When humans are young high-quality sleep is almost a given. Unfortunately, it is a simple fact of aging that it becomes more and more difficult to achieve restful sleep as we grow older. Part of this shift is due to neurochemical changes in the brain as it ages, but some of this is due to behavioral changes or habits that humans pick up that actually inhibit the ability to sleep deeply and restfully. Unless you correct these habits you may never know what your baseline is regarding sleep quality and your efforts to sleep better with pills or relaxation may be unnecessarily hampered. Sleeping pills are generally not the full answer to long-term struggles with insomnia. Pharmacology has its place but it is only part of the picture.
Jeffrey Becker, MD
The Two Stages of Sleep – REM vs NREM
Before understanding what you need to do in order to sleep better you should understand the different stages of sleep. Human beings experience two distinct stages of sleep. REM sleep is named for the “Rapid Eye Movement” that characterizes this stage of sleep. The other is called NREM, or Non-REM, because the eyes remain still.
For the most part humans dream and perform memory consolidation tasks during REM. Many people feel that dreaming is the most important stage of sleep due to that attention that dreams have gotten both in psychology and psychiatry, as well as in the popular culture. In reality humans can live without dreaming at all (there are medications that do this), but they quickly deteriorate and feel quite poorly when they start to lose their slow-wave sleep (SWS), which resides in the NREM stage of sleep. While dreaming is important to the process of memory consolidation and psychological processing, NREM and SWS is important to physical recovery and rebuilding of tissue and molecular reserves.
One interesting phenomena of human sleep is that during the rest that follows sleep deprivation deep sleep is the first thing that the brain and body demands. After this debt is repaid dreaming starts to occur. This arrangement makes sense if it is understood how important the deep sleep component is to basic functions. It is often characteristic of psychological difficulties that dreaming increases proportionally, at the expense of deep sleep.
NREM Sleep Stages
Stage 1: Twilight Sleep
This stage is just on the cusp of awake and asleep. As such, it does not feel particularly restful. People often report that they are not even asleep when woken during this stage even though an EEG recording the electrical waves within their brain establishes that they are technically asleep.
Stage 2: Light Sleep
In this stage the subject is clearly asleep, and will report as much, but the delta waves (slow, synchronized waves) that characterize deep sleep are not yet present to any significant degree. The amount of time spent in this stage of sleep grows as we age. For complicated reasons humans essentially trade the deeper stages of sleep for increases in Stages 1 and 2 (or even stage 0, which is essentially awake in bed) as they grow older. Stage 2 sleep is more common in people who are anxious, depressed, in pain, inflamed or sick with viral or bacterial infections, or in people who are under the influence of certain medications as well. While this stage of sleep is better than nothing it is clearly not as restful as the deeper stages of sleep.
Stage 3 (and 4): Deep Sleep or SWS
Stage three is distinguished by the appearance of “Delta Waves” which are very slow for the brain and signify that the brain is beginning to “synchronize.” One might say that the brain is finally “off” in this stage. It can be likened to rebooting a computer after a long day of work. The entire brain gets back to basics. During this stage people are less likely to wake for a random noise or other distracting stimuli. This is the stage that children are likely in when they don’t wake from being carried in the house from the car.
Recently the sleep stages of 3 and 4 were consolidated for research and descriptive purposes. Both of these stages are now referred to as Stage 3 sleep, slow-wave sleep or deep sleep. Until this changes many research papers would distinguish between stage 3 and 4 with stage 4 representing the deepest sleep with the densest delta wave activity. Now they are reported together
What is Sleep Hygiene?
Improving sleep quality involves adopting a set of daily habits, known as sleep hygiene, that signal to the body that it’s time to wind down. Establishing a routine can pave the way for a restful night’s sleep. As an example, take the familiar practice of brushing our teeth before bed—we do it almost automatically, ingrained in our nightly rituals.
Cycling through REM and NREM
The majority of SWS normally occurs during the first sleep cycle. Immediately upon falling asleep the brain should enter into SWS as delta waves grow and become dominant. During this first period the hypothalamus and pituitary synchronize and coordinate the complex symphony of neuroendocrine signaling. Growth hormone is one of the hormones released by the pituitary during this first cycle of sleep.
You may have noticed this SWS in a partner you sleep next to. Usually they will be most deeply asleep in the first hour, often not waking despite light from a bedside lamp, or noise from turning pages or a television. In contrast, in a later sleep cycle they might wake simply from your turning over in bed, or getting up to use the restroom. While some portion of a person’s deep sleep occurs later in the night, often in pieces, almost two thirds usually occurs in the first few hours or sleep.
You may have noticed this SWS in a partner you sleep next to. Usually they will be most deeply asleep in the first hour, often not waking despite light from a bedside lamp, or noise from turning pages or a television. In contrast, in a later sleep cycle they might wake simply from your turning over in bed, or getting up to use the restroom. While some portion of a person’s deep sleep occurs later in the night, often in pieces, almost two thirds usually occurs in the first few hours or sleep.
Sleep Hygiene and Other Sleep Tricks – a behavioral approach to sleeping better
Sleep Hygiene is a name given to the collection of good practices and habits that can improve and maintain sleep quality. While medication may be appropriate at times in treating fibromyalgia, sleep hygiene is a general set of behavioral rules that research has shown can greatly increase your sleep quality. It has been interesting to discover how many of my patients do little of what is on this list and yet expect to sleep well when they want to. We live busy lives in this century and now more than ever a focus upon the rest and recovery is vital.
Some of these recommendations will pertain to your situation while others will not, but the bottom-line is that this approach really works . . . if you practice it. While some of this will make intuitive sense, other recommendations may seem silly. But try to do all the things on this list because they work. Start with the simplest and then tackle the more difficult.
If you find yourself wondering whether a particular activity would be part of a good sleep hygiene program just ask yourself whether you would have a two year old do the same thing. Parents have rituals with their children that allow them to move toward sleep in a seamless manner. Bedtime stories, warm milk, dimming the lights, and saying “night-night” all facilitate the movement into sleep. Alternatively, there are activities that we do not encourage right before a child’s bedtime. Would one recommend that a four year old child watch television, drink Coca-Cola or eat a huge meal right before bed? Probably not, but as adults we think we don’t have to follow the same rules. We would all probably sleep better if we followed the sleep regimen we practiced in kindergarten.
No caffeine after 2 pm
Caffeine’s effects last longer than many people think, generally for over 12 hours. So, if you take an afternoon coffee or tea you are likely living with caffeine in your blood stream at all times. This causes tolerance as well as poor sleep quality. The effects of caffeine can be seen on a sleep EEG.
If you want to feel the alerting effects of caffeine each morning, refrain from using it in the afternoon or evening. You will feel the effects anew each morning. People often report that caffeine does not affect their sleep but this is unlikely; excessive caffeine inhibits sleep quality and deep sleep . . . period. Individuals that do not especially feel the effects of caffeine are the most likely to benefit from cutting out afternoon and evening caffeine because they are most likely to be tolerant to caffeine’s effects. They are deriving minimal positive benefit while inhibiting their sleep quality!
Breakfast light exposure
The pineal gland releases melatonin to maintain the circadian rhythm of human activity. Bright light exposure in the morning is what sets this clock and you can use this to your advantage. Melatonin is naturally sedating and even has effects upon some of the receptors that are known to help cause deep sleep and growth hormone release. To take advantage of this natural mechanism for sleep quality get full sunlight exposure early upon waking for at least 20 minutes. This will reset your internal clock and helps your brain to know that it is time to sleep 16 hours later. There are some people whose internal clocks run a little long naturally. These are the “night-owls” of the world, who go to bed later and later each night if they were allowed to. This intervention is especially effective in these individuals.
Temperature
Keeping the temperature of your room comfortable but on the cool side can actually facilitate sleep. The body does cool down while we sleep and if your room is too warm it can disrupt this process. If there is no cooling available, sometimes a light breeze from a fan can help.
Light
Use blinds or eyeshades to keep early morning light from waking you. Humans used to wake with the sun, but this is a little early for most people now. You may be fighting millions of years of evolution and physiology however if you allow the sun to shine into your bedroom in the morning. Some people seem to be more susceptible to this than others. If shades are not an option, quality eye shades can be kept on the bedside and donned when the morning is approaching.
White noise
Especially in sleep-disrupted individuals, the normal noises of the city of house at night can become a frustrating source of distraction and sleep disruption. White noise machines and CDs can help with this. The sounds of waves, rain, or even just radio static helps drown out random noise.
Wind Down
Try to spend an hour before bed officially allowing yourself to wind down with warm herbal tea, a massage, stretching, etc. Try to avoid potentially stressful activities such as phone calls, emailing, planning the next day, television shows. This allows you and your subconscious to accept a shift in priority toward rest and recovery.
Light snack
Some people appear to benefit from a very light snack before bed. It is possible that this decreases the incidence of low blood sugar while sleeping. The important thing here is to keep the snack light and to include protein, complex carbohydrate and fat. A sugary snack before bed can make things worse.
People with fibromyalgia and adrenal fatigue often have hyper-reactive sugar regulation. When sugars drop low enough there can be cortisol, or even adrenaline release, which can wake a person with a feeling of panic. If you have hypoglycemia or you feel that you may have blood sugar lows in the day, you may be having them during sleep as well.
If you experience waking from sleep with a fast pulse, shortness of breath and a feeling of panic or anxiety, you may be experiencing these sugar lows. It can also be a sign of something more dangerous however, so tell you doctor what is occurring. These can be signs of a heart problem called CHF or Obstructive Sleep Apnea.
No large meals before bed
Large meals or rich food can sometimes make for a fitful night’s sleep. There are multiple steps involved in processing new molecules for the body, and the liver can become overloaded if it is given more than it can handle. Molecules that are only partially processed can get out into the general circulation and make you sleep poorly. This basic principle is true for daytime meals as well, but it can be especially detrimental to sleep quality.
No television in bed
This is hard for many people to adhere to. Unfortunately, a television in the bedroom invites a person to be entertained in a location where entertainment is not the goal. It actually makes it hard to drift off to sleep and allows people to remain awake long after they would normally fall asleep without the stimulation.
The television becomes a sort of distraction in the bedroom because it can always be turned on, and sometimes I hear from patients that it is never turned off. If it stays on during sleep, the television content infiltrates the sleep and reduces sleep quality. Ideally one should watch television in the living room until bedtime, and then turn it off. I saw a report once that found that people watching television in bed slept almost one hour less per night than those that don’t.
No eating in bed
Again, eating in bed is another distraction we don’t need. Humans learn to associate locations and times with activities. Eating in bed invites hunger and more eating in bed at a future date. If one follows perfect sleep hygiene the bed should be for sleeping and sex. That is it.
No worrying in bed
Humans are learning creatures and we can quickly learn to use the bed as a place to dissect all of the unnamed fears and worries our complex minds can invent. Worrying in bed for long periods can invite more of the same the next night and thus you should try to do your worrying elsewhere.
This may sound strange but you should get up and go into a different room if you find that you are worrying in bed for more than 20 minutes. Once you get out of bed, you can worry all you want. You can also follow the recommendations below for making a list of worries. After you get your worries on paper you can read something, preferably unexciting, if you are still not feeling tired. After a while you will start feeling sleepy and you can return to the bedroom.
Make a list
This is a very helpful intervention. For bedtime worriers it can be very effective to make a list of your worries in the evening (not too close to bedtime) and leave the list safely in another room. Metaphorically, when you enter the bedroom that night you leave the list, and your worries, behind. While this practice helps to reinforce the point that you are not allowed to worry in bed, it also allows your subconscious to let go of the important details of your life and allow you to rest.
If you find that you are still worrying about the same details on your list, remind yourself, repeatedly, and out loud if need be, that “I can let go of these worries now because they are listed completely out in the living room.” Allow yourself to feel that your worries are “out there,” that “they are safe for you to pick up again tomorrow” and you “no longer need to remember what they are.” Keep performing this reorientation — that the worries are recorded already and you can let them go — until your subconscious starts to listen and believes what you say. You may even visualize gathering up your worries and placing them on the list for further reinforcement and permission to let go.
I recommend that anything and everything that qualifies as a worry should go on the list. Thus, remind yourself to write that thank you note, apologize for last weeks fight, call your accountant about taxes, and stop by the gym to get your water bottle you left behind. It all belongs on the list.
Turn the clock away
Feel free to set the alarm, but don’t watch the clock. This is just another of the myriad ways in which we irrationally increase our anxiety and ultimately sabotage our ability to rest. Watching the clock just creates anxiety.
Get some exercise
It has been shown that exercise helps most people to sleep more deeply and restfully. But, try not to exercise within three hours of your bedtime if you find that wakes you up instead.
Reduce your alcohol intake
While alcohol may make humans somewhat sleepy or tired it actually inhibits quality sleep. Alcohol is metabolized quickly, usually within hours. As the blood levels drop there is a form of withdrawal that occurs and the brain wakes up with a start leaving people wide-eyed in the middle of the night. Sometimes this can be associated with significant worry and anxiety as well.
If you drink alcohol in the evening and you notice that you often wake in the middle of your sleep period, it is worth a trial without your evening alcohol.
Wake up at the same time
Humans are creatures of habit . . . like most animals. Waking at the same time each day will become a habit that will help increase sleep quality the next evening. It is more than the morning light at work here. Many people practice the opposite, trying to go to be at the same time but sleeping in when they get the chance. While this can be an effective way to make up for lost hours, too much of this can affect sleep rhythms and regular morning waking can be the answer.
Avoid naps
Until you get your insomnia under control avoid daytime naps if possible. While it is a natural physiologic process to take a nap in the afternoon, it can impede your progress towards improved sleep at night. Naps in the afternoon reduce the total hours of sleep at night and this is what we are trying to avoid. If you do choose to nap try to keep it short. A 15-30 minute catnap will sometimes take you through to bedtime and allow you to fall asleep at an appropriate hour.
Try not to use the bathroom
When you feel urgency to urinate it is not necessarily true that your bladder is full. The bladder can contract creating a sense of urgency even if there is more room available. If you make a trip to the bathroom each time you wake you may be training your bladder to contact long before it needs to. Once the bladder becomes trained the contraction can actually wake you up to use the bathroom needlessly.
You can assess this by waiting for a few seconds and feeling whether the urgency dissipates. A few times falling back asleep without using the bathroom will help your bladder to accept more volume without contraction.
Reduce evening fluids
By reducing fluids in the evening you reduce the chances of waking to use the bathroom. The brain and the kidneys work together to concentrate the urine during sleep, but you can easily overwhelm this system with too much fluid after 6 pm.
Ask you mate
Do you snore intensely? Do you have periods where you stop breathing while you sleep? Do you kick you legs or twitch a lot while asleep? Do they feel uncomfortable to the point where you have to get up and walk it off? If you experience any of these symptoms you should talk to your doctor about it. See the section on medical issues to watch for more information.
Avoid Blue Light at Night
Blue light is a type of light with a short wavelength, emitted by many electronic devices like smartphones, tablets, and computers, as well as energy-efficient lighting. It’s also present in daylight, which helps to keep us alert and awake during the day. However, at night, exposure to blue light can be disruptive. Here’s why: In our eyes, there are special cells containing melanopsin receptors that are sensitive to blue light. When these receptors detect blue light, they send signals to the suprachiasmatic nucleus in our brain – a region that regulates our circadian rhythms, essentially our internal biological clocks.
The interaction with these receptors due to blue light exposure during nighttime can “reset” our circadian clocks. This resetting can disrupt our natural sleep/wake cycles and inhibit the production of melatonin, the hormone that helps us feel sleepy and regulates our sleep patterns.
To help improve your sleep, we advise reducing your exposure to blue light at least an hour before bedtime. This can be done by turning off electronic devices, using blue light filters on screens, or even wearing glasses that block blue light. By doing so, you can help your body better prepare for sleep and maintain a more natural sleep cycle, which is crucial for your overall health and well-being. This is also crucially important to remember if you wake up during the night – be careful to not turn on an electric light as it could reset your circadian clock, making it challenging to go back to sleep.
Sleep Toolkit
By utilizing a combination of different tools, such as herbal remedies, sleep nutraceuticals, safe prescription drugs, and natural remedies, we can work together to create a personalized treatment plan that addresses the underlying causes of your insomnia. Remember that every person’s body is unique, and it may take some trial and error to find the best solution for you. You can find a variety of sleep toolkit items we recommend on your protocols page.
Summary
In modern times, maintaining optimal health critically hinges on good sleep hygiene, particularly as individuals age. Understanding sleep architecture, which encompasses the various stages of sleep and their specific functions, is essential. Additionally, recognizing the role of Zeitgebers—such as light, activity, and food—in regulating the sleep-wake cycle is crucial for achieving restful sleep.
Adopting lifestyle adjustments, such as engaging in regular physical activity, practicing mindful eating, and limiting caffeine intake, significantly enhances sleep quality. Moreover, incorporating supplementation and sleep tracking can further optimize sleep. Ultimately, developing a personalized sleep routine through patience and experimentation is key to reaping long-term health benefits.
Supporting Research
Mouth tape and sleep apnea
https://pubmed.ncbi.nlm.nih.gov/36141367/
Caffeine half life
Zeitgebers and sleep
https://pubmed.ncbi.nlm.nih.gov/30365354/
Circadian rhythms, sleep, and metabolism
https://pubmed.ncbi.nlm.nih.gov/21633182/
Sleep hygiene
https://www.sciencedirect.com/science/article/abs/pii/S1087079214001002?via%3Dihub
Walk to a better night of sleep: testing the relationship between physical activity and sleep
https://www.sleephealthjournal.org/article/S2352-7218(19)30105-6/abstract
Meditation and sleep
https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2012.00054/full
Sleep wake and biological rhythm
https://www.annualreviews.org/content/journals/10.1146/annurev.psych.52.1.277
