Today I’m going to talk to you about what happens when you sleep, a little bit about insomnia and health, changes in sleep during the COVID-19 pandemic, and review some basic sleep treatments, both for insomnia, as well as things we can do on our own. There has been a lot of attention in the media, especially lately, about how important sleep is for health. This New York Times article from a few years ago, stated that sleeping more is the simplest way to drastically improve your life.
Sleep deprivation, which affects about 1/3 of all people, has negative effects on health and well-being, and yet it’s hard to know exactly how much sleep is enough sleep. This CNN article, again, from a couple of years back, shows that even too much sleep can be linked to poor health. Ultimately sleep is really heterogeneous among individuals, and sleep is related to health, but it’s not clear for each person what is the optimal amount, or type of sleep, or how it impacts health for each individual. This is part of why I’m so interested in sleep is that it is so personal, and it’s so heterogeneous, and we need to learn more about how to improve things for each person.
First of all, what happens when you sleep?
Let’s start with how sleep changes as we age. From infancy, we spend about 70 percent of our day sleeping. We often wake to start our days, and our parents’ days, around 5:00 AM. Then we grow into becoming teenagers who have phase-delayed sleep. We end up going to sleep late, often spending a lot of time on sleep and waking up late.
Given that schools tend to start on the early side, we’re often quite sleep-deprived and tired during the day. Then as we age into being adults, our sleep phases shift earlier again. We go to bed earlier. We wake earlier. However, most adults, especially Americans, do not actually sleep well, but 35 percent of Americans are sleep-deprived, which means sleeping about less than seven hours a night.
About 50-70 million US adults have a sleep disorder, the most common being insomnia, about 30 percent with short-term issues and about 10 percent with chronic issues.
Unfortunately, those types of issues worsen as we age. Older adults have higher rates of insomnia as well as other sleep disorders. They have more frequent overnight awakenings and shorter overall sleep time, and about half of older adults report having some type of sleep problem. So why is sleep so important?
Sleep is clearly a biological process that’s key to development and health. It’s been shown to be important for promoting growth, regulating metabolism, heart and lung function. The purpose of dreams, it’s not exactly clear, but that’s an important function that happens while asleep. Sleep is important to solidifying memories as well as to clearing toxins from the brain. That’s been an area of increasing interest over the last few years.
Clearing toxins such as amyloid and tau proteins, which are key in the pathogenesis of Alzheimer’s dementia, has been shown to happen as we sleep.
Insomnia, obstructive sleep apnea, short sleep duration, or poor sleep quality have all been identified as independent risk factors for cognitive impairment in the development of Alzheimer’s dementia and vascular dementia. We know that poor sleep is linked to issues with memory, attention, mood problems, as well as falls. So sleep really has a mechanistic impact on cognition, which we are still learning a lot about. In terms of insomnia, insomnia itself has a strong impact on health.
What is insomnia? Some of the major signs of insomnia include difficulty of falling asleep, staying asleep, or waking too early and not being able to fall back asleep again. It causes clinically significant impairment or distress in at least one of these key areas including fatigue or low energy, daytime sleepiness, mood disturbances, behavioral difficulties, cognitive problems that can impair concentration, attention, or memory, impaired abilities to complete occupational or academic functions, impaired interpersonal or social functioning, and it can also affect your caregiver family functions.
Diagnosing sleep apnea usually starts with a clinical evaluation with your doctor to rule out other medical problems that can interfere with sleep. Many times it can be helpful to get referred to as sleep specialist.
Sometimes it can be helpful to track your nightly patterns of sleep with a sleep diary, looking at bedtimes, awakenings, your overall sleep quality, and the use of interfering substances like caffeine, alcohol, and medications. There can be a number of questionnaires that can help to understand about these sleep symptoms as well as the potential precipitating factors, lab test to rule out other medical issues, and then even sleep studies. The health consequences of insomnia are pretty broad. Poor sleep has been linked to metabolic issues such as obesity, heart problems, cardiovascular disease, hypertension, even immune dysfunction, as well as depression and anxiety. Some of this may be a little bit bidirectional in that sleep can cause these problems, as well as some of these issues can worsen sleep as well.
During COVID-19, about 41-70 percent of older adults in certain studies have reported sleep problems. The sleep problems have been associated with female sex, having increased anxiety or depression, complaints of loneliness, either not working or being confined to the home, and social distancing measures have been shown to be associated worse on sleep. Again, however though, the sleep quality during COVID-19 has been variable. Certain populations are reporting worse sleep quality, while others have actually reported better sleep quality.
Again it seems to affect different populations differently.
Another interesting point is that good quality sleep is really important for optimal immune function. Even a single night of poor sleep can actually affect inflammatory biomarker levels, lymphocyte counts, which are a key immune cell in the body, as well as your vaccine antibody response the following day. One of the notes I remember seeing when the COVID-19 vaccine came out was that having a good night’s sleep before can actually make the vaccine more effective. Chronic poor sleep can actually upregulate innate immune system activity and affect how leukocytes are trafficked or brought to different sites of the body to help with fighting off infections.
Our work in schizophrenia, bipolar, as well as healthy adults have shown that a lot of the night-to-night changes or variability of sleep patterns can actually be strongly associated with inflammation. We’ve seen that people with more labile sleep patterns when they sleep very short amounts one night and maybe much larger amounts the next night, so the changes from night-to-night are larger for those folks, actually, may have increased levels of inflammation or oxidative stress.
Another important impact of sleep in addition to the effects in immunity, the stressors of COVID-19 can also affect sleep in turn. COVID-19 has created what was coined by a group of authors, including Smith and colleagues, as a connectivity paradox. While the risk of social isolation and loneliness may be increased by taking further social distancing or isolation measures, you’re really balancing the COVID-19 infection risk against the risk of social isolation and loneliness.
This is important to us because we’ve seen that there’s been an increased prevalence of loneliness during the COVID-19 pandemic, and other studies have actually shown, pre-COVID, that loneliness is strongly associated with sleep problems. We’ve seen a number of studies that have shown loneliness, associated with decreased sleep efficiency, which is less percent time sleeping overnight, increased overnight awakenings, also called WASO or wake after sleep onset, longer sleep latency, which means it takes longer to actually fall asleep when you go to bed, worse sleep quality, and even having insomnia associated with loneliness.
Again this may be bidirectional in that loneliness is associated with poor sleep, and poor sleep is associated with loneliness. In one of our studies of older adults in collaboration with IBM, we’ve actually seen that loneliness is linked with psychosocial functioning and other behaviors. We found that when we looked at reported sleep quality and loneliness here on the x-axis, so higher levels of loneliness were associated with higher scores on the sleep quality, which actually indicates worse sleep quality.
We are seeing that lonely older adults had worse self-reported sleep quality. When we put fitness trackers on them to actually assess objectively how their sleep was, this density plot here shows data from 362 nights from about 39 older adults. As opposed to showing the actual mean sleep, it actually plots the overall curve of how they sleep over time. Each individual here is shown by a line. The red lines indicate people who reported higher levels of loneliness, and the blues are the individuals with lower levels of loneliness.
The flatter curves are the individuals with more variability in their total sleep time. We found that, while mean sleep duration was similar between lonely and non-lonely individuals with the average amount that they sleep at night, the actual intra-individual variability was higher in lonely individuals.
It seems that this variability of sleep, which we’ve shown in other studies we associated with inflammation and other negative health outcomes, may actually be worse in lonely people. The reason why we’re so interested in that is because sleep may actually be a mediator of how loneliness affects health. Just to close, I’m going to talk a little bit about some common sleep treatments for insomnia, as well as some general recommendations on how to improve your sleep.
Focusing on insomnia, there are a number of medications that people have been prescribed for sleep. One common group is called the Z-drugs, which are specific medications that hit the benzodiazepine receptors but are usually marketed specifically for sleep. You might have heard of Ambien or zolpidem and other medications like that. These medications, on the bright side, are best suited for acute issues and are often available through primary care doctors. However it does come with a number of side effects, as well as, it may not be useful for chronic long-term use.
There’s also a number of over-the-counter options that are marketed for sleep issues. You might have heard of Seroquel or using Benadryl or Unisom. There tends to be less dependence from those medications, but unfortunately, similar, the efficacy often wanes when they’re being used for chronic treatment. There’s also therapies that can be helpful. One in particular I’m going to talk about is cognitive behavioral therapy for insomnia.
This treatment has been shown to be safe and effective. It has lasting effects on improving insomnia. However, it does require a bit of motivation on behalf of the patient. It does take time, often six weeks or more, and then it tends to be less successful in terms of finding therapists who are skilled in CBTI for different patients. The other thing that many people will talk about is sleep hygiene.
When you don’t have a diagnosed sleep disorder, there’s a number of different things you can do to try to improve your sleep. One key point is to avoid caffeine, alcohol, nicotine, or exercise around bedtime, for the most part stimulating things, that may make it difficult to fall asleep, but also alcohol.
If you’re thinking about it as a sleep aid, it may make you drowsy in the short term, but it may wear off before you’re ready to wake up. However, on the other hand, exercising regularly is important for maintaining and improving sleep quality overall, as long as it’s not right before you go to bed. Having regular meals can be an important way to reregulate your body to be more aligned with regular circadian activities or circadian rhythms.
Having regular bedtimes even on weekends. There’s been some studies that show that catch-up sleep on the weekends is actually not associated with better cardiovascular health, and having that regular bedtime and wake time everyday can be better for your body. Trying to schedule enough sleep, so at least seven hours of sleep, can be very important. Having calming bedtime routines, so avoiding stimulating TV or stressful task right before sleep, can help to avoid having anxiety or trouble falling asleep at night.
Maintaining a dark, quiet, cool environment, trying to avoid having a lot of clocks in the bedroom, and then, of course, using your bed only for sleep and sex.
No eating, studying, TV. Try to avoid all these other associations of active things you might be doing in bed. During COVID-19, there’s a number of other things that have been shown to be helpful for sleep. Going outdoors everyday, getting the natural sunlight, managing the stress related to COVID-19, so practicing mindfulness, self-compassion and gratitude, maintaining a daily routine, even at a time when things may be blending together, and we may be feeling like we’re in groundhog state, and everyday is the same, this can be a real key part to actually provide definition and creating structure to our day.
Another one is cultivating meaningful daily social interactions.
That’s been one area that a lot of patients have told me is a real challenge. They miss almost the regular minor social interactions you might have at a coffee shop, or on the bus, on the way to work, things like that, and finding ways to cultivate meaning through social activities is important. Another one is, again, providing structure, but it may be more along the lines of a longer-term scale, is looking at how to celebrate milestones and actually plan for the future. Then the last of course is, if symptoms are getting worse in terms of sleep or even mood and stress contributing to sleep problems, the key thing is to seek help from your doctors and getting evaluated to see if there are other things that can be done.
One of the most important things I find about sleep is that is so modifiable and treatable, that it’s important to consider that as a key integral part of your health.
So just to summarize, sleep is a key biological process for the growth, maintenance, and for aging successfully, sleep disorders are treatable, COVID-19 has affected sleep in many populations, including older adults, and that we can improve our own sleep through changing habits, and rituals, and other enriching activities. It’s important to emphasize that. Last of all, I just want to thank you all, my audience, my sources of funding, as well as our wonderful team at UCSC. Thank you so much for your attention.
Read More: HOW TO GET BETTER SLEEP: 10 practical tips to sleep well 😴
