Advice About Sleep Deficiency in Midlife, Part 1
By THE NEW YORK TIMES
Published: September 25, 2013
Nearly 200 people sent questions about sleep to Orfeu Marcello Buxton, a neuroscientist who studies chronic sleep deficiency in the workplace and home and how it contributes to disorders like obesity, diabetes and cardiovascular disease.
Dr. Buxton is an associate neuroscientist in the Division of Sleep Medicine in the Department of Medicine at Brigham and Women’s Hospital in Boston, as well as anassistant professor at Harvard Medical School and the Harvard School of Public Health. He received his doctorate from Northwestern University in Evanston, Ill. (Note: Dr. Buxton is a researcher, not a physician, and he emphasizes that his responses should not take the place of recommendations from your health care provider.)
More responses will be posted next week. Because of the volume of questions, not all may be answered.
Disclosure statement: Dr. Buxton’s current research is financed by several branches of the National Institutes of Health. He is a consultant to the Harvard School of Public Health Center for Work, Health and Well-being and is on the scientific advisory board for Matsutani America (a dietary fiber supplement manufacturer). He has served as an expert witness for Dinsmore L.L.C., received speaking/consulting fees from Takeda Inc., and was the principal investigator on investigator-initiated research financed by Cephalon Inc. (now Teva) and Sepracor Inc. (now Sunovion).
Introduction
Thank you to all readers who commented and submitted questions. The breadth of the questions speaks to the many different ways that we sleep, and how our expectation about sleep, and our sleep patterns and habits can vary with circumstances and our environment, and across the course of life.
Healthy Sleep in Midlife
Q. I go to sleep fairly early (8:30 p.m.) because I am exhausted, yet I wake up around 2:30 or 3 a.m. and cannot get back to sleep. I used to sleep much longer and arise more rested. Is this probably just age? Are there things I can do to help myself sleep longer? — CM, Placitas, N.M.
A. Many readers addressed directly or indirectly the question, “What is ‘normal sleep’ in midlife?” Setting aside the possibility of a sleep disorder (some of which are addressed below), normal sleep has a physiological basis, but also a cultural basis (see below on the relatively modern emergence of an expectation of a single consolidated night’s sleep). What we might consider normal sleep in midlife varies depending on individuals and their circumstances.
Typical advice has been to get a full eight hours of sleep, but this is the “tyranny of the mean.” Our individual sleep need is roughly the same across adulthood, though as discussed below (“Sleep and Aging”), the amount of sleep we need may decline slightly as we age. For most adults, routinely sleeping seven to nine hours per night regularly is appropriate for optimal functioning and health. That said, there will be some people who need less, and some who may need more sleep; it’s just that there are far more of us getting less than we probably need (the United States average is just above seven hours a night, and the proportion of short sleepers is increasing). Information is available from the Harvard Division of Sleep Medicine on the benefits of healthy sleep and getting enough sleep, including a “sleep makeover,” and 12 simple steps to improving your sleep.
So how can you tell if you are getting enough sleep at this time in your life? I have a nonclinical litmus test. First, pay off your sleep debt by getting plenty of extra sleep for a few weeks. Vacations outside of our normal pressures can work well for this. Then, begin going to sleep and waking up at about the same times each day, and you will find that your individual number may emerge — the number of hours of sleep after which you wake up and generally feel refreshed, without stimulants. The test is: can you sleep this amount, get up without an alarm clock (except for backup to avoid worrying about missing a morning obligation), and feel good? Bonus: someone else may also report you are (even more) pleasant?
As you can imagine, maintaining healthy sleep is a lifestyle and is not achieved through a quick fix. We don’t go to the gym once and expect immediate fitness, or eat salads for one day and expect leanness. Getting enough sleep gives more energy for vigorous exercise and improves healthy food choices. But where is the time for all this, you might say? To achieve healthy sleep, prioritize your health and recognize that being your best, rested self is more important than something else like watching television or mobile-device screens, especially in their most ad-infused forms, or social media indulgences that don’t bring real joy. The three pillars of health (diet, sleep and exercise) can help everything else go better in our lives, especially the most important things like our relationships and true passions.
Sleep Apnea
Q. How we can differentiate between normal snoring and sleep apnea? — Jnanawala, Surat, India
A. Some readers asked directly about the symptoms of sleep apnea and snoring, or described extremes of daytime sleepiness that might suggest sleep-disordered breathing or other sleep disorders that would be good to rule out. Sleep-disordered breathing results in a lack of sufficient oxygen being taken into the lungs and throughout the body, usually because of a constriction of the airway, but possibly also related to structural issues or sometimes breathing centers in the brain not working ideally. Sleep-disordered breathing also causes frequent interruptions and awakenings during sleep.
Symptoms of sleep-disordered breathing include excessive daytime sleepiness, choking or gasping during sleep and sometimes morning headaches because of low oxygen during sleep. In response to falling oxygen levels in the blood (and or rising carbon dioxide levels), a brain “arousal” lightens sleep and a gasp or deeper breathing takes in more air. Risk factors include having a greater than 17-inch neck size, obesity, being male and a family history of apnea. But it is possible to have none of these factors and have sleep-disordered breathing. Snoring is much more common than sleep-disordered breathing, and snoring doesn’t necessarily mean one has sleep-disordered breathing. But the cessation of breathing for more than 20 seconds during sleep is an indicator of sleep apnea. A diagnosis of sleep apnea involves a sleep test at a sleep clinic or in the home.
There are a variety of treatment options, but the most common is an air pump and a mask that is worn during sleep to provide enough extra air pressure to overcome the obstruction. These work best if worn the entire night.
The Harvard Division of Sleep medicine has accessible and engaging content on sleep apnea here. Detailed patient information about sleep-related breathing disorders and treatment options is available from the American Academy of Sleep Medicine.
Insomnia
Q. What can be done about middle-of-night insomnia? I go to bed at 9:30 or so, exhausted and fall asleep in 2 seconds. Then I wake up anywhere from 1:30 to 4 a.m., and cannot fall back asleep for hours if at all. It turns the days into endurance events. Once in a great while, I get a full seven to nine hours and feel magnificent. There is no pattern to it and I cannot make it happen. I cannot take my 1:30 a.m. start of the day. Don’t want to take pills to sleep. — xojoyox, Brooklyn
A. Difficulty getting to sleep or staying asleep on a regular basis (three or more times per week for at least a month), and a complaint about this sleeplessness causing other problems, is chronic insomnia. Acute insomnia usually has a clear precipitating cause, like stress, anxiety, conflict, grief or a medical condition or medication with side effects. In contrast, chronic insomnia can have less obvious or long-past precipitating factors. Chronic insomnia is thought to be perpetuated by established habits and expectations about sleep, as well as potential brain neurotransmitter or brain system changes that cause the brain to be hyperaroused during sleep, or in other words, cause the wake centers of the brain to be stuck in the “on” position. Chronic conflict at work, harassment at work, or stress at work in general can contribute to insomnia.
The inability to sleep in the middle of the night is an especially difficult form of insomnia on the minds of many of us in midlife. Sleep maintenance difficulty is, for example, more strongly related to diabetes risk than short-sleep duration or difficulty getting to sleep. But it’s important not to overly worry about this because this rumination can worsen insomnia.
There are several active steps to take.
Try to understand what might be causing the awakening: is there a regular interruption like noise that is contributing to this? Snow days are so peaceful and restful when airplane flights are canceled and snow dampens traffic and other sounds, but only until the snow plows grind down the street. Pets and bed partners can be a source of potential interruptions.
If it seems that the awakenings are internally generated, start with an assessment of sleep disruptors, like excess caffeine; or a sleep environment that is too bright, hot, cold or noisy.
If these things don’t work, it may be time to talk to your physician about potential medical causes of insomnia, like medications, sleep disorders (sleep apnea, restless-legs syndrome) and medical and psychiatric causes.
Additionally, consulting a sleep specialist may help. New formulations of F.D.A.-approved medications with short half-lives may be useful in treating middle-of-the-night insomnia — in the short term. In the long term, behavioral treatments to improve sleep, including cognitive behavioral therapies or mindfulness practice can improve sleep, and have a sustained impact after the cessation of active treatment. A lot of work remains to be done to determine the effectiveness of these various pharmacological and behavioral treatments, especially head-to-head comparisons, but promising ones are available now.
For useful patient information on all manners of sleep disorders, include information from the American Academy of Sleep Medicine, which includes a Find a Sleep Center tool.
Sleep and Aging
Q. What can a 65-year-old woman, who ever since menopause wakes up 10 times a night, do to get a good night’s sleep? — Bonnie Rozanski, Lawrenceville, N.J.
A. Many of us are concerned about sleep changes with age. In general, sleep is much deeper when we are very young — thus the expression “sleeping like a baby.”
Insomnia reports are thought to be more common in women than men in midlife, and further increase in peri-menopause and post-menopause.
There are several aspects of sleep changing with age, including our response to the sleep environment.
External stimuli are less likely to awaken us during this deep, non-R.E.M. or slow-wave sleep. The amount of deep, slow-wave sleep declines over the first several decades of life. In the third decade of life the amount of this deep sleep decreases rapidly, and thus we become more likely to be awakened by external stimuli like sounds. Also, even in healthy sleepers, as we grow older it can take a bit longer to fall back to sleep once we are awake. This causes us to be awake for longer periods of time, increasing our chances of remembering awakenings during the night that might otherwise be so brief as not to be recalled the next day. We also exhibit more awakenings during the night. It also appears that as we age we have a reduced capacity for sleep, or potentially, even a reduced “need” for sleep.
It is important to remember that frequent and longer awakenings in midlife are fairly common. Bonnie and other readers with similar questions about generally sleeping better did not express a concern with some aspect of daytime functioning, like excessive sleepiness. A sleep-related complaint might warrant a closer look, but adjusting expectations and not worrying about sleep unnecessarily is also part of sleeping better. If you think that your daytime function is not optimal because of a sleep problem, and the 12 simple steps to improving your sleep, which you can read here, don’t seem to help, you may want to consult your physician and then a sleep specialist.
More answers from Dr. Buxton will be posted on Booming on Oct. 2.
Nearly 200 people sent questions about sleep to Orfeu Marcello Buxton, a neuroscientist who studies chronic sleep deficiency in the workplace and home and how it contributes to disorders like obesity, diabetes and cardiovascular disease.
Dr. Buxton is an associate neuroscientist in the Division of Sleep Medicine in the Department of Medicine at Brigham and Women’s Hospital in Boston, as well as anassistant professor at Harvard Medical School and the Harvard School of Public Health. He received his doctorate from Northwestern University in Evanston, Ill. (Note: Dr. Buxton is a researcher, not a physician, and he emphasizes that his responses should not take the place of recommendations from your health care provider.)
More responses will be posted next week. Because of the volume of questions, not all may be answered.
Disclosure statement: Dr. Buxton’s current research is financed by several branches of the National Institutes of Health. He is a consultant to the Harvard School of Public Health Center for Work, Health and Well-being and is on the scientific advisory board for Matsutani America (a dietary fiber supplement manufacturer). He has served as an expert witness for Dinsmore L.L.C., received speaking/consulting fees from Takeda Inc., and was the principal investigator on investigator-initiated research financed by Cephalon Inc. (now Teva) and Sepracor Inc. (now Sunovion).
Introduction
Thank you to all readers who commented and submitted questions. The breadth of the questions speaks to the many different ways that we sleep, and how our expectation about sleep, and our sleep patterns and habits can vary with circumstances and our environment, and across the course of life.
Healthy Sleep in Midlife
Q. I go to sleep fairly early (8:30 p.m.) because I am exhausted, yet I wake up around 2:30 or 3 a.m. and cannot get back to sleep. I used to sleep much longer and arise more rested. Is this probably just age? Are there things I can do to help myself sleep longer? — CM, Placitas, N.M.
A. Many readers addressed directly or indirectly the question, “What is ‘normal sleep’ in midlife?” Setting aside the possibility of a sleep disorder (some of which are addressed below), normal sleep has a physiological basis, but also a cultural basis (see below on the relatively modern emergence of an expectation of a single consolidated night’s sleep). What we might consider normal sleep in midlife varies depending on individuals and their circumstances.
Typical advice has been to get a full eight hours of sleep, but this is the “tyranny of the mean.” Our individual sleep need is roughly the same across adulthood, though as discussed below (“Sleep and Aging”), the amount of sleep we need may decline slightly as we age. For most adults, routinely sleeping seven to nine hours per night regularly is appropriate for optimal functioning and health. That said, there will be some people who need less, and some who may need more sleep; it’s just that there are far more of us getting less than we probably need (the United States average is just above seven hours a night, and the proportion of short sleepers is increasing). Information is available from the Harvard Division of Sleep Medicine on the benefits of healthy sleep and getting enough sleep, including a “sleep makeover,” and 12 simple steps to improving your sleep.
So how can you tell if you are getting enough sleep at this time in your life? I have a nonclinical litmus test. First, pay off your sleep debt by getting plenty of extra sleep for a few weeks. Vacations outside of our normal pressures can work well for this. Then, begin going to sleep and waking up at about the same times each day, and you will find that your individual number may emerge — the number of hours of sleep after which you wake up and generally feel refreshed, without stimulants. The test is: can you sleep this amount, get up without an alarm clock (except for backup to avoid worrying about missing a morning obligation), and feel good? Bonus: someone else may also report you are (even more) pleasant?
As you can imagine, maintaining healthy sleep is a lifestyle and is not achieved through a quick fix. We don’t go to the gym once and expect immediate fitness, or eat salads for one day and expect leanness. Getting enough sleep gives more energy for vigorous exercise and improves healthy food choices. But where is the time for all this, you might say? To achieve healthy sleep, prioritize your health and recognize that being your best, rested self is more important than something else like watching television or mobile-device screens, especially in their most ad-infused forms, or social media indulgences that don’t bring real joy. The three pillars of health (diet, sleep and exercise) can help everything else go better in our lives, especially the most important things like our relationships and true passions.
Sleep Apnea
Q. How we can differentiate between normal snoring and sleep apnea? — Jnanawala, Surat, India
A. Some readers asked directly about the symptoms of sleep apnea and snoring, or described extremes of daytime sleepiness that might suggest sleep-disordered breathing or other sleep disorders that would be good to rule out. Sleep-disordered breathing results in a lack of sufficient oxygen being taken into the lungs and throughout the body, usually because of a constriction of the airway, but possibly also related to structural issues or sometimes breathing centers in the brain not working ideally. Sleep-disordered breathing also causes frequent interruptions and awakenings during sleep.
Symptoms of sleep-disordered breathing include excessive daytime sleepiness, choking or gasping during sleep and sometimes morning headaches because of low oxygen during sleep. In response to falling oxygen levels in the blood (and or rising carbon dioxide levels), a brain “arousal” lightens sleep and a gasp or deeper breathing takes in more air. Risk factors include having a greater than 17-inch neck size, obesity, being male and a family history of apnea. But it is possible to have none of these factors and have sleep-disordered breathing. Snoring is much more common than sleep-disordered breathing, and snoring doesn’t necessarily mean one has sleep-disordered breathing. But the cessation of breathing for more than 20 seconds during sleep is an indicator of sleep apnea. A diagnosis of sleep apnea involves a sleep test at a sleep clinic or in the home.
There are a variety of treatment options, but the most common is an air pump and a mask that is worn during sleep to provide enough extra air pressure to overcome the obstruction. These work best if worn the entire night.
The Harvard Division of Sleep medicine has accessible and engaging content on sleep apnea here. Detailed patient information about sleep-related breathing disorders and treatment options is available from the American Academy of Sleep Medicine.
Insomnia
Q. What can be done about middle-of-night insomnia? I go to bed at 9:30 or so, exhausted and fall asleep in 2 seconds. Then I wake up anywhere from 1:30 to 4 a.m., and cannot fall back asleep for hours if at all. It turns the days into endurance events. Once in a great while, I get a full seven to nine hours and feel magnificent. There is no pattern to it and I cannot make it happen. I cannot take my 1:30 a.m. start of the day. Don’t want to take pills to sleep. — xojoyox, Brooklyn
A. Difficulty getting to sleep or staying asleep on a regular basis (three or more times per week for at least a month), and a complaint about this sleeplessness causing other problems, is chronic insomnia. Acute insomnia usually has a clear precipitating cause, like stress, anxiety, conflict, grief or a medical condition or medication with side effects. In contrast, chronic insomnia can have less obvious or long-past precipitating factors. Chronic insomnia is thought to be perpetuated by established habits and expectations about sleep, as well as potential brain neurotransmitter or brain system changes that cause the brain to be hyperaroused during sleep, or in other words, cause the wake centers of the brain to be stuck in the “on” position. Chronic conflict at work, harassment at work, or stress at work in general can contribute to insomnia.
The inability to sleep in the middle of the night is an especially difficult form of insomnia on the minds of many of us in midlife. Sleep maintenance difficulty is, for example, more strongly related to diabetes risk than short-sleep duration or difficulty getting to sleep. But it’s important not to overly worry about this because this rumination can worsen insomnia.
There are several active steps to take.
Try to understand what might be causing the awakening: is there a regular interruption like noise that is contributing to this? Snow days are so peaceful and restful when airplane flights are canceled and snow dampens traffic and other sounds, but only until the snow plows grind down the street. Pets and bed partners can be a source of potential interruptions.
If it seems that the awakenings are internally generated, start with an assessment of sleep disruptors, like excess caffeine; or a sleep environment that is too bright, hot, cold or noisy.
If these things don’t work, it may be time to talk to your physician about potential medical causes of insomnia, like medications, sleep disorders (sleep apnea, restless-legs syndrome) and medical and psychiatric causes.
Additionally, consulting a sleep specialist may help. New formulations of F.D.A.-approved medications with short half-lives may be useful in treating middle-of-the-night insomnia — in the short term. In the long term, behavioral treatments to improve sleep, including cognitive behavioral therapies or mindfulness practice can improve sleep, and have a sustained impact after the cessation of active treatment. A lot of work remains to be done to determine the effectiveness of these various pharmacological and behavioral treatments, especially head-to-head comparisons, but promising ones are available now.
For useful patient information on all manners of sleep disorders, include information from the American Academy of Sleep Medicine, which includes a Find a Sleep Center tool.
Sleep and Aging
Q. What can a 65-year-old woman, who ever since menopause wakes up 10 times a night, do to get a good night’s sleep? — Bonnie Rozanski, Lawrenceville, N.J.
A. Many of us are concerned about sleep changes with age. In general, sleep is much deeper when we are very young — thus the expression “sleeping like a baby.”
Insomnia reports are thought to be more common in women than men in midlife, and further increase in peri-menopause and post-menopause.
There are several aspects of sleep changing with age, including our response to the sleep environment.
External stimuli are less likely to awaken us during this deep, non-R.E.M. or slow-wave sleep. The amount of deep, slow-wave sleep declines over the first several decades of life. In the third decade of life the amount of this deep sleep decreases rapidly, and thus we become more likely to be awakened by external stimuli like sounds. Also, even in healthy sleepers, as we grow older it can take a bit longer to fall back to sleep once we are awake. This causes us to be awake for longer periods of time, increasing our chances of remembering awakenings during the night that might otherwise be so brief as not to be recalled the next day. We also exhibit more awakenings during the night. It also appears that as we age we have a reduced capacity for sleep, or potentially, even a reduced “need” for sleep.
It is important to remember that frequent and longer awakenings in midlife are fairly common. Bonnie and other readers with similar questions about generally sleeping better did not express a concern with some aspect of daytime functioning, like excessive sleepiness. A sleep-related complaint might warrant a closer look, but adjusting expectations and not worrying about sleep unnecessarily is also part of sleeping better. If you think that your daytime function is not optimal because of a sleep problem, and the 12 simple steps to improving your sleep, which you can read here, don’t seem to help, you may want to consult your physician and then a sleep specialist.
More answers from Dr. Buxton will be posted on Booming on Oct. 2.
