Bedtime Advice

How can we improve bedtime and night time sleep.

Falling asleep is outside our control. As the popular saying goes,

“We can will to go to bed, but we cannot will to fall asleep”.

However, we can help our body in the process. The best way is by tapping on the body’s own sleep promoting factors. These can be explained as follow:

W, which stands for prior wakefulness.
C, which stands for body clock.
M, which stands for two things; medication-relaxation and also medications.
Sleep depends on prior wakefulness

The first factor, which determines sleep, is how long we have been awake beforehand (W for wakefulness). For example if we were to stay awake for 24 hours, no matter what time of the day it is, we are likely to fall asleep. Some people may argue that they will not fall asleep after being awake for 24 hours. Keep them awake for 48 hours continuously without being allowed to lie down or close their eyes and almost certainly they will fall asleep. This is based on the fact that the need for sleep is one of the most important needs in life; it is like being hungry or thirsty. At some stage the need to sleep will override any other need. This fundamental requirement is referred to as homeostatic drive to sleep.

We want to exploit this principle in a strategy that is called restriction of time in bed. For example if a person usually goes to bed at 10pm, fall asleep at 11pm and get up at 7 am, we would suggest them not to go to bed before midnight (physically in bed) and to get up by 6am irrespective of how much sleep the person has obtained and continue doing so for at least 10 days to 2 weeks (a more precise method to prescribe restriction of time in bed is explained in chapter Four).

Two things follow this strategy. The person needs to be aware that their function during the day will get worse because they will actually get less sleep than before starting the restriction of time in bed. However, each day the lack of sleep accumulates progressively more, so that after 10 days to 2 weeks the pressure to fall asleep is so intense that the person tends to fall asleep quicker and to maintain a deeper sleep.

If after a couple of weeks sleep onset occurs within half an hour or so of turning the light off, bedtime can be moved 15-30 minutes earlier, let’s say 11.30-11.45pm but maintaining unchanged wake up time. This new bedtime-wakeup time schedule, 11.30pm-6am, is maintained for another 10 days to 2 weeks. If sleep onset occurs within 30 minutes and the person stays asleep, perhaps waking up once, he can then move bedtime a little bit earlier, say 11pm.

This process is repeated again every 10 days to 2 weeks. If sleep quality is satisfactory the person can move get up time a little later, say 6.30am. If someone were to sleep between 11pm-6.30am that would be approximately ~7.5 hours sleep, which is the average for our population. However each individual will have a different sleep length need.

It is important to avoid napping through the day and also to avoid falling asleep in the evening while waiting for bedtime.

Please note that it will take at least one to two months before you can feel the full benefit of this strategy. You need to be made aware of possible worsening of daytime function (more sleepy during the day), and that benefit will take 4 to 8 weeks to become apparent. In restriction of time in bed we are actually causing sleep deprivation, even though in a controlled way. In simple terms we are telling our body: “This is the window of time you can sleep (say 12MN to 6am). Take it or leave it!” Initially the usual pattern of insomnia will continue and therefore you are likely to feel worse in the morning. However after a couple of weeks or so the body, driven by the need for sleep (the homeostatic drive), will “take it” and sleep onset and continuity of sleep will start improving.

Problems with restriction of time in bed

Some people have difficulty following restriction of time in bed because they have job or family commitments in the morning and they cannot afford to be more tired than they normally are for the first 2-4 weeks. In that case we can use medications to help falling asleep at bedtime for the first couple of weeks. We recommend taking one sleeping tablet at bedtime every night for the first week and then every second night in the second week in order to ease the person into the program.

Another objection that people have is that they are unable to stay awake until late. In that case one can adopt a slightly different strategy. For example let’s assume that someone has the urge to fall asleep at 9.30pm and cannot manage to stay up until midnight. In that case we recommend the person try to stay awake until 9.30pm for the first week, 10pm the second week, 10.30pm the third week, 11pm the fourth week and so forth until he is able to slowly stay awake until midnight and then start the program as explained above.

‘C’ for body clock

The other important physiological factor that drives sleep is our body clock (called the circadian drive).

There is a small area in the deep part of our brain called the supra-chiasmatic nucleus (figure 4), which receives information regarding light and darkness through its connection with the eyes. The body clock synchronizes sleep and wake with the light and night cycling due to the earth’s rotation. This is a very important determinant of when we fall asleep and when we are awake. The way the body clock works, in very simple terms, is through the effect of light mediated by a substance called melatonin. Melatonin is usually secreted in a cyclical way through the 24 hours (figure 5). During the day with bright light the level of melatonin in our body is very low, usually not detectable in the blood or in the saliva where it is normally measured. At dusk the melatonin starts rising, stays up through the night with maximal level around 3-4 am and then falls back again at dawn. The cycle repeats on a 24 hours basis (circadian: circa-diem = about a day).

Fig 4: Pineal Gland
Fig 4
When the melatonin rises at dusk, let’s say about 5pm in winter and later in summer, it signals that about 3 to 4 hours later the body can go to sleep. Of course if there is high stress such as something upsetting the person or there is a threat due for examples to a bush fire or flood or any other stress, the person can overcome this signal. However, in normal circumstances, when the melatonin rises in the blood, it gives the signal to the rest of the body that about 3hours later we can go to sleep. Sometimes due to aging, to medications and sometimes for reasons which are not completely clear, melatonin does not rise, rises late or is very irregular and that can lead to difficulty initiating and maintaining sleep (insomnia). In order to make sure that the signal is present and strong we often give 0.5-3mg of melatonin about 3 to 4 hours before intended bedtime. For example if our recommendation with restriction of time in bed were to be physically in bed at midnight, we would give the melatonin around 8-9pm and we would continue this strategy for at least 8 weeks all through the period of restriction of time in bed.

Fig 5
Fig 5
Melatonin is not measured in clinical practice, only for research purposes, as it needs to be sampled in the saliva or blood every 30 minutes. Melatonin is considered a safe substance (see at the end of this chapter a profile on melatonin).

Probably the most well understood example of how melatonin works is in people who are totally blind. This means blind for sight but also blind to light. Some people who are legally blind cannot see properly but they can still perceive light. In most of the people who cannot perceive light the body clock is very irregular and they can suffer from insomnia as a consequence. In these cases the use of melatonin is very effective in re-synchronizing the body with the light and night cycle and promoting sleep.

Restriction of time in bed and the use of melatonin reinforce timing, quality and continuity of sleep. We need to continue for at least for 8 weeks, sometimes longer, before a full benefit can be achieved.

This strategy seems to be effective in most cases irrespective of how chronic insomnia started. It is effective in insomnia due to depressive illness and in the population above the age of 60 when the level of melatonin is often declining (figure 6). Probably the most striking example of a very low melatonin is in people with Alzheimer’s disease, other forms of dementia and in some cases of Parkinson’s disease. Use of melatonin supplementation in these cases can be of benefit and need to be continued long term.

Fig 6 Melatonin level becomes less and less as we get older
Fig 6 Melatonin level becomes less and less as we get older
Some of the medications we use for other medical illnesses could suppress melatonin (table 1). For example beta-blockers (propanolol, metoprolol, atenolol) commonly used for hypertension and in people with coronary artery disease, are suppressants of melatonin production. Also medications that cause depletion of vitamin B6 (important in the synthesis of melatonin) reduce melatonin levels (oral contraceptives, estrogen, hydralazine, frusemide).

Use of light for insomnia

As described above the body is synchronized by exposure to light. With bright light melatonin secretion is suppressed, with darkness melatonin is released. This knowledge gives us another instrument to help sleep and overcome insomnia.

In order to promote sleep we need to avoid light in the evening. In some susceptible individuals even the light of a TV screen or a computer in the evening can delay sleep onset. In a particular case of insomnia (delayed sleep phase, see chapter 2) exposure to light in the evening tends to push sleep onset well past midnight, sometimes 2am, 3am or 4am.

On the contrary light in the morning helps falling asleep at night. Morning light also increases serotonin levels in the brain that accounts for improvement in the person’s mood. So we can use melatonin and light together to our advantage. We use melatonin ~3 hours before intended bedtime, avoid light in the evening and expose ourselves to bright lights in the morning.

Light intensity is measured in lux (light intensity of a candle at one meter distance). The intensity of light needed to affect the body clock changes with age. As we get older we need more light to be effective in synchronizing our body clock. This is part due to structural changes of the eye. The light intensity outside the house even on a cloudy day is usually sufficient. Indoor light is usually insufficient. Artificial sources of light (light box) are becoming popular particularly in winter and at high latitudes when the amount of daylight is much reduced. Light box can use “white” light, but more recently “blue” light has shown to be more effective. A light intensity between 2,500 and 10,000 lux is most beneficial. This light exposure can be achieved by having breakfast on the veranda or going for a walk after sunrise for 30minutes. Exposure of up to 2 hours may be required if using artificial light indoor.

These simple strategies, restriction of time in bed, the use of melatonin and light are the cornerstone of our treatment often implemented irrespective of the origin of the insomnia. They tend to be particularly effective in improving bedtime and night problems. However it cannot be overemphasized that improving sleep requires addressing the daytime component of our therapeutic strategy as well.

On top of these strategies we also consider a third option, which consists of:

‘M’ for meditation-relaxation and medication

The use of relaxation-meditation techniques has been discussed earlier in this chapter as part of daytime intervention.