to healthy sleep. Our staccato, frenzied pace, overstimulation with media, caffeine, and nocturnal lights all break the natural rhythms of the body that are conducive to good sleep. Many health conditions can contribute to poor sleep such as pain, obstructive sleep apnea, many respiratory and cardiac conditions, GERD, anxiety, depression, urinary problems, restless legs syndrome, fibromyalgia, hot flashes, and more. In geriatric practice, perhaps there is no more frequent complaint than insomnia, though constipation and arthritis certainly are highly prevalent.

Increasingly recognized is that poor sleep itself increases the risk of heart disease, diabetes, obesity, strokes, viral infections, and auto accidents. Studies among house staff found that staying up for 30 hours created decreased function and reaction time equivalent to a blood alcohol level of 0.1, legally drunk in all states. Sleep and dream debt cause dangerous mental smog and daze.

We may actually be suffering from a darkness deficiency. LAN (light at night) undermines life’s fundamental rhythmicity. Rush hour, prime time, happy hour, late night TV, drugs, alcohol, and incessant web-browsing, texting, and e-mail all interfere with the yin and yang of natural sleep and wakefulness. Because of these factors, taking a sleep history is an essential part of the integrative consultation process. In addition to past history, dietary and exercise patterns, and other lifestyle issues, identifying sleep problems is essential though often overlooked or underappreciated. Yet, even when a patient complains of insomnia, our tendency is to reach for a prescription sleep aid without more exploration.

Insomnia comes in several varieties: 1) problems falling asleep, 2) problems staying asleep, 3) premature wakening, 4) poor quality of sleep. Each requires a different approach.

Here are some basics to an integrative approach. First, take a good sleep history, including a patient sleep diary if appropriate. Emphasize good sleep hygiene which ought at a minimum emphasize avoiding overstimulation such as stimulant medications, substances, or exercise prior to sleep. Encourage rhythmicity, ritual, and regular patterns much as we do with children with sleep issues. Sleep experts recommend using the bed as a place for sleep or sex but not other activities such as watching TV. Especially for the elderly, avoid daytime naps. Identify contributing medical or psychiatric issues, painful conditions, stimulant prescription medications, e.g. decongestants, beta blockers, calcium channel blockers, thyroid, anti-depressants, anti-convulsants, bronchodilators, steroids, among others.

Treatment always begins with education about healthy sleep patterns and sleep hygiene, e.g., if not asleep in 20 minutes, get up and do something for awhile before returning back to bed. Eliminate worrying or problem solving at night. Resolve anger before going to bed. Keep the room to be dark, cool, and quiet. Avoid watching the clock.

Mind-body therapies to improve sleep include meditation, relaxation and breathing techniques, body scan, imagery, progressive muscle relaxation, or alpha wave training are all useful. Multiple herbs and supplements may be useful and ought to be considered before use of medications as they are less likely to disturb slow wave sleep or be habit forming. These include valerian (1000mg at bedtime), melatonin (2-6mg), St John’s Wort, chamomile, hops, passion flower, kava, lavender, lemon balm, and skullcap.

In some cases, psychotherapy or hypnosis may be helpful and of course, some patients really need medications. In addition to popular prescriptions such as Lunesta, Sonata, Ambien, and in some cases benzodiazepines, I have often found tricyclics like Elavil, especially for those with neuropathic pain and/or anxiety; trazodone and analgesics can also contribute to a good night’s sleep.

Remember that homeostasis requires rhythm, repetition, regularity and routine. Rhythms rule our world and are powerful and healing. Rhythmic activities of our body and mind include our hormones, circulation, indigestion, brain waves, and states of consciousness. The question of why we spend a third of our lives asleep likely has to do with our need to allow our immune system to do its work effectively, to allow our brains to process, integrate, and sort out life through dreams and images, to re-establish our biorhythms, as well as the benefits of physical rest.

How much sleep is enough? While recent studies show that there are “elite sleepers” who seem, like my wife, to do just fine with 5 hours of sleep or less, most adults need 6 ½ to 8 hours of quality sleep per night. Less than that can result in accumulating the sleep and dream debt mentioned above with both short and long term negative health consequences. Interestingly, some studies show that there is actually such a thing as too much sleep. It seems that adults sleeping more than 8 hours at night had decreased longevity. I guess that’s me as I like the “early to bed and late to rise” rhythm!

Kids and adolescents in their growth phases may need even more sleep. How mothers survives with newborns as they stay up night after night with a fussy or breastfeeding baby matches only the sleep-deprivation endurance I have seen among my surgery colleagues My daughter, herself a colicky infant who sleep-deprived her mother and I until she was about 4 months old, is now coming full circle with our new grandson. This little guy prefers to stay up whenever possible while she desperately needs is a short nap or a good night’s sleep. Sleep debt over several weeks is a tough thing for new moms though it doesn’t seem to bother the babies at all. I honor new moms. Their sleep debt on behalf of their baby is on deposit in some cosmic bank account and will bless them later.

So, in conclusion, remember to take a good sleep history. Recognize the essential role of sleep to a happy, healthy life. And develop a broad range of methods and a mindful, consistent approach to managing sleep and sleep disorders in yourself and your patients. Finally, remember the old proverb, “One hour of sleep before midnight, is worth two after.”