Easy Tips to Combat Summertime Insomnia

Don’t you love summer?  All the barbecues, outdoor festivals, vacations; school’s out, with all the freedom that goes with that.

I love summer as much as the next guy.  Many of my sleep patients don’t, however.  I’ve found that there are a couple of times of the year in which my patients experience a spike in their insomnia:  during the holidays, and during the summer.

There are several reasons why summertime can trigger or worsen difficulties falling and/or staying asleep.  First, many people and many families experience lifestyle changes during the summer as compared to during other times of the year:  kids can sleep in in the morning; vacations with jet lag; modifications in work hours or work timing; late-night parties and alcohol use.  These changes tend to dysregulate sleep schedules, leading to insomnia.  Second, it’s hot!  It’s hard to sleep when you’re sweltering and sweating in bed every night; we here in Seattle have been in a month-long heatwave, a major problem because most homes here have no air conditioning!  Third, because of the tilt of Earth’s axis during the summer, it’s light out late.  As most can easily understand, if the sun is still up in the evening, it feels naturally for YOU to stay up.  Exposure of your eyes–and hence your brain–to light has a profound impact on your sleep/wake cycles.  No wonder why people tend to have insomnia during these precious summer months!

So here are some pointers to improve your sleep for the remainder of this summer:

1.  Choose a time to awaken each morning, and stick with it.  Even if you’re not in school or not working, determine a preferred awakening time, set your alarm clock or smart phone for that time, and awaken and get out of bed that same time every morning, including weekends.  Your body clock “wants” regularity, no matter what your personal situation.  Sleeping in by several hours can throw off your body’s circadian rhythms, dysregulate your sleeping patterns, and promote delayed sleep phase.

2.  Keep your sleeping environment DARK.  Usually Venetian blinds suck at keeping out substantial light from your room when the sun is out late.  I recommend getting thick black curtains that completely cover up your bedroom window.

3.  Keep your sleeping environment QUIET.  Whether it’s motorcyclists or firecrackers outside your bedroom window, summertime often means lots of noise outside your bedroom.  Insulate your bedroom from the noise the best you can.  A fan near the bed can create a white-noise effect to drown out noises from outside.  Some may resort to sleeping in another, quieter room in the home, one that is further away from the street for example.

4.  Keep your sleeping environment COOL.  The fan in the room helps with this, obviously, if you don’t have AC.

5.  Avoid naps if you can.  Naps are tempting if you have the time and opportunity, particularly if you’re chronically sleep-deprived.  However, naps during certain times of the day–particularly the mid- to late afternoon–can cause substantial subsequent problems falling asleep later at night.

6.  Don’t spend too much time in bed.  Remember, most adults need about 7-8 hours of sleep per night, and your body generally won’t let you sleep more than what your body needs.

School is starting back up before you know it.  Enjoy the remainder of your summer!

 

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Why Do Dogs Make Such Good Alarm Clocks?

Like most everyone else, I enjoy the occasional brief distraction from whatever serious thing I’m doing by popping up a quick funny video during breaks. A friend recently sent me this little clip of dogs forcing their humans out of slumber and out of their beds in the morning.

As fun as these videos are, there’s something instructive about them:  they reveal some hidden but important messages about sleep.  Here are a couple things you can learn as you enjoy watching them:

1.  Animals have sleep cycles like humans do.  In fact, even the most primitive creatures on the planet demonstrate some form of simple, behavioral rest with measurable regularity, and usually with timing that relates in some way to the earth’s 24-hour day-and-night cycle.  Why does your dog always awaken you at 6 a.m., including on days in which you want to sleep in?  Probably because she regularly awakens shortly prior to 6 a.m. every day, right in keeping with her body clock, and wants to play.  That’s what our Maltese, Molly, does.

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2.  Your dog awakens you in the morning when you want to sleep in probably because you’re sleep-deprived.  There’s likely not a lot of published literature support for what I’m about to write here, but I would venture to guess that most dogs, not having to toil every day at work or staying out late with the guys, are usually “sleep-sated,” meaning that they get as much sleep during a 24-hour period as their bodies and brains require–through nocturnal sleep and/or by napping during the day when the humans are away.  The amount of sleep a dog needs depends on his age, size and breed.  However, the vast majority of human adults require between 7.5 and 8 hours of sleep per night–and on a regular basis–to feel fully rested during the day.  How many people do you know that get that much sleep per night most or every night?  If you routinely get less than 7-8 hours of sleep per night, chances are good that your body and brain will attempt to “make up” the lost sleep by trying to “sleep in” when they get the chance–on weekends and days off, for example.  In other words, your dog is doing what you should be doing–getting proper amounts of sleep–and he is now on your bed, lapping at your ear to remind you that obeying your innate biological needs is the natural thing to do, the best thing to do.

I say dogs make great alarm clocks:  you can’t get too mad at them, there’s no “snooze” button, and they make sure you know you should wake up and get up not only sonically, but also tactilely:  with paws, claws, and slobber.  Have you ever awakened briefly at your usual time in the morning, following a long period of sleep deprivation and though you intend to sleep in, and wondered why you awakened at that time instead of sleeping straight through?  That’s your circadian rhythm telling you it’s your natural time to wake up.  Look at your dog as a big furry biological clock “by proxy:”  she obeys her body clock every day and wonders why you’re not doing the same.  Just another reason to love your dog:  she can teach you to love your sleep and respect your sleep needs!

Finally, certain dogs, like pugs and boxers (dogs with thick necks) are also predisposed to snoring and obstructive sleep apnea, but I suppose that is a topic for another day.  Enjoy the remainder of your weekend, this first weekend of 2015!  Cheers!

Sleep Well This Summer!

 

Shortly I’ll be on a plane to Wichita, Kansas, for my high school reunion.  Every time I step foot on Kansas soil a flood of great memories returns:  Friday night football games, Knolla’s Pizza, midnight movies, parties, Bionic Burger, the River Festival, Galaga, and, especially around this time of year, the all-important beginning of summer.

 

Where I grew up, summer was all about crowded public swimming pools, Dairy Queen Hot Fudge Brownie Delights, baseball, mowing a huge yard all day every Saturday, hay fever, washing dishes at a restaurant by day, dragging Douglas by night, and listening to the Police and Marillion in my little green 2002.  It was also about hanging out with my friends, and to be perfectly honest I often didn’t sleep as much as I should have.  What did I know?  Sleep deprivation and sleeping in were pretty common during the sweltering, humid summer months of my teenage years.

Sleep often suffers in the summertime.  So before I depart I will leave you with some quick, easy tips to make your sleep easier, better, and more enjoyable during these hot summer months.

1.  Keep your bedroom dark, quiet, and cool.  Insulate your room and windows from noise and light to the extent that you can.  It’s a tough time for many of us financially, but if you are unable to sleep because the room is hot, use your air conditioning; sleeping well is worth the money spent on utilities.  If you can’t fix your hot, light, loud bedroom, try sleeping in the basement.

2.  Strive to keep your sleep schedules regular.  School’s out; loved ones are visiting; the neighborhood BBQ is in full swing; you’re off on a family vacation.  There is always the temptation to party late, sleep in, and not set your alarm clock during the summer.  Your body clock doesn’t care about any of that, however.  A common cause of insomnia and daytime sleepiness is dysregulation of sleep schedules.  Continue to awaken around the same time every morning (if you don’t have to awaken at any one specific time, you would do well to choose a preferred awakening time and stick with it), including on weekends and non-work days.

3.  Mind your late-night alcohol.  Alcohol has sedative effects for the first couple hours after you ingest it.  However, after several hours it tends to be a sleep disrupter.

4.  If you’re a night shift worker, get thick black curtains for your bedroom windows and wear dark sunglasses on your way home from work in the early morning.  Remember:  it’s light out early in the morning and late in the evening when it’s summertime, so your brain can be tricked into making you feel more awake and alert if there is bright light exposure around the time that you should be sleeping.

5.  Avoid late-night exercise.  The release of stimulatory hormones when you exercise hard can last for several hours, causing insomnia.  I recommend that you stop heavy aerobic activity 2-3 hours prior to your projected bedtime.

6.  Take care of yourself.  Don’t sacrifice your health for all that summertime fun.  Obviously, anything that causes physical discomfort can be a detriment to your sleep.  Avoid sunburns and dehydration.  Use nasal sprays or see your doctor for those seasonal allergies.  Minimize hangovers.  Don’t overextend yourself.  And, as I will probably see firsthand this weekend, it’s best to remember you’re not in your 20’s when you’re, uh, no longer in your 20’s, just ’cause it’s summer.

Utilize these simple suggestions and chances are you likely you’ll be able to avoid a . . .

The Differences Between Brain Death, Coma, and Vegetative State

You may have noticed over the past week several major news stories of brain dead or comatose people, their loved ones, and their unfortunate circumstances.  For many years neurologists have been concerned about the substantial confusion that exists regarding what is meant by certain terms that are utilized by the media pertaining to types of impaired consciousness.  Brain death, coma, and vegetative state are in fact very specific terms in clinical medicine, and there are volumes of medical literature describing and discussing all of them.  So today I will take off my sleep medicine hat, put on my neurology hat, and do my best to define these terms and distinguish them from each other for you, as briefly and succinctly as possible.

 

These 3 terms all refer to altered states of consciousness.  They are distinctly different from conventional sleep, which is a normalpredictable, temporary, diurnal and readily reversible state of unconsciousness necessary in and common to virtually all animal species.  All 3 of these states are generally bad–that is, with very few exceptions (such as drug-induced coma to prevent prolonged and life-threatening seizures, for example)–but neurologically speaking they are associated with varying levels of badness, not only in terms of unawareness of the patient’s environment but also in terms of prognosis for eventual “meaningful” neurologic recovery (i.e., return of consciousness with abilities to function independently, engage in basic activities of daily living, and enjoy the process of life).

Coma refers to deep sustained unconsciousness.  The patient is alive, but there is no sign of conscious or behavioral movement, vocalization, or voluntary eye opening.  The patient cannot be awakened; he or she does not respond to verbal commands or other conventional stimuli.  However, physical examination may demonstrate basic neurologic reflexes and variable (usually primitive or abnormal) responses to painful (“noxious”) stimuli.  There are a great many potential causes, including stroke, brain hemorrhage, severe closed head injury, medications, hypothermia, drug overdose, and prolonged deprivation of oxygen (such as from drowning or cardiac arrest).  The chances of someone regaining consciousness and substantial neurologic function depend on a variety of factors, including the nature, duration and severity (and potential reversibility) of the underlying cause(s), the duration of the coma, and how severe the coma is based on a thorough physical neurologic examination conducted by physicians.  In general, however, if the cause is severe and irreversible, and if the patient remains comatose for a long time (such as several weeks) following an injury, the likelihood of meaningful neurologic recovery is unfortunately small, even if he or she remains technically alive.

Vegetative state is a term is so deeply entrenched in the medical and popular literature that it is still utilized clinically.  In this form of impaired consciousness, the patient episodically appears awake but does not demonstrate evidence of awareness of self or environment; some refer to this as a state of “wakeful unconsciousness.”  The patient may appear awake upon casual observation, open and move the eyes, and exhibit sleep-wake cycles.  However, voluntary movements or vocalizations and purposeful behavioral responses to conventional stimuli are not observed.  It is usually associated with severe injury to the brain and it is prolonged in duration.  Basic brainstem functions are preserved, allowing the patient the possibility of many years of life in this fashion.  Unfortunately, this neurologic condition can be confusing (and often agonizingly so) for family members and clinicians, because signs on neurologic examination, the “depth” of neurologic impairment, causes and outcomes can all be so highly variable, and because the patient appears awake, though signs of awareness remain absent.

Brain death is the ultimate badness, referring to the complete and irreversible absence of all neurologic activity in the brain.    Physical examination demonstrates an absolute lack of response to stimuli; there are no movements or reflexes.  Diagnostic tests, such as electroencephalography (EEG), demonstrate an absence of brain and brainstem electrical activity.  The patient does not breathe without the assistance of a mechanical ventilator; when the ventilator is stopped, there is sustained apnea.  If other potentially reversible “mimics” of brain death (such as barbiturate intoxication and hypothermia) are ruled out, and if brain death is certain, there is no coming back from this; there is no chance of return of neurologic function or meaningful neurologic recovery.  Though historically people have thought of death as the permanent cessation of heart function and breathing, many people and most clinicians consider brain death consistent with clinical death, even if mechanical ventilation can keep vital organs of a brain-dead person functioning for long periods of time.  The Uniform Determination of Death Act (UDDA) is a draft state law approved for the United States in 1981 and has been adopted by most states.  It defines death as “either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem,” the determination of which is made “in accordance with accepted medical standards.”

There are several important issues to bring up briefly here.  First, it’s important to recognize that these terms may be confused with each other in the media, and sometimes even used interchangeably; be very careful of what you read and hear, and be prepared to challenge terms that are used.  Second, the clinical condition and neurologic status of the comatose or vegetative patient can change and evolve over time, and sometimes highly improbable or unexpected outcomes have been reported to occur without explanation or warning, such as spontaneous neurologic improvement following sustained coma for example; as one of my mentors once told me during my residency, “patients don’t read the textbooks.”  Finally, and importantly, there is an ongoing debate regarding the ethics of what these decreased levels of consciousness may mean for the patient, how loved ones should make decisions on behalf of the patient, and how society defines or views the concepts of death and a meaningful life over time.  These are all obviously very complex issues, affected and influenced by individual, ethnic, generational, and religious differences.  But we all–particularly those in the media–should at least strive to keep our terms and definitions as accurate and appropriately descriptive as possible, for the sake of ourselves and our loved ones.

A Connection Between Exercise and Sleep

I’m a proud dad today.  Yesterday my boys both ran their first 5K race.  One, who turns 12 next March, outran me by an entire minute!  I’ve told my boys for years now that one of my goals is for them both to end up being better than me at everything, and that’s starting to happen now!

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A lot has been made of the relationship between exercise and quality of sleep over the years.  Recently, the 2013 National Sleep Foundation Sleep in America poll demonstrated “a compelling association between exercise and better sleep.”  Paraphrasing the data, those polled who did not exercise regularly indicated their sleep quality was “very bad” as compared to those who exercised regularly by a substantial margin:  14% as compared to 3-4%.  In addition, 76-83% of those who exercised regularly felt their sleep quality was “very good” or “fairly good,” as compared to 56% of those who did not exercise regularly, despite insignificant differences in sleep duration between the two groups.  These data and additional data from the poll support the longstanding idea of an association between good sleep habits and a lifestyle involving regular exercise.

We all know that regular exercise has been associated with improved overall health across a wide spectrum of parameters, ranging from cardiovascular fitness to mood.  Here are a couple simple exercise tips as pertains to your sleep:

1.  Exercise in the morning in general can help sleep quality and reduce the amount of time it takes to fall asleep once in bed at night.

2.  Though the notion of whether late-night exercise is detrimental to sleep has been challenged in recent years, I still recommend to my patients that it’s likely best to avoid intense aerobic exercise within 1-2 hours prior to their projected bedtimes; heavy aerobic activity can promote the release of stimulatory hormones.

3.  Consider exercise outdoors early in the morning.  The combination of aerobic activity and light exposure early in the day can further increase levels of wakefulness during the day and quality of sleep at night.

4.  Keep in mind:  the promotion of great sleep habits and hygiene originates from the same mindset that generates a schedule that includes regular exercise:  discipline to maintain a lifestyle geared toward good health, happiness, and longevity.  Use the same discipline for your sleep as you do to get yourself to the gym.  Stay regular with your sleep times and sleep scheduling.  Awaken around the same time every morning to the extent that you can.

5.  Your exercise tolerance and energy levels probably will improve with proper amounts of sleep every night!  Obey your body’s intrinsic need for sleep; most adults require around 7.5-8 hours of sleep per night, regularly, to feel fully awake and alert during the day.

Stay healthy, everyone!

 

Sleep Well This Summer, Part 3: Keep Your Bedroom Quiet

It’s been a while since my last entry; too much going on this summer!  I hope you all are staying cool; it’s been a scorcher throughout most of the U.S. this month.

In recent entries we tackled how to keep your bedroom dark and cool.  I’m finishing off this summer sleep writing triad today with some tips on how to keep your sleeping environment quiet during these summer months.

Summer presents some challenges to sleeping in a peaceful quiet place.  It’s light out late, it’s vacation time, the kids are out of school, and the heat’s got people a little crazy.  So there are block parties, summer traffic, teenagers out raising a ruckus in their back yards, barbecues that run late . . . you know, all the stuff that’s great fun when you’re in the fun, but not so fun when you’re in your bedroom trying to get some winks.

As I’ve mentioned before, sleeping during the summer months is best achieved if you keep your sleeping environment dark, cool, and quiet.  Here are some suggestions to make for a quiet place in which to sleep.

1.  Fix broken or uneven windows and door and window frames, basically anything that can cause a draft.  Things that leak in unwelcome air will also leak in unwanted noise.  Doing so will probably reduce your energy bills too.

2.  Fortify your windows to insulate them from noise.  Try thicker glass or double-paned glass.  A cheaper and easier alternative would be to place thick, black curtains in front of the windows.

3.  Try a little “white noise,” particularly if you live in an area in which outside noise is unavoidable (train tracks, a busy intersection, or what have you).  A fan works well, because the convective effect of the circulating air cools you down as well.

4.  If you live in an apartment, request a corner apartment farthest away from the street.  And preferably as far away from loud, selfish, obnoxious neighbors as possible.

5.  Sleep in a room closest to the center of your dwelling.  The more drywall that separates you from the outside world, and the fewer windows in the room, the quieter in general your sleeping environment will be.

6.  Sleep in the basement, if you must.  Nothing like surrounding earth to insulate you from the noise and heat in the summertime.

7.  Though earplugs may be helpful, I personally advise against this, simply because you want to be able to hear potential problems around the house:  a crying baby, for example, a fire alarm, etc.

8.  If your bed partner snores substantially, discuss this with your bed partner and consider informing his or her physician.

9.  This is embarrassingly obvious, but turn off whatever beeping, pinging, whirring, droning electronic gadgets you have in your bedroom if you possibly can.

10.  Turn off TV’s, radios, and iPods.  Many people feel like they can’t sleep without background noise from such gadgets, but let me assure you that the reason why this feels this way is because of simply habituation:  your body does not biologically require such noises, but if you’ve had some sounds in the room at night for years, it feels like you need them when you don’t.  Turn off these devices and you should fairly quickly come to enjoy the silence.

11.  Particularly if you work night shifts, have open discussions with your family and loved ones about how to keep the noise of other people from disrupting your sleep.  As with most other situations, it’s always best to communicate openly and honestly about such topics!

Enjoy the rest of our summer, everyone!  I wish you deep, comfortable sleep!

 

Sleep Well This Summer, Part 2: Keep Your Bedroom Dark

Hi, all!  This is the continuation of my short series how to sleep well during the warmer and longer days of summer.  As mentioned in Part 1, people generally find a dark, cool, quiet environment most conducive to sleep.  Today’s entry is devoted to improving your sleep by keeping your sleeping environment dark.

 

By way of background, light is an extremely potent outside influence on your “body clock,” which regulates the timing of certain biological functions of your body.  Exposure of your retinas to light stimulates a neurologic pathway through your brain, essentially telling your body clock it’s time to be awake.  As such, exposure to light shortly upon arising in the morning can cause you to feel more awake and alert, and bright light exposure late at night can cause insomnia.  Even relatively modest light can have a stimulatory effect.  It makes sense, then, that shielding your bedroom from bright light is important during the summer, when the sun often shines relatively late into the evening, carrying both light and heat into your room.

Here’s a couple of considerations to darken your room.

1.  Sleep in a room without windows.  If you can.  Basements are great for that, for example, and some of my patients simply migrate to a basement bedroom each summer to sleep better.

2.  Sleep in a room which has windows that don’t face westward.  The sun sets in the west.

3.  Cover your windows.  I recognize this seems obvious, but it’s amazing how many people sleep in bedrooms with bare windows.

4.  Cover your windows with something dark (preferably black) and thick, such as black curtains.  Venetian blinds generally don’t do a great job of shielding the room from light.

5.  Turn your bed away from your windows.

6.  Turn off all the lights and the television when you’re ready to go to sleep.  Again, I’m stating the obvious here, but many people sleep with lights and other electronics on.

7.  Turn around or turn off glowing electronics, like digital alarm clocks.  If you’re an insomniac, turning your nightstand clock around will have the added benefit of keeping you from the deadly habit of “clock-watching,” which I’ve written about in previous entries.  It would also be helpful to turn off the lights one night and simply look around the room, looking for electronic lights.  You might be surprised about how much glowing, blinking stuff coinhabits your sleeping space, from your DVR, stereo, laptop, cable box, or whatever.  Turn off or hide whatever light sources you can, even if they’re small.  Turn down brightness levels as well if possible.

8.  Reconsider your nightlight.  Some people have long slept with a nightlight without problems, but bed partners may be bothered by this.  Discuss this with your spouse or bed partner.  If a nightlight is absolutely necessary, consider getting one that can be dimmed.

9.  If necessary and if all else fails, sleep masks or even dark sunglasses can help.  Hopefully, however, you can keep your entire bedroom dark throughout the night.

Sleep well, everyone!  The third and final entry in this series:  how to keep your bedroom quiet during the summer.  Enjoy these months of warmth:  winter is coming.