Montgomery Medicine No. 754

Insomnia Part 2

I want to follow up on last week’s column where I discussed the causes of insomnia by focusing now on prevention and treatment. If the cause of insomnia isn’t readily apparent, it can help to keep a sleep diary for two to four weeks and share it with your physician. The diary should include when you go to bed and wake up, any naps, and how long you actually sleep. A downloadable sleep diary is available at bit.ly/3DZjTRH.

The most frequent problem uncovered in a sleep history or diary is poor “sleep hygiene.” Sleep hygiene refers to daily behaviors and routines that promote good quality sleep and daytime alertness.

When patients are asked what they do when they can’t fall asleep, many say they just lie in bed and watch the clock. That is the worst approach. A core principle of sleep hygiene is that your bedroom should be reserved for two things: sleep and sex. It should not be a place for watching TV, using your phone or laptop, working, or exercising. Your brain needs to associate the bedroom with winding down and resting.

If you can’t sleep, it’s best to get out of bed and go to another quiet space. Do something low-key, like reading or a crossword puzzle, until you start to feel sleepy. Then go back to bed. If you still can’t sleep after 15 or 20 minutes, repeat the process. This may take multiple attempts, but the goal is to retrain the brain. It’s also important to resist the urge to sleep in the next day. Keeping your time in bed consistent from night to night helps regulate your sleep cycle.

A bedtime ritual helps signal the body that it’s time to sleep. Begin winding down at least 30 minutes before bed. A warm shower or bath can help, as can a cool bedroom, since a drop in core temperature promotes sleep onset. A light snack that isn’t greasy may also be helpful. Meditation apps such as the free Oak app can guide relaxation. Several of my patients have had success with it.

Having a consistent bedtime is important, but maintaining a consistent wake time seems even more critical. This can be particularly hard for night shift workers who want to flip their schedule on the days they’re off. As difficult as it may be, trying to keep the same sleep and wake schedule throughout the week leads to better rest.

For night shift workers, a helpful trick is to wear dark wrap-around sunglasses before leaving work and continue wearing them until they are in a dark room at home. This reduces light exposure and keeps the brain from switching to daytime mode too early.

Medications and substances can also interfere with sleep. Caffeine stays in the body for up to eight hours, so it’s wise to avoid it late in the day if you’re having sleep issues. Decongestants such as pseudoephedrine (found in Sudafed®) and nicotine are stimulants that can disrupt sleep. If you smoke, consider talking to your provider about quitting. Alcohol, though often used as a nightcap, fragments sleep and reduces its restorative quality. It’s probably the worst choice for someone with insomnia.

Some people benefit from natural products, especially melatonin. It should be used cautiously. Start low – a half to one milligram – and take it about two hours before bed. Higher doses are rarely more effective and can increase side effects.

Prescription sleep medications should be a last resort. On average, they add only a few extra minutes of sleep each night and come with risks, especially for older adults. These drugs can be habit-forming and lead to daytime drowsiness or confusion.

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a proven, highly effective treatment. It addresses the thoughts and behaviors that interfere with sleep. While it may not be available in every community, many patients have found success using CBT-i Coach, a free smartphone app. More information on CBT-I is available at bit.ly/3wRuGwt.

If you want to read more about sleep and insomnia, I recommend two excellent books: The Sleep Solution: Why Your Sleep is Broken and How to Fix It by Dr. Chris Winter and How to Sleep: The New Science-Based Solutions for Sleeping Through the Night by Dr. Rafael Pelayo. Both provide practical and evidence-based advice.

An additional resource on insomnia can be found at bit.ly/39XAkPC. I hope these suggestions help bring you a better night’s sleep.