DEAR DOCTOR K:
I fall asleep just fine, but then I wake up around 4 a.m. It’s too early to get up, but I can’t fall back asleep. Help!
Practically everyone has sleep problems occasionally. And a lot of people have sleep problems often. Sometimes it’s trouble falling asleep. Sometimes, as in your case, it’s trouble staying asleep. And sometimes it’s just waking up unrefreshed, even though you think you’ve slept soundly.
Sleep doctors call waking up in the middle of the night “sleep-maintenance insomnia.” That’s difficulty staying asleep, particularly waking too early and struggling to get back to sleep.
When my patients tell me they keep waking up at night for no good reason, I ask them if they wake up once or repeatedly. Sometimes they wake up just once, a few hours before they want to wake up — as seems to be the case with you. That can be a sign of depression, even in people who aren’t aware that they are depressed.
At least as often, patients say they wake up multiple times at night, not just early in the morning. There’s no good reason: The dog isn’t barking, the baby isn’t crying, a car hasn’t driven by the house playing its radio too loud. They just wake up.
Sometimes the problem is a stressful day. You lay your head on the pillow, and events from the day keep streaming through your brain. You’ll benefit from relaxation techniques. We’ve discussed those before in this column, so no more detail here. Consider meditation, deep breathing, progressive muscle relaxation or biofeedback.
Sometimes the problem is stimulants — stimulant medicines or an alcoholic “nightcap” before bed. Alcohol makes many people sleepy and helps them fall asleep. But a few hours into sleep, alcohol becomes a stimulant to the brain and causes people to awaken easily.
Sometimes the problem is pain. A person with arthritis, for example, may have joints that ache — not so much that they are aware of pain during the night, but enough to stimulate the brain. Some people with this problem sleep a lot better if they take an aspirin or acetaminophen pain pill at bedtime.
When depression, life stresses, stimulants or pain are not the cause, cognitive behavioral therapy (CBT) can be helpful. Working with a therapist, you’ll learn new ways to think about your sleep problems and develop better strategies for dealing with those problems.
For example, you may believe that you need eight hours of sleep and that you won’t be able to function the next day if you don’t get that much. Some people do need an average of eight hours a night, but still can function fine after one or two nights of less sleep. CBT can help change such beliefs, making it easier to relax and fall back asleep.
Finally, I’ve put a list of so-called “sleep hygiene” tips — habits that promote healthful sleep — below.
Sleep hygiene tips
Stay away from stimulants. Avoid caffeinated beverages (coffee, many teas, chocolate, and some soft drinks) after 1 or 2 p.m. — or altogether, if you’re especially caffeine-sensitive. Caffeine blocks the effects of adenosine, a brain chemical thought to promote sleep. Limit alcohol to no more than one drink a day, preferably taken at least two hours before bedtime. Alcohol interferes with deep sleep and can interfere with breathing. Stop smoking, and avoid secondhand smoke. Nicotine makes it harder to fall asleep and harder to stay asleep.
Don’t nap if you can avoid it. If you can’t stay awake in the afternoon, take a 15- to 20-minute nap — that’s usually long enough to improve alertness but not so long that you feel groggy afterward. Don’t nap at all in the evening before you go to bed. (And no falling asleep in front of the television!)
Exercise. Getting regular aerobic exercise such as walking, jogging, or swimming can help you fall asleep faster, get more deep sleep, and awaken less often during the night. But avoid exercise within a few hours of bedtime.
Set a sleep schedule. A regular sleep schedule helps synchronize your sleep/wake cycle. Once you determine how much time in bed you need, go to bed each night and get up each morning at the same time.
Make your bedroom a sleep sanctuary. Reserve it for sleep, intimacy, and restful activities such as meditation and reading for pleasure. Keep it cool, dark, and quiet. To block out noises, use a fan or other appliance that produces a steady “white noise.” Make sure your mattress is comfortable.
Eat sensibly. Finish dinner several hours before bedtime. If you need a snack in the evening, eat a small serving of something you know won’t disturb your digestion, such as applesauce, yogurt, cereal and milk, or toast and jam.
Don’t watch the clock. Watching the sleepless minutes pass makes it harder to fall back to sleep in the wee hours. Turn the clock face so you can’t see it.
Establish a relaxing routine before bedtime. Consider meditation, a warm shower, listening to quiet music, or some simple stretches to loosen muscles. Avoid activities that might cause stress, such as work or emotional discussions.
Limit fluids before bedtime. To minimize nighttime trips to the bathroom, don’t drink anything during the two or three hours before bedtime.