A Provider's Cheat Sheet Guide to Understanding Sleep

Joanna Fong-Isariyawongse, MD, FAAN, FAES

(Credit: UPMC)

Importance of Sleep

Sleep is often overlooked and undervalued, but it is essential for physical and mental health. It plays a vital role in the restoration and repair of many bodily functions, including memory consolidation, emotion processing, cellular repair and growth, immune system strengthening, and hormone regulation.^1-4 Sleep insufficiency has been linked to an increased risk of cardiovascular and cerebrovascular disease, diabetes, obesity, mental health issues, and accidents and injuries.^5-8

Prevalence of Sleep Insufficiency

Sleep insufficiency is a pervasive issue affecting individuals in the US, with 75% of adolescents and 35% of adults not achieving the recommended sleep duration.⁹

Recommended Healthy Sleep Duration¹⁰

1. Adults: 7-9 hours
2. Adolescents (14-17 years): 8-10 hours
3. Children (6-13 years): 9-11 hours

Sleep Hygiene Strategies

1. Maintain a regular sleep-wake schedule

Encourage patients to establish a regular sleep-wake cycle, aligning with their natural circadian rhythm. Consistency helps regulate the body’s internal clock.

2. Create a relaxing bedtime routine

Recommend calming activities before bedtime, such as reading, gentle stretching, or practicing relaxation techniques. Discourage stimulating activities like using electronic devices 1 to 2 hours before bedtime. When using electronic devices, utilize a blue-light filter setting or wear blue-light filter glasses. Consider ambient light settings; make sure intensity is low and avoid white light (amber and yellow light contain less blue light) at least 1 hour before bed. These practices can help the natural release of melatonin.

3. Optimize sleep environment

Emphasize the importance of a comfortable and conducive sleep environment, namely one that is dark, quiet, and cool (best at 68 °F).

4. Limit stimulants and avoid alcohol

Caffeine has a long half-life, so it is important to advise patients to avoid caffeine 8 hours before bedtime. Avoid nicotine in the evening, as it is stimulating. Alcohol is harmful to sleep as it fragments sleep.

5. Regular exercise

Highlight the positive impact of regular physical activity on sleep quality. However, recommend avoiding vigorous exercise close to bedtime to prevent overstimulation.

Common Types of Sleep Disorders

1. Insomnia

Insomnia is a condition characterized by difficulty falling asleep (lasting more than 30 minutes) or difficulty maintaining sleep, and it affects about 10% of the US population. It can result in daytime impairments such as sleepiness or fatigue, mood changes, and trouble with concentration and attention, and negative impacts on social, family, and work performance. Good sleep hygiene practice should be recommended to all patients with insomnia. When insomnia becomes persistent, consider a sleep specialist referral for psychological interventions (eg, cognitive behavioral therapy for insomnia or brief behavioral treatment for insomnia) and/or pharmacological treatments. The Insomnia Severity Index can be used as a tool to screen for insomnia.

2. Obstructive sleep apnea

Obstructive sleep apnea (OSA) is a sleep disorder related to partial or complete airway closure during sleep. Common symptoms include snoring, waking up gasping or choking, pauses in breathing, and daytime sleepiness. OSA is associated with an increased risk of cardiovascular disease, atrial fibrillation, stroke, and systemic hypertension. The STOP-Bang questionnaire can be used to screen for OSA. A polysomnogram or home sleep test is the recommended diagnostic testing for OSA. Continuous positive airway pressure is the first-line treatment. Weight loss is recommended in patients with OSA who have obesity, as it reduces severity of OSA (10% weight gain is associated with 6-fold increase in risk of OSA).

3. Restless legs syndrome

Restless legs syndrome (RLS) causes discomfort in the legs, more commonly in the evenings and at rest, and causes an irresistible urge to move, as movement typically alleviates the discomfort. Iron deficiency and other medical conditions may contribute to RLS symptoms. Consider testing for ferritin levels, as low iron storage is linked to problems with dopaminergic neurotransmission. RLS can negatively impact quality of life and result in insomnia, with difficulty initiating and maintaining sleep. Substances such as caffeine, alcohol, nicotine, and medications with antidopaminergic effects such as antiemetics, antihistamines, and some psychotropics can aggravate symptoms. Consider both nonpharmacological treatments (cold or warm baths, massage, stretching) and medical treatment with antiseizure medications or dopaminergic medications. If ferritin is less than 75 ng/mL, consider iron supplementation as first-line treatment.

Conclusion

Promoting healthy sleep is a cornerstone of preventive medicine. As clinicians, we can incorporate sleep assessments into routine care and provide education on sleep hygiene practices to empower patients to take an active role in improving their sleep health. Understanding the intricate relationship between sleep and overall well-being allows for more comprehensive and patient-centered health care.

REFERENCES
1. Dijk DJ. Regulation and functional correlates of slow wave sleep. J Clin Sleep Med. 2009;5(suppl 2):S6-S15.
2. Irwin MR, Opp MR. Sleep health: reciprocal regulation of sleep and innate immunity. Neuropsychopharmacology. 2017:42(1);129-155. doi:10.1038/npp.2016.148
3. Sangalli L, Boggero IA. The impact of sleep components, quality and patterns on glymphatic system functioning in healthy adults: a systematic review. Sleep Med. 2023;101(322-349). doi:10.1016/j.sleep.2022.11.012
4. Besedovsky L, Lange T, Born J. Sleep and immune function. Pflugers Arch. 2012;463(1):121-137. doi:10.1007/s00424-011-1044-0
5. Antza C, Kostopoulos G, Mostafa S, Nirantharakumar K, Tahrani A. The links between sleep duration, obesity and type 2 diabetes mellitus. J Endocrinol. 2021;252(2):125-141. doi:10.1530/JOE-21-0155
6. Bertisch SM, Pollock BD, Mittleman MA, et al. Insomnia with objective short sleep duration and risk of incident cardiovascular disease and all-cause mortality: Sleep Heart Health Study. Sleep. 2018;41(6):zsy047. doi:10.1093/sleep/zsy047
7. Huang K, Ihm J. Sleep and injury risk. Curr Sports Med Rep. 2021:20(6):286-290. doi:10.1249/JSR.0000000000000849
8. Chen MC, Burley HW, Gotlib IH. Reduced sleep quality in healthy girls at risk for depression. J Sleep Res. 2012;21(1):68-72. doi:10.1111/j.1365-2869.2011.00934.x
9. Liu Y, Wheaton AG, Chapman DP, Cunningham TJ, Lu H, Croft JB. Prevalence of healthy sleep duration among adults-United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(6):137-141. doi:10.15585/mmwr.mm6506a1
10. Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1), 40-43. doi:10.1016/j.sleh.2014.12.010