Who couldn’t use a little more sleep? Or at least a little more good-quality sleep. Here’s what can help...and what’s a waste of money.
Michael V. Vitiello is professor of psychiatry and behavioral sciences at the University of Washington. With more than 30 years of research experience, he is an expert on the causes, consequences, and treatment of age-related sleep disorders. Vitiello spoke with Nutrition Action’s Caitlin Dow in November, 2017.
Q: How many people suffer from inadequate sleep?
A: It depends on who you ask and how you ask the question. In some surveys, as much as 40 to 50 percent of the population report sleep complaints.
Q: That doesn't necessarily mean they have insomnia, right?
A: Right. People with insomnia have chronic trouble falling asleep, staying asleep, or waking up too early. That means the problems last for months or longer.
They also have trouble functioning during the day, which they attribute to their sleep difficulties. And they have these sleep issues despite having adequate opportunity to sleep.
Q: So it’s not just an occasional sleep problem?
A: Right. And if somebody comes to me and says “I’m having trouble sleeping,” but they’re working three jobs and only allowing themselves to sleep for three or four hours a night, I wouldn’t diagnose them with insomnia.
Q: How many people have insomnia?
A: It probably hovers between 6 and 10 percent of adults. It’s a very sizable number of people.
Q: Does sleep change as people get older?
A: Yes. Most studies report that people get less deep sleep, less REM sleep—that’s the rapid eye movement sleep stage when we dream—more awakenings, more light sleep, and more fragmented sleep. But most of those changes occur earlier than we once thought. The vast majority occur between post-adolescence and 50 to 60 years old.
Q: So your sleep might not get worse beyond your 60s?
A: If people stay healthy as they age, their sleep doesn’t change much when they go from, say, age 60 to 100.
Q: What active ingredients are in over-the-counter sleep aids like zzzQuil and Tylenol PM?
A: There are really only two. Most contain diphenhydramine, and a few contain doxylamine. They’re both antihistamines.
Q: Do they work?
A: They may work for occasional sleeplessness, but not for treating insomnia. There is no evidence that they are helpful for everyday use, and the labels even say not to use them chronically. There’s very little data that they improve sleep at all. And most of that data come from just a few trials.
Q: Are there risks in taking them?
A: Yes. The big side effects—cognitive clouding and grogginess—are a particular problem for older adults. The American Geriatric Society lists these compounds as drugs that older adults should not take. Then there are the other side effects like dry mouth, constipation, and incomplete bladder emptying.
Q: Anything more serious?
A: In 2015, a colleague of mine here at the University of Washington published a paper that found an increased risk of dementia and Alzheimer’s in people who take OTC sleep meds over the long term. That kind of study can’t prove that OTC sleep meds cause Alzheimer’s. But to play it safe, people should be cautious about using them.
Q: Does melatonin help with sleep?
A: While people who take it in studies report few side effects, as a sleep aid—and I emphasize sleep aid—it is not effective. However, it may work if you have a circadian rhythm disorder, like jet lag. The circadian rhythm is the body’s internal biological clock. If it’s out of alignment, your sleep-wake cycle can be off.
Q: How could taking melatonin help?
A: There’s a track of nerves that runs from the eyes directly to the pineal gland. Light keeps the gland from secreting melatonin, and darkness triggers it.
Melatonin doesn’t put you to sleep, but it preps your body for sleep. If you take it at the right time, it may help re-align your circadian rhythm if it’s out of whack.
But you may not be getting what you paid for. A number of years ago, researchers found that quality control for over-the-counter brands of melatonin was ghastly. So just because it said 2 mg on the bottle, for example, it didn’t mean there was 2 mg in the pill.
Q: Does valerian work as a sleep aid?
A: Does it work reliably and consistently in the broad population? No. We’ve published data showing that people who take valerian do no better than those who take a placebo.
That said, they don’t report more side effects than placebo takers, and valerian has probably been used for so long because some people believe it works.
Also, the placebo effect is a wonderful thing when it comes to sleep. If people feel like valerian helps them, I’d recommend it. That’s also true for melatonin or any other safe sleep supplement.
Q: What’s the best way to treat insomnia?
A: Cognitive behavioral therapy is the gold standard. Unlike many behavioral programs for, say, weight loss or alcohol reduction, CBT capitalizes on your body’s inherent drive for sleep and your circadian timing of sleep. It teaches you behaviors that maximize those biological drives. That’s probably why it’s so powerful.
Q: How does CBT work?
A: One of its two biggest components is stimulus control. It’s about having the bedroom environment predict sleep and reassociate the bed with sleep—like going to bed only when sleepy, getting out of bed when unable to sleep, and not watching the clock.
The second is time-in-bed restriction. People with insomnia often try to get more sleep by spending more time in bed. That doesn’t work. In order to be the most efficient and effective sleeper, you need to be in bed only as long as you’re asleep.
Q: What else is involved?
A: Therapists also usually review sleep hygiene. And sometimes they add relaxation techniques. Patients might also work on beliefs about sleep or how to deal with anxiety.
Q: What kind of anxiety?
A: Some people are worriers. They use the bed as a time to go over everything that was terrible today and anticipate everything that will be terrible tomorrow. There are techniques that can help them stop doing that, which lets them fall asleep.
Q: What relaxation techniques does CBT use?
A: One example is a deep breathing exercise called the Benson Relaxation Response. You can look it up online. It doesn’t require anything other than lying there quietly with your eyes closed, concentrating on your breathing in a rhythmic, mindful way.
If you have a busy brain, it gives you something to focus on. If you get distracted, you don’t worry about that. You just go back to your breathing.
And deep breathing produces a physiological response, where your nervous system switches into a relaxed state. There’s nothing mystical about it. You can do it pre-sleep, if you wake up during the night, or even at your desk at work.
Q: How long does CBT training take?
A: About six weeks. Some people start benefiting within a couple of weeks.
Q: What kind of benefits?
A: The most powerful is the absence of fragmented sleep. One of the things that’s most annoying is if you go to bed and your eyes stay open and your little brain stays active and it’s 45 minutes before you fall asleep.
And then your eyes pop open in the middle of the night, and you spend an hour maybe once or twice being unable to get back to sleep. Most insomnia complaints have to do with difficulty returning to sleep.
Q: Do online CBT programs work?
A: The data are limited, but they show that online programs seem to be as effective as in-person approaches. And they’re available everywhere, which makes it a heck of a lot easier to participate.
Q: What else may work for insomnia?
A: There is some data showing that meditative movement like tai chi and yoga might help. But the evidence isn’t as strong as it is for CBT.
Q: What’s your bottom line?
A: There are many ways to sleep wrong and many factors that contribute to poor sleep. But there are many ways to fight your way back. The tools are there. People just have to be aware of them and be willing to use them.