Exercise and sleep

Regular exercise has been shown to improve sleep quality. This article discusses that research in the past decade has confirmed that. However, I'm unsure of some of the statements in this article. Specifically, how taking sleeping pills is as dangerous as smoking a pack of cigarettes per day. No studies are cited, which makes it difficult to assess the accuracy of such statements.

Sleep quality and Alzheimer disease

Patients with Alzheimer's disease often have poor nocturnal sleep quality and daytime sleepiness. In fact, the sleep difficulties at night are a common reason that Alzheimer sufferers are put in nursing homes. Caregivers are unable to stay up at night to ensure their loved one's safety, and then function in the daytime. This study showed that there is a relationship between individuals' sleep quality and Alzheimer disease markers in spinal fluid. I don't full access to the article, so can only comment on the abstract.

This study has some limitations. Participants sleep quality was assessed only via questionnaire, not by objective sleep testing. So it's unclear what is contributing to the reduced sleep quality. Also, the participants were already at risk for Alzheimer disease, having a family history of it. From this study, we can't conclude that poor sleep quality leads to Alzheimer disease. And it's not clear if improving sleep quality would lead to a decrease in the biomarkers for Alzheimer disease.

Yoga for sleep

Individuals with insomnia are seeking natural remedies to improve sleep. This article is written by a yoga instructor, as she makes some interesting claims. First, she writes that "sleeplessness" is linked to all sorts of health problems. I wonder if she is confusing sleep deprivation with insomnia. Insomnia, when diagnosed by a doctor, has not been definitively linked to all of the health problems she lists. Sleep deprivation has been studied and data links it to some of the health conditions listed. Sleep deprivation is not the same as insomnia.

Then she writes about her treatment plan for insomnia, which includes yoga poses and breathing. However, no links to studies showing this helps is provided. The one aspect that may help is counting backwards, as this technique may distract individuals from their own thoughts when in bed attempting to fall asleep. The most helpful way to improve insomnia is with a form of psychotherapy, called cognitive behavioral therapy for insomnia (CBT-I).

Sleep apnea and insomnia on the rise in the US Military

This article shows how both sleep apnea and insomnia diagnoses have increased from 2005 - 2014. In my clinic, both conditions make up the bulk of the diagnoses and often exist together. The article states how the rates are higher in more senior personnel. This may be because sleep apnea is more prevalent with advancing age. Also, I frequently see senior personnel who are close to retiring, and have decided to start taking care of themselves. Usually it's because they finally have time to get their medical problems addressed as they approach separating from the military. Some of them wish they had gotten evaluated years prior, as treating their sleep apnea can significantly improve their quality of life.

Float therapy?

I've never heard of float therapy until I saw this article. Apparently, some derive benefit from floating in body temperature, salty water that is inside a sound-proof vessel. The article mentions that "float therapy" may help some with insomnia. I'm not aware of any studies to that effect - the report is only anecdotal. The article states that one reason it may help people sleep could be the same reason why a warm bath is helpful. I just hope people don't fall asleep while in the float chamber.

Wearable sleep-tracking devices and apps

This article points out a trend I've seen in my practice with some of my patients. Patient, typically with insomnia, describe their sleep quality based on what their FitBit watch tells them, rather than on their own perception of their sleep quality. The problem with these wearable sleep-tracking devices is that they are not very accurate at measuring sleep - they only record movements. Those movements could be from the patient, their bedpartner, or a pet in the bed.

The article highlights 3 separate patients who put more trust in their sleep-tracking device rather than on more accurate diagnostic tools (like sleep studies) and the sleep therapist who was using validated treatments like cognitive-behavioral therapy for insomnia (CBT-I). The study authors are concerned that these sleep-tracking devices are interfering with CBT-I, reinforcing sleep-related anxiety or perfectionism for some patients. For example, they explained how all three patients were spending excessive time in bed in an attempt to increase sleep duration as measured by their sleep-tracking device. But spending excess time in bed is one of the behaviors that worsens insomnia.

The authors explained what they tell their patients about the sleep tracking devices - that the trackers measure movement and not brainwaves. Therefore, these devices cannot determine light from deep sleep. They explain that the best use of these devices is probably to monitor their sleep patterns, including how much time they are spending in bed, rather than the number of minutes spent awake or asleep.

High blood pressure and insomnia

Insomnia refers to an inability to sleep the desired amount despite adequate allotted time in bed. People with insomnia often misperceive their sleep duration. Research studies have linked chronic insomnia with increased risk of high blood pressure (HTN). Sleeping less than 6 hours is considered being a "short sleeper" and is also associated with HTN.

This study looked at the association between short sleepers with insomnia and HTN. Participants underwent two consecutive in-lab sleep studies to objectively monitor sleep duration. They also had the participants record their subjective sleep duration with a sleep diary. Results showed that insomnia with objectively-measured sleep duration less than 6 hours was associated with increased risk (Odds Ratio 3.59) for HTN. This finding was independent of the following confounders: age, gender, race, body-mass index, frequency of sleep aid use, sleep apnea severity, daytime sleepiness, diabetes, high cholesterol, depression, alcohol use, tobacco use, or caffeine consumption.

The authors concluded that the results provide further support for measuring sleep duration objectively, rather than subjectively for those patients with chronic insomnia. This means the authors are advocating for sleep studies in the evaluation of chronic insomnia to help determine morbidity risks associated with the insomnia.

Pets and sleep

Lots of people sleep with their pets in their bed. This is fine unless it disrupts your sleep. This article discusses research at the Mayo Clinic showing that 18% of pet owners feel their pets disturb their sleep. The article goes on to discuss how you can get your pet out of your bed if it is bothering your sleep.

Insomnia and empathy

Insomnia can significantly affect your daytime functioning - most with chronic insomnia report daytime tiredness, concentration problems, and irritability. Here is an article about research presented at the annual Sleep meeting in Seattle. Researchers studied how insomnia levels affect healthcare workers ability to feel empathy for their patients. Workers with a sufficiently high insomnia scored demonstrated less empathy than those with lower insomnia scores. The article doesn't specify whether the healthcare workers had temporary insomnia, long term insomnia, or just sleep deprivation from rotating work and call schedules.

Insomnia and mortality

Chronic insomnia is a frequent problem, and several studies have attempted to link insomnia with medical problems, even death. However, it's not clear from these studies that the relationship is as stated. One methodology problem with these studies is the fact that most of them define insomnia based solely on the research subjects' description of their sleep quality. In other words, secondary causes of insomnia are not ruled out with objective testing like sleep studies. This abstract is about research done on subjects with chronic insomnia. I don't have access to the actual article, so my analysis of the study is limited. I can't tell from the abstract if the research subjects had secondary causes of insomnia ruled out with sleep studies.

Researchers used data from a community-based cohort and categorized subjects into having either persistent, chronic insomnia, only intermittent insomnia, or no insomnia. The researchers defined persistent based on the subjects' description of their sleep quality over a six year period. They then determined when the subject died for up to a 20 year period. The researchers also examined levels of a marker of inflammation called serum C-reactive protein (CRP). There were 1409 research subjects - 249 with intermittent insomnia and 128 with persistent insomnia. The results showed that the subjects with persistent insomnia were 58% more likely to die than those without insomnia. Those with intermittent insomnia were not more likely to die than those without insomnia. Of note, most of the deaths were cardiovascular. CRP levels were higher in those with persistent insomnia than in those with either intermittent or no insomnia. The authors noted that CRP levels were associated with increased mortality by themselves. However, adjustment for CRP levels did not notably change the association between persistent insomnia and mortality. Also, the results were adjusted for confounders such as age, sex, body mass index, smoking, physical activity, alcohol, and sedatives.

Energy drinks and athletes

Energy drinks like Red Bull and Monster are all the rage right now. Apparently, athletes are using them to enhance performance. This study assessed responses to energy drinks compared to placebo in athletes. The results showed athletes increased their "sporting performance by between 3% and 7%." Athletes were also able to up their performance at high intensities. The results also showed that "Energy drinks increase jump height for basketball players, muscle force and power for climbers and trained individuals, swimming speed for sprinter swimmers, hit force and accuracy for volleyball players, and the number of points scored in tennis.”

However, the energy drinks increased the frequency of insomnia, nervousness, and the level of stimulation in the hours following the competition. The researchers attributed all of the positive and negative effects to the caffeine in these energy drinks. The other ingredients did not seem to produce any benefit above the caffeine.

Insomnia and obstructive sleep apnea

I've followed Dr. Barry Krakow's work for years, starting when I was a fellow at Dartmouth. Dr. Krakow is an expert on insomnia, nightmare treatments, and obstructive sleep apnea (OSA). I have a copy of one of his insomnia books, called Sound Sleep, Sound Mind, and I recommend it highly. Besides treating nightmares, Dr. Krakow has brought to the mainstream the common co-existence of insomnia and OSA, and the relationship to each other. Now, he has published an exciting paper in the Mayo Clinic Proceedings, but I don't have access to it - all I have is the abstract.

In this study, Dr. Krakow evaluated over 1200 patients with chronic insomnia. Almost three-fourths of the insomnia patients did not respond to medications for their insomnia. Dr. Krakow studied 942 of them in the sleep lab using the most modern testing equipment, not done in older insomnia studies. Results showed that over 90% of these patients had moderate to severe OSA! The results are somewhat surprising with respect to the percentage of insomnia patients that had undiagnosed OSA. In my clinic, I regularly get patients referred to me for "insomnia" that actually have OSA, and sometimes it is severe. In these cases, treating the OSA usually improves sleep quality significantly such that sleeping pills are no longer needed.

The bottom line is that patients with chronic insomnia that do not respond to medications may benefit from referral to a sleep specialist for evaluation of underlying medical causes of the insomnia, such as OSA.

Insomnia and high blood pressure

Primary insomnia means difficulty sleeping not due to another medical or sleep disorder. It's a common problem but has not been conclusively linked with increased risk of medical illness. It has been shown to increase risk of depression. Part of what I do when I treat chronic insomnia is to explain that insomnia by itself is not medically dangerous. The studies that have shown links between insomnia and medical problems have not distinguished primary from secondary insomnia. Insomnia secondary to obstructive sleep apnea (OSA) can increase risk for cardiovascular (CV) disease, but it's the OSA, not the insomnia that is raising the CV risk.

Here is an article confirming what's already known about primary insomnia and high blood pressure. The results showed no link between insomnia and high blood pressure, even for 'severe' insomnia.

Human growth hormone and sleep quality

Human growth hormone (HGH) is popular amongst some athletes who use it for performance enhancement. A significant amount of HGH is secreted at night when asleep. Sleep deprivation can reduce HGH levels. HGH levels also naturally decrease with age. HGH can be used to treat certain medical conditions, like Prader-Willi Syndrome, which can cause sleep problems. I've not seen it used however in otherwise healthy people to improve sleep quality.

This study did just that - subjects took HGH at bedtime and reported significant improvement in time to fall asleep. They also had less time awake in the middle of the night and woke more rested in the morning. No reason for why HGH may improve sleep quality is given. Perhaps scientists will discover a novel mechanism of action to help those with reduced sleep quality.

Insomnia and stroke

Sleep duration and cardiovascular disease gets lots of press, even though the studies are inconclusive. Some speculate a "U" shaped curve where too little sleep and too much sleep is associated with higher risk of cardiovascular disease. It's unclear, but insomnia gets linked to sleep deprivation, and thus the news runs with stories that insomnia can increase risk of cardiovascular disease. I have blogged about it multiple times, here, here, and here. There are relatively few studies that have examined the relationship between insomnia and stroke.

This study is a retrospective cohort study based in Taiwan. They looked at patients with a diagnosis of insomnia, and used a comparison group without insomnia. They excluded those patients with a known diagnosis of obstructive sleep apnea and those with previous diagnosis of stroke. Then they tracked the populations for 4 years to analyze the number of strokes that occurred. There were 21,438 subjects with insomnia diagnoses and 64,314 subjects without insomnia. As expected, prevalence of diabetes, high blood pressure, high cholesterol, depression, anxiety, and atrial fibrillation were all higher in the insomnia population. During the 4 year follow up period, 583 of the insomnia patients developed stroke, whereas 962 of the patients without insomnia developed stroke. The incidence rate was significantly higher in the insomnia patient group than in the group without insomnia.

Again, there are some important limitations in this study, some of which are not addressed by the study authors. One big one is that we really don't know if the patients had primary or secondary insomnia. For all we know, the patients with insomnia and stroke may all have had undiagnosed obstructive sleep apnea. Also, the researchers relied on a diagnosis code for insomnia, but that does not mean these patients had a clinical interview by a sleep physician to determine that diagnosis. We don't know who is making the diagnosis of insomnia or how it is being made. There seems to be too many details left out to make any reasonable conclusions. I do agree with the authors that we need to screen and treat insomnia. It's also important to make an accurate diagnosis.

The reason I harp on this topic is that many of my patients with chronic insomnia inadvertently worsen their insomnia by worrying about the supposed health effects of insomnia. The news media and magazine articles make "insomnia" sound so dangerous. But if these individuals have primary insomnia, then they are not necessarily at increased risk just from the insomnia alone.

Sleep and technology

This article discusses the findings from the National Sleep Foundation's Sleep in America Poll from 2011. Some of the questions involved sleep quality and use of technology in the hour leading up to trying to sleep. The results showed that using stimulating technology that was interactive, like video games, cell phones, and computers was more disruptive to sleep than passive technology like watching TV or listening to music. The authors speculate that using stimulating technology may prevent the natural withdrawal of the sympathetic nervous system activity that is needed for sleep onset.

The implications of this research are intriguing. The results challenge, at least in part, that using passive technology in the bed can disrupt sleep. What seems to be most disruptive to sleep is stimulating technology. These findings could be extrapolated to other stimulating activities performed in the hour before bedtime, whether technology is involved or not. So perhaps the rule that the bed should be used for sleep only needs to be modified - it's possible that passive activity is not necessarily going to disrupt sleep. This goes along with my clinical experience in treating patients with chronic insomnia. Some of them have been going to sleep with the TV on in their bedroom since middle or high school. Yet their insomnia does not start for several years later, often in their late 20's. In these individuals, watching TV in the bedroom may not negatively impacting sleep quality as once thought.

Caffeine and sleep disruption

Most of us have used caffeine. And most of us have heard that caffeine consumed close to bedtime can worsen sleep quality. I tell my patients to not have caffeine within 8 hours of desired bedtime. This was what I was taught in sleep fellowship. Apparently, there are few studies that have determined that people should stop consuming caffeine within so many hours of bedtime.

This study sought to determine how caffeine affects sleep quality when taken at bedtime and at 3 and 6 hours prior to bedtime. It's a small study, with only 12 healthy, younger volunteers. The volunteers did not have insomnia but did consume caffeine regularly. Sleep was measured by subjective report and by objective home monitoring. The results showed that the 400mg of caffeine negatively impacted sleep quality when taken at bedtime and at 3 and 6 hours prior to bedtime. Interestingly, caffeine affected both subjective and objective sleep quality when it was taken at bedtime and 3 hours before bedtime. However, the study participants did not report reduced sleep quality when caffeine was consumed 6 hours prior to bedtime. But objective home measurement showed that the caffeine taken 6 hours prior to bedtime did negatively impact sleep. This lack of perceived disruption in sleep quality may explain why some patients ignore recommendations to eliminate caffeine consumption close to bedtime.

Eexercise and sleep

Exercise has been shown to improve sleep quality. This study was looked at the relationship between physical activity and subjective and objective sleep in midlife women. Physical activity was assessed with questionnaires and the level of activity was split into 3 domains. The first domain was labeled Active / Living and consisted of things like watching television and active transportation such as walking to work. The second domain was Household / Care-giving activities such as housework and child care. The last domain was Sports / Exercise which included participation in recreational activity or sports. The women's sleep was measured via in-home sleep study, daily sleep diaries, and questionnaires about their sleep.

The results showed that women who consistently participated in regular Sports / Exercise had better objective and subjective measurements of sleep, including sleep quality, sleep continuity, and depth, but not sleep duration. Women in this group also had reduced odds of meeting the diagnostic criteria for insomnia. This relationship was observed despite statistical adjustment for factors such as body mass index and other health behaviors. This association was not seen for those women in the domains of Active / Living and Household / Care-giving.

The relationship between the Sports / Exercise group and sleep was strongest when the pattern of activity existed over multiple years rather than just exercising immediately prior to the sleep assessment. In other words, regular exercise over many years may improve sleep more than sporadic exercise.

Yoga may improve insomnia

This article discusses research showing that twice a week yoga may help woman with breast cancer sleep better. Improvements were seen in sleep quality and duration in women with a clinical diagnosis of insomnia and in those that just had mild sleep disruption. Those that were in the yoga group reduced sleep medicine use by 21 percent per week. Those not in the yoga group increased their sleep aid use by 5 percent per week. The participants use Gentle Hatha yoga, which focuses on physical postures, and Restorative yoga, with an emphasis on relaxation, breathing and meditation. I've never done yoga, so I am not sure if other types of yoga would also benefit sleep quality.

CDC says 9 million Americans take sleeping pills

This article discusses new research from the Centers for Disease Control (CDC) that says that 9 million Americans report taking sleeping pills, whether prescription or over-the-counter to improve their sleep. This study was a survey, and there is nothing new from a clinical standpoint. Some highlights included that women are more likely than men to take sleeping pills, 5 percent versus 3 percent. More whites take pills - nearly 5 percent, compared to 2.5 percent of blacks and 2 percent of Hispanics. Prescription use increases with age, to 7 percent of those 80 and older.

Taking sleeping pills is not the only way to get better sleep. Talk to your doctor about seeing a sleep medicine physician, who can work with you to improve your sleep without necessarily resorting to pills.