A good night’s sleep is a key component of good health, but patients’ sleep history often receives little attention among clinicians. When a patient complains of sleep problems, practitioners often reflexively prescribe sleeping medications without inquiring further. When academic sleep pioneers first performed sleep studies in the 1970s, it was soon evident that sleep is multifactorial and complex. More recent studies have revealed that cyclic alternating patterns intrude into deep sleep, thereby reducing its restorative quality.
Practitioners who pose questions about sleep problems and sleep quality often find that patients will have difficulty falling and staying asleep, thus necessitating a two-pronged approach. Patients’ self-descriptions may suggest either a sleep disturbance or a systemic disease. A patient’s partner can be helpful in providing further history, such as snoring, periods of apnea, or restless legs.
Many cases of disrupted sleep lead to fatigue, irritability, and depression. Normal worries and concerns can trigger insomnia, while PTSD can cause severe night terrors and vivid dreams, leading to major disruptions in quality of life. For some, blood pressure remains difficult to control until patients start sleeping more soundly. Sleep disturbance can also cause fibromyalgia and an increase in pain in other conditions, such as rheumatoid arthritis, osteoarthritis, and systemic lupus erythematosis.
Many patients fall asleep reasonably easily but then wake up a few hours later and are unable to fall back asleep. This leaves them feeling exhausted in the morning. To date, there are no prescription medications approved by the FDA to deepen sleep, though many physicians use a variety of medications “off-label” for this purpose.
Encourage Good Sleep Hygiene
The cornerstone of treatment of sleep disturbance is sleep hygiene, which includes only using the bed for sleep, avoiding caffeine or other stimulants, and not eating or drinking too late in the evening. Keeping regular bedtime hours and resisting the temptation to look at the clock (which heightens both frustration and alertness) are other components to good sleep hygiene. Alcohol can make people sleepy, but sleep is often fragmented after alcohol intake once they fall asleep. Similarly, some prescription medications can adversely affect sleep quality.
Although it’s possible to order formal sleep studies for patients, most clinicians reserve them for severe cases or suspected sleep apnea that might merit definitive treatment. Sleep studies are expensive and can be cumbersome for patients. Standard treatment is thus empirical, involving both sleep hygiene measures and pharmacologic agents. That said, many gaps in knowledge and understanding of sleep persist.
What remains beyond debate is the importance of a good night’s sleep. Clinicians should focus more on sleep quality than quantity, as more and more studies are showing that quality sleep is associated with lower rates of hypertension, diabetes, obesity, and depression, and promotes longevity in general.
Readings & Resources (click to view)
National Institutes of Health. Sleep disorders – overview. Available at: www.nlm.nih.gov/medlineplus/ency/article/000800.htm.
Van Cauter E, Leproult R, Plat L. Age-related changes in slow wave sleep and REM sleep and relationship with growth hormone and cortisol levels in healthy men. JAMA. 2000;284:861-868.
Moldofsky H, Scarisbrick P, England R, Smythe H. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects. Psychosom Med. 1975;37:341-350.
Parrino L, Ferri R, Bruni O, Terzano MG. Cyclic alternating pattern (CAP): the marker of sleep instability. Sleep Med Rev. 2012;16:27-45.
Moldofsky H, Harris HW, Archambault WT, Kwong T, Lederman S. Effects of bedtime very low dose cyclobenzaprine on symptoms and sleep physiology in patients with fibromyalgia syndrome: a double-blind randomized placebo-controlled study. J. Rheumatol. 2011;38:2653-2663.
Moldofsky H. The significance, assessment, and management of nonrestorative sleep in fibromyalgia syndrome. CNS Spectr. 2008;13(Suppl 5):22-26.