Why so tired? Sleep expert unravels the mystery of exhaustion
Discover insights from Dr. Abhinav Singh on how good sleep is integral to health, the risks of untreated sleep apnea, and the natural pattern of circadian rhythms.
Almost everyone is familiar with the sensation of tossing and turning in bed, finding sleep elusive.
For some, that’s a rare event. For others, it’s every night.
There are myriad reasons. Biology. Time of life. Illnesses.
But for most people, there are ways to improve both the quantity and quality of sleep.
These strategies take knowledge, discipline, ingenuity and maybe a good fan – not medication or gizmos and gadgets, according to experts. The vast majority of people can even continue their caffeine habits. At least, in moderation and in the morning.
“The best sleep comes when we’re practicing the healthy sleep strategies that set us up for success at night,” said Rebecca Robbins, an investigator in the division of Sleep and Circadian Disorders at Brigham and Women’s Hospital in Boston.
How to fall asleep fast: ‘Don’t try so hard’
For the roughly 15% of people who struggle to consistently get a good night’s sleep, researchers like Harvard University’s Dr. Charles Czeisler have a lot of advice, starting with a simple suggestion: Don’t worry so much.
Many people who think they sleep terribly have an unrealistic expectation of what a good night’s sleep is, likely remembering earlier years, when they could sleep like a rock for half the day. That’s simply not realistic in middle age, he and others said.
If you have to get up in the middle of the night to go to the bathroom or find yourself waking up a few times, so be it, the experts say. In modern society, we all want to be able to sleep efficiently and we get impatient when we don’t, said Czeisler, who directs the Division of Sleep Medicine at Harvard Medical School.
Before the Industrial Revolution put a value on the workday, our ancestors used to sleep in two chunks with a gap of a few hours in between, historical research suggests.
Some people may think they can’t sleep well, Czeisler said, because they aren’t accounting for their body’s natural desire for this gap.
“They may just not be allocating enough time in bed to get as much sleep as they need. They want to be asleep 95% of the time they set aside for sleep, which they’re going to minimize,” he said.
Czeisler and others advocate patience, instead.
Even a well-rested person takes 15 to 20 minutes to fall asleep and older people take the same amount of time to fall asleep or fall back asleep as younger ones. “It’s important not to throw in the towel on the night just because you have awakened,” Czeisler said.
Tracking sleep with wearable devices might help some people, several experts said, but too often, they become a source of stress.
Sleep is not a time for perfectionism.
“We want people to get in bed feeling like sleep could happen,” said Jennifer Martin, a professor of medicine at the UCLA David Geffen School of Medicine. “Ultimately, they have to just stop trying so hard.”
Sleep hygiene
The term “sleep hygiene” refers to good habits and practices that can help people sleep well most nights.
While the specifics of when to go to bed and when to wake up will be different for everyone based on their individual needs and demands of daily living, the basic principles apply to everyone.
“All these behavioral changes are the secret sauce for healthy sleep,” Robbins said.
Here are some basics:
- Go to bed and wake up at roughly the same time every night. Drastically different bedtimes will confuse your body clock and make it harder to fall asleep.
- While some people might need a bedtime snack to fall asleep, others find food before bed disruptive. “Breakfast of kings, lunch of princes, dinner of paupers,” works best for most people, Robbins said. In other words, eat a lot in the morning, modestly in midday and not as much at night.
- Avoid drinking “nightcaps.” While alcohol at night might help people fall asleep initially, it has been shown to disrupt sleep later and makes sleep apnea worse.
- If you’re sensitive to caffeine, avoid consuming too much, especially in the afternoon. If you’re not sure, try an experiment for a week, cutting back or eliminating it entirely.
- Manage stress. Meditation or breathing exercises can help decompress.
- Keep naps short and not close to bedtime.
- Get as much natural light as you can in the morning. This sets up circadian rhythms and helps with alertness in the morning.
- Some sleep researchers have special lights in their homes or software on their computers (f.lux is one) to limit exposure to blue light in the evenings. Blue light is what signals “morning!” to the brain.
- Have a bedtime routine. This includes turning off devices like phones and bright lights and other stimulating activities for a period of time.
- Feel the need for noise? Opt for a fan, not the television, said Dr. James Rowley, president of the American Academy of Sleep Medicine board of directors. “There’s no yelling and no car crashes” on a fan. Even reading can be too stimulating for some.
- A phone “needs to be face down on the side of the bed being charged and it should not be on you,” Rowley said.
Medications can work, but at a cost
Drugs developed as sedatives work pretty well in the short term, Rowley said.
He worries more about people using drugs designed for other purposes like allergy or cold medicines that have sedation as a side effect. “That’s where a lot of us get upset,” Rowley said, speaking about the feelings of sleep specialists.
One patient, who recently came into his office, was taking an “all natural” sleep aid that included about 15 ingredients, all of which might interact with other medications. “You have to be cautious,” he said.
Melatonin has not been shown to be effective for insomnia in any research trial. In addition, most people do not use it correctly, using either too high a dose or taking it too close to bedtime to make a difference, Rowley said.
“If melatonin’s going to help you, it’s probably going to help at .5 to 3 (mg),” Rowley said. “Not that it’s great for insomnia, but if it’s something you want to try, low doses are probably better than high doses.”
Plus, Martin said, “If you have a hard time staying asleep and you’re taking melatonin in the evening, it might actually make your problem worse, not better.”
At least one new drug therapy is now in late-stage clinical trials, but researchers said they’re withholding judgement until they see whether new medications perform better than existing ones or than behavioral changes.
Much better than medications so far is a kind of talk therapy called cognitive behavioral therapy for insomnia or CBT-I, Martin said.
CBT-I trains people to avoid behaviors and ways of thinking that make their insomnia worse.
“The way people think and the actions they take are what sustains their insomnia problems,” Martin said. “If we can help people get into bed in a better mindset and structure their sleep and wake habits and routines in a way that makes sleep most likely to happen when they’re in bed, that seems to get people back on track.”
When to get medical help: sleep apnea
People who have true sleep issues need to have them addressed by a specialist, the experts said. And sleep problems are more common with advancing age.
Many physical and mental ailments are associated with sleep problems. People with ADHD, autism or depression often report problems with sleep, for instance. Getting help with sleep issues may limit other symptoms.
Typically, a sleep issue that lasts more than about three months, should be treated, as should sleep apnea, which is often characterized by loud snoring and choking that wakes someone up (and often the person next to them).
One study followed people with and without sleep apnea for 18 years, starting at age 48. In the group that had sleep apnea, only 58% were still alive at age 66, compared to 94% of those without sleep apnea. That’s a 6- or 7-fold increased risk of death, mainly due to heart attack and stroke, “so it’s really important to get it treated,” Czeisler said.
The standard therapy, called CPAP (continuous positive airway pressure), which uses a machine to keep airways open, can be cumbersome and hard to stick with, but most patients can adjust over time, experts said.
One widely used brand was recalled in 2021 year, stigmatizing the industry and confusing patients. Supply chain problems with the microchips used in the devices meant many people went without CPAP machines for long periods. These barriers unfortunately persist and limit treatment of an already complex and hard-to-address condition Robbins said.
Other apnea treatments include implantable devices, which are increasingly being covered by health insurance, and surgery.
Busting myths about sleep
In a study published in 2020, Robbins and Czeisler, among other experts, weighed in on 20 popular myths about sleep. Robbins recently offered a take on some of the most enduring ones.
Falling asleep anywhere anytime isn’t the sign of a good sleeper. It’s the sign of someone who is sleep-deprived.
Evidence suggests seven to nine hours of sleep provides the most optimal health and well-being. People who think they can get away with sleeping less are likely setting themselves up for health problems later on.
Older adults don’t need less sleep than younger ones, though they often get less, because they don’t sleep as well and are more likely to have disrupted sleep.
When you sleep does matter. Eight hours of shut-eye in the middle of the day are not as restful as eight hours in the darkness, though it’s better than less sleep.
Lying in bed does not count as time sleeping.
Staying in bed isn’t a good idea if you can’t fall asleep. Instead, experts suggest changing your environment, doing low-stress activities for a little while before trying again to fall asleep. That doesn’t mean picking up your phone or getting work done, but maybe taking a warm shower or doing some stretching until you feel tired.
Finally, experts say, sleep is not a time when the brain is “turned off.” The brain is not passive during sleep, but instead is actively firing, clearing waste, storing memories and preparing for the day.
In general, Robbins said, the public has begun to realize sleep is just as important as diet and exercise in maintaining health.
“Gone are the days of bragging about not getting enough,” she said.
Contact Karen Weintraub at [email protected].
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.
Rachel Carter is a health and wellness expert dedicated to helping readers lead healthier lives. With a background in nutrition, she offers evidence-based advice on fitness, nutrition, and mental well-being.
