Sleeping Problems audio transcript

Sleeping Problems – An NHS Self help guide
The written version of this guide was Highly Commended at the British Medical Association Patient Information Awards 2011.

“I toss and turn for hours on end. No matter what I do, I just can’t seem to get off to sleep”.

“I’m very restless through the night, often waking and not able to get back to sleep”.

“I wake up two or three hours before I need to get up and just lie there trying to drop back off to sleep”.

“I never feel like I’ve had a proper night’s sleep. I sleep very lightly and seem to drift in and out of sleep”.

“I have no trouble sleeping. In fact I sleep way too much but I still feel really tired”

These are all comments made by people who suffer from different kinds of sleep problem.

This guide aims to help you understand your sleep problem and to learn some simple ways to sleep better. Although hopefully some of the suggestions in this guide may help, if you remain concerned about your sleep you should talk to your GP.

Understanding sleep and sleeping problems

Sleep problems are very common and are often referred to as insomnia. One study in America found that only 5% of adults reported never having trouble sleeping.

A recent study found that as many as 30% of the adult population are affected by sleep problems. Sleep difficulties are particularly common in women, children and those over 65. In fact, roughly half of the elderly population complains of insomnia. Therefore to have trouble sleeping at some point in your life is quite normal.

How much sleep do we need?

People can become very distressed when they feel they are not getting a good night’s sleep, which can then make it harder to get off to sleep.

But what is a normal amount of sleep? How much sleep do we need?

The answer is that people vary greatly in their need for sleep. There is a popular idea that we all need 7 to 8 hours sleep every night. This is not true. Although for an adult 7-9 hours is recommended, many studies have shown that people can range between needing 6-10 hours a night. Also the amount of sleep a person needs varies throughout their life. For example, a newborn baby spends 14 to 17 hours sleeping per day. As children grow older they require less sleep, possibly 11-14 hours as a toddler and maybe 8 to 10 hours as a teenager. Older adults, aged 65 and over, usually need slightly less sleep, but the recommendation is still around 7-8 hours.

Not only does the need for sleep vary from person to person, and with age, it also varies depending on level of activity. For example, if someone has retired from work, they may be less active and therefore require less sleep. On the other hand, if they have a young family and are constantly on the go, then they may require quite a bit of sleep. Basically, if you awake refreshed and get through the day without feeling tired then you are probably getting the right amount of sleep for you.

Are there different sorts of sleep?

Sleep is not like a light bulb which is either on or off, but has different stages, varying from light to deep sleep. There are two main types of sleep. Broadly, sleep is divided into what is called Rapid Eye Movement (REM) and non-REM (NREM) sleep. REM sleep occurs several times during the night and is where most dreaming is thought to take place. Non-REM sleep is divided into three stages, each stage being a bit deeper, almost like a staircase of sleep.

The three stages of non-REM sleep are:

• Stage 1 Light sleep
• Stage 2 Deeper sleep
• Stage 3 Deepest sleep

During the night whilst asleep, people go up and down this staircase many times and in fact wake up several times. We may not remember these brief wakenings but it is entirely normal to wake about every 90 minutes or so.

On a typical night an adult who sleeps well will spend about 20% in REM sleep, 5% in Stage 1, 50% in Stage 2, and 25% in stage 3.

As with the amount of sleep we need, the sort of sleep we have changes as we get older. Sleep in older people tends to be lighter, with more frequent wakening. This is normal and nothing to worry about.

For a typical person aged 70, deep sleep takes up less than 10% of the night’s sleep. Therefore, an older person may report waking more times throughout the night.

In summary, sleep in older people does tend to be shorter and more easily disturbed, but it should still be refreshing.

Are there other changes in sleep patterns?

Not only does our sleep become lighter with more wakenings as we get older, but our pattern of when we sleep often changes too. It becomes more likely that we go to bed sooner, wake up earlier or drop off to sleep during the day, so our natural rhythm of sleep can be disturbed.

What causes sleep problems?

There are a number of reasons why sleep problems can develop.

Effects of ageing. As mentioned, when people get older they tend to sleep less deeply and may also sleep less well at night. Some people will then tend to drop off to sleep during the day which again reduces the need for sleep at night. This in itself is not a problem, but often not sleeping at night becomes a great cause for worry, frustration and concern, which in turn leads to sleeping less well.

Medical reasons for disrupted sleep. There are many health related reasons for poor sleep which may or may not be to do with getting older.

• Needing to go to the toilet at night. The need to go to the toilet during the night occurs more in later life. About 60% of women and about 70% of men, aged over 65 get out of bed at least once a night to go to the toilet. This can also happen for other reasons of course, such as pregnancy. Getting out of bed at night isn’t always a huge problem, but it can be frustrating if it is difficult to get back to sleep.
• Many women report disturbed sleep around the menopause, often related to hot flushes. Difficulty sleeping often remains, and generally, post-menopausal women are less satisfied with their sleep with as many as 61% reporting insomnia symptoms.
• Another common medical reason for poor sleep is pain. This again can be common in older age with joint problems such as arthritis.
• Other health problems can also affect sleep, for example diabetes, high blood pressure and breathing difficulties.
• Some medicines can interfere with sleep, so it is worth checking with your doctor if you are on any tablets.
• Depression and low mood can affect sleep. Disturbed sleep is a common symptom of depression. It is quite usual for a depressed person to wake up early in the morning and be unable to get back to sleep, or alternatively to have difficulty getting off to sleep.
• Obstructive sleep apnoea is a treatable condition present in around 5% of women and 10% of men most commonly in middle age. People often don’t know they have it, but if someone snores and breathes loudly with pausing and gasping, then sleep apnoea may be the problem. It is more common in people who are overweight and in people who smoke or drink alcohol. If severe your GP will be able to refer you to a specialist.
• Restless legs syndrome is present in about 5% of the population and people with this have an urge to move their legs and find it really hard to keep their legs still in the last hour of the evening or getting into bed at night. This can also be made worse by some medicines.

Stress, worry and anxiety. When someone is stressed and anxious they may often find it hard to get off to sleep, with their mind full of worries and their body tense.

Bereavement. The emotional upset of bereavement or other trauma can affect sleep. Nightmares and upsetting memories are common.

Surroundings. Our surroundings can make a big difference to how we sleep. For example, a bedroom that is over hot or over cold, a bed that is too hard or too soft, a room that is too noisy or too light can all make a difference to how well someone sleeps. Sleeping in a strange place can also affect someone’s sleep.

Disrupted sleep routine. People who work shifts which change frequently often have disrupted sleep. This gets worse with age and is affected by lifestyle factors such as smoking and drinking alcohol.

Sometimes it may be a combination of a few different causes, rather than just one thing. But it is helpful to know what is causing your sleep problem, as this may help you find a solution.

What sort of sleep problem do you have?

Getting to sleep
The most common sleep problem is trouble getting to sleep. For some people it can take several hours to drop off to sleep, but once they are asleep the quality of sleep is good.

Staying asleep
The next most common problem is a disturbed sleep pattern, with frequent waking in the middle of the night and difficulty getting back to sleep.

Waking too early
A third problem is waking earlier than is desired, again with difficulty getting back to sleep.

Poor quality sleep
Some people report sleeping lightly, with restless, disturbed and inconsistent sleep.

Sleeping too much
Another common problem is when people find themselves sleeping too much, often feeling sleepy or dozing during the day.

You may have a mixture of these but knowing a bit more about what sort of sleep problem you have can help when it comes to trying to deal with it. Keeping a sleep diary to look for patterns in your sleep can be very helpful.

Summary
Sleep problems are very common and affect people in different ways. There is no “right” amount of sleep as this varies between people and across the life-span. Sleep problems can occur for a number of reasons: as a result of age; medical reasons; emotional reasons; unhelpful surroundings; disrupted sleep routines. There are different sorts of sleep problems. It is also possible to think you have a sleep problem when in fact you are still getting enough sleep but it is different from what you expect.

Overcoming your sleep problem

One of the first steps in overcoming sleep difficulties is finding out any possible causes and trying to look for solutions.

Is sleeping your main problem, or is there another problem which may be causing you to have difficulty sleeping?

If there is another problem, is there anything you can do about that problem?

Review these common reasons for insomnia and try to work out which, if any, apply. There may be different solutions for different problems.

Problem:
Worrying about not getting enough sleep – are you expecting too much sleep and worrying about not getting enough? Sometimes people lie in bed and worry about not sleeping. As we have already mentioned, worrying about not getting enough sleep makes matters worse. Thoughts such as “I’ll be exhausted tomorrow”, “I’ll never get to sleep”, “I must sleep, it’s ruining my health”, may run through your mind. The effect of this is that you feel tense and anxious and less likely to drop off to sleep, which in turn leads to more worrying thoughts.
Solution:
Try to find ways to relax and clear your mind. You know you will always fall asleep eventually. Lying calm and relaxed in bed can be pleasant if your mind is cleared of worrying thoughts about not getting enough sleep. Don’t keep looking to see what the time is. Try to put sleep out of your mind. Have a daydream instead about something pleasant such as somewhere you have enjoyed a relaxing holiday. Bring the picture in to your mind as vividly as you can, remembering all the sights, sounds and smells. You can also focus on your breathing, breathing in deeply through your nose, and making sure you have a nice long out breath. Use your breathing as an anchor, so if your thoughts wander off you simply bring your mind back by focusing on your breathing. Deep muscle relaxation can also be helpful. This can be done by gently tensing and relaxing the main muscle groups in the body and focusing your attention on the relaxed feeling as it begins to spread through your body.

There are many free recordings available online of relaxation techniques, as well as those that can be bought.

Problem:
Needing to go to the toilet in the night – are you up several times in the night needing to empty your bladder?
Solution:
If you have to go to the toilet several times in the night, there may be a medical reason for this and the solutions will depend on what is causing the problem. Bladder retraining can be useful, as can restricting caffeine intake and fluid late at night, however medical advice should be sought if this is a problem.

Problem:
Are you in a lot of pain and does this wake you up or stop you getting off to sleep?
Solution:
Deep muscle relaxation can help with pain, as being tense can make pain worse. It may be helpful to speak to your GP about your pain as there may be a treatment that can help.

Problem:
Loss and bereavement – have you experienced a loss or bereavement recently?
Solution:
It is very common to have disturbed sleep following bereavement. Try not to add to your difficulties by worrying about not sleeping. Your sleep pattern should return to normal in time. The relaxation techniques described in this guide may help. Talking about your feelings may also help, either to a friend, counsellor or to your GP. A self help guide like this one for bereavement is available at www.cntw.nhs.uk/selfhelp

Problem:
Anxiety, depression, stress – are you suffering from stress at the moment? Or are you depressed or anxious? If so, then your sleeping is probably affected. It may be that as soon as your head hits the pillow your mind starts working overtime thinking about problems such as work, relationships and money worries.
Solution:
The following might help. If your mind starts to race try to use the relaxation techniques described earlier, such as focusing on a relaxing image or on your breathing. By making your breathing deeper and slower, this can decrease your heart rate which in turn reduces cortisol, one of the hormones released when we are anxious. If you notice your mind starting to worry again, try saying to yourself ‘I will deal with this tomorrow’ and bring your focus back to your breathing. Basically anxious, worrying thoughts will keep us awake, and calming, happy thoughts will help us sleep.

Writing down a few things we are grateful for before bedtime each night has been found to be helpful in getting a good night’s sleep. If worry is a big problem for you, it may be helpful to set aside 30 minutes a day ‘worry time’. Take a pencil and pad and write down everything that is worrying you. Taking each problem in turn, ask yourself if there is anything you can do to solve the problem? If no, score the problem out and move on to the next problem. If yes, write down every possible solution you can think of. Choose the most helpful solution and write down all the steps you are going to need to take. Write as much as you can. Write down any obstacles and how you might tackle them. Make a plan for when you are going to deal with the problem.

Whenever you find yourself worrying, remind yourself to save it till your next ‘worry time’. Sometimes if worrying thoughts pop in to your head at night just ask yourself ‘is there anything I can do about this?’ No? Then let it go. Yes? Jot it quickly down and tell yourself you will deal with it tomorrow.

Self help guides like this one for stress, depression and anxiety are available at www.cntw.nhs.uk/selfhelp. It may be that you need treatment for your depression or anxiety. Your GP will be able to advise.

Problem:
Do you suffer with restless legs syndrome?
Solution:
Mild restless legs syndrome that isn’t linked to an underlying health condition can be managed with just a few lifestyle changes. For example, avoiding stimulants such as caffeine, and decreasing alcohol in the evenings; stopping smoking; taking regular daily exercise, but not just before bedtime; and having good sleep habits as described later in this guide, can all help. Symptoms may be relieved by: massaging your legs; taking a cool shower in the evening; walking and stretching; distraction and relaxation exercises. If symptoms are more severe, medication may be needed and you should see your GP. Restless legs caused by an underlying health condition can often be cured by treating that condition. For example, anaemia may cause restless legs, and this can be treated by iron tablets. Restless legs syndrome can be made worse by certain medications. If you think this is the case do not stop taking the medication, but speak to your GP.

Problem:
Do you think you may have sleep apnoea? Do you snore loudly, pausing and gasping frequently in the night? You may not be aware of this if you sleep alone. But if you are very tired during the day and seem to be sleeping okay or possibly even too much, then sleep apnoea may be the problem, particularly if you are overweight, male and over the age of 40.
Solution:
Sleep apnoea is treatable. Lifestyle changes such as losing excess weight, cutting down on alcohol and sleeping on your side can help. Other medical treatments are available. If you think this is a problem for you then see your GP who can refer you to a sleep clinic for further help.

You may find that getting help in another area has a knock-on effect on your sleeping. Your sleeping may well right itself if you can solve some of your other problems. Even so, you may have got into some “bad habits” which are not helping you get off to sleep. Many people have bad sleep habits and may get away with it for most of their life. Having a cigarette last thing at night may not always affect sleep. Lying in bed reading for hours, watching TV and drinking coffee may be fine for some people some of the time.

However when a sleep problem starts, it is most helpful to try and get rid of any bad sleep habits we may have built up over the years. The following simple checklist of good sleep habits may help.

Good sleep habits

• Don’t worry – try not to worry about sleep – it may be that you are getting enough, but it’s just less than you expect. Don’t take naps during the day to catch up if you can help it, this will affect your natural rhythm and only add to your problem. Remember that the amount of sleep we get is an individual thing and may change throughout our life.
• Surroundings – go through this basic check list and see whether there are any simple changes you can make:
  – Noise. Is your sleep disturbed by noise either in or outside your room? Earplugs may help.
  – Light. Is your room too light? Are electronic devices emitting light? Blackout blinds or an eye-mask may help.
  –  Temperature of room (too hot, too cold?) Wearing socks, electric blanket, hot water bottle, can all help.
  – Is your partner keeping you awake? Earplugs or a spare room may help.
• Food and drink – anything that contains caffeine, taken near to bedtime, will reduce the quality of sleep. Examples include coffee, tea, hot chocolate and cola. Chocolate also contains caffeine. It is best not to have any of these things within six hours of bedtime. If you are having a bedtime drink try to make sure it is decaffeinated. There is some evidence that having a malty drink at bedtime can increase length of sleep and reduce broken sleep.
• Cigarettes – smoking last thing at night can keep you awake as nicotine is a stimulant. If you do smoke, try to have your last cigarette at least four hours before bedtime. Nicotine patches or chewing gum could also affect sleep.
• Medicines and other drugs – some drugs can affect sleep because they are stimulants. If you are taking medicine it is worth checking with your pharmacist or doctor. Examples are certain drugs for asthma and for migraine. Sleeping tablets, whilst they can help in the short term often cause sleep
  problems as they interfere with the quality of sleep and can alter sleep patterns. They should only be taken for short periods. You can discuss this with your GP.
• Alcohol – whilst people often feel sleepy after drinking a lot of alcohol, again the quality of sleep is affected. It is best to avoid drinking large amounts of alcohol close to bedtime if you are having sleep problems.
• Consistency – try to get a consistent timetable so that your body knows where it is. Getting up at the same time each day is much better during insomnia than trying to catch up on lost sleep or going to bed early or napping at odd times during the day. It is better to go to bed feeling sleepy rather than too early in an attempt to try and catch up. If you feel the need to sleep in at weekends try to make it not more than an hour later than usual.
• Pre-sleep routine – try to use the hour before going to bed to unwind and prepare for sleep. Dim the lights, listen to some calming music. It is helpful to get into a pattern.
• Electronic devices – avoid using electronic devices (TVs, gaming machines and more importantly, tablets and smartphones) in the hour before bedtime and in the bedroom. Blue light emitting from these gadgets stimulates the brain and inhibits melatonin production – the hormone that helps you sleep.
• Tiredness – this may seem obvious but do not go to bed until you feel sleepy.
• Activity – gradually increase your daytime activity and exercise, but don’t exercise too near to bedtime.
• Get up – if you have not fallen asleep within 20 minutes – get up. Don’t lie in bed feeling tense. Listen to relaxing music, read a relaxing book or watch something boring on TV until you feel sleepy. Some people find that having a warm milky or malty drink can help.
• Bed for sleep – make sure your bed is associated with sleep. For example, don’t watch TV, eat, and talk on the telephone in bed. The only exception to this is sex which can in fact help with sleep.

These simple guidelines really can improve your sleep but they take time. Please be patient, your hard work will pay off although it can take many weeks to develop new sleep habits.

Summary
The simple rules outlined in this guide can help improve your sleep. The following checklist is a brief summary of some of the ‘dos and don’ts’ for a good night’s sleep

• Do get up at a regular time.
• Do have a bedtime routine and wind down before bedtime.
• Do get up if you are worrying, or are not asleep after 20 minutes, and do something relaxing.
• Do exercise regularly, but not in the late evening.
• Do remember that sleep changes throughout the life cycle so try not to worry about lack of sleep.
• Do make sure your bed and bedroom are comfortable, for example, noise, temperature, light, etc.
• Do check whether any medicines you are taking may be affecting your sleep.

•  Don’t worry about not getting enough sleep.
•  Don’t lie in bed worrying about other problems.
•  Don’t use your bed for things other than sleep and sex.
•  Don’t eat or drink caffeine close to bedtime, and cut down during the day.
•  Don’t smoke close to bedtime.
•  Don’t drink alcohol close to bedtime.
•  Don’t go to bed until you feel sleepy.
•  Don’t take naps during the day.
•  Don’t stay in bed longer to catch up on lost sleep.

These techniques have been proven to help many people but take time and hard work.

If you feel you are making little progress or the problem is getting worse then speak to your GP. Your GP may be able to refer you to local services with training in sleep disorders. In addition there are NHS and commercial digital CBT packages (CBTi) for sleep available which you can discuss with your GP.

Good luck and sleep well.

A list of useful contacts, books and references are available in the written version of this guide.

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.

Many thanks also to Dr Kirstie Anderson, Consultant Neurologist, and colleagues from the Regional Sleep Service, The Newcastle upon Tyne Hospitals NHS Foundation Trust for their helpful comments.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.