How to work with clients that say nothing helps them sleep better?

Highlights 

• Insufficient amount of sleep has a negative impact both on physical and mental health
• Simple changes in the routine – like temperature and light level adjustment – may help to improve the quality of sleep
• To help clients adhere to the new sleeping routine the changes should be gradually introduced and persistently repeated

Introduction

Statistics show that more than 30% of adults in the U.S. suffer from an insufficient amount of sleep (1). Lack of sleep influences not only productivity during the daytime but also has a negative impact on physical and mental health. Permanent insufficient sleep can raise the risk of chronic health problems such as diabetes, obesity, hypertension, and heart disease (2); and can increase vulnerability to mental health issues such as cognitive impairment, anxiety, and depression (3). In some cases, the reason behind insufficient sleep is sleep disorders, but in many cases, the critical element in improving sleep quality and lifting the related difficulties are sleep habits.

Sleep stages

The sleeping process can be divided into five stages – two stages of light sleep, two stages of slow-wave sleep (S.W.S.), and a phase of rapid eye movement (R.E.M.). At the first stage of light sleep, the mind is semi-conscious, followed by the slowing of heart rate and a drop in body temperature at the second stage. At the S.W.S. stage, a person experiences deep sleep and muscles and tissues repair. At the R.E.M. stage body is “paralyzed”, and dreams start. A person consecutively switches between these stages 5-6 times during the night, starting from the first stage of light sleep, “descending” to the second, and so on, until reaching the deepest sleeping stage. Then switching happens in “ascending” order. Each “ascent” and “descent” take on average 1,5 hours, and for most people require 5-6 cycles to get a good night’s sleep. The exception is people with a mutation in the DEC2 gene, who require only four such cycles per night. The sleep stages and their alternation serve as a prerequisite for WHO-recommended 7-9 hours of sleep for adults but may vary individually (4). One of the main aspects of sleep improvement is developing a constant, comfortable sleeping routine. Through the following parts of the article, we will explore the mechanisms of sleep and how to employ this knowledge to make better sleep recommendations.

Melatonin and circadian rhythms 

The efficacy of the sleep mechanism depends on various factors, including hormonal regulation. Excessive levels of stress hormones, such as cortisol, adrenaline, and noradrenaline, may disrupt the sleeping cycles and decrease sleep quality (5). But the key hormone for sleep regulation is melatonin (6), produced by a small endocrine gland called epiphysis cerebri or pineal gland. Melatonin concentration increases at night, thus controlling the sleep-wake cycle and playing an important immunomodulatory role. Though the many details of the mechanism remain unknown, associations between melatonin with immunity, inflammation, and aging have been described (7,8).

But how a brain detects the “time” to increase melatonin synthesis? This function is carried out by the part of the hypothalamus called suprachiasmatic nuclei (S.C.N.), which uses the external levels of light as an indicator for the 24-hour cycle (9). The prevalence of artificial light, especially in the blue spectrum, disrupts the proper functioning of S.C.N., and correspondingly the synthesis of melatonin.

Several meta-studies showed that using melatonin as a supplement is slightly effective only in treating jet lags and insomnia (10,11) but shows no significant improvement for the sleep quality of healthy adults. However, there is another approach to regulating melatonin synthesis – regulation of the light levels. Schechter et al. studied the influence of blocking nocturnal light from electronic devices on sleep quality and demonstrated that blocking blue-specter light using amber lenses led to significant sleep improvement (12). Using lenses is one way of approaching this problem, but the research shows that light exposure has a short-term impact on melatonin levels. Within 15 minutes cessation of light exposure, melatonin goes back to normal (13).

However, light levels are crucial for melatonin production not only before sleep but also during sleep when the pineal gland produces the largest quantities of melatonin. Light exposure during sleep can decrease melatonin production by greater than 50% (14). To avoid light exposure during sleep, one can use a sleep mask or install black-out curtains to block the light. 

Room temperature and vasodilation

Our body slightly cools when we sleep, reaching a temperature minimum between 4 and 6 a.m. (15). If the skin cooling rate is increased, one can faster fall asleep, and one of the mechanisms that can be employed is vasodilation (16) – the widening of the blood vessels resulting from the relaxation of smooth muscle cells within the blood vessels walls. Such dilation increases body temperature, thus also increasing skin-to-air heat transfer in temperatures lower than one of the body. The procedures such as a warm shower or bath (17) or even simple wearing of socks (18) decreased sleep onset.

Described above also does not imply the necessity of sleeping in a cold room. The wide-spread myth is that one should sleep at temperature below 20oC, but it was demonstrated that no significant difference in sleep quality is observed in a temperature range from 13o to 23oC (19). However, a temperature higher than 23oC may negatively impact sleep quality (20).

Noise

Noise is one of the most omnipresent sleep disruptors, and research shows that any environmental noise, including the one from the transport, can seriously decrease sleep quality (21). Earplugs have shown their efficacy even in intense care units conditions (22), and there are a variety of options. But this solution may not suit everybody, and in that case, it is possible to use noise-reduction techniques such as white noise generation (23,24). White noise is a random signal with equal intensity at different frequencies, and is able to mask loud sounds that excessively stimulate the brain.

Caffeine control

Though well-known, the effect of caffeine-containing drinks like coffee and tea is frequently disregarded by people with sleeping problems. For a cup of coffee, on average 30 minutes pass before caffeine takes effect, another 1,5-2 hours before the perceived effect ends, and 3-7 hours until the complete caffeine elimination (25). Multiple studies show that caffeine consumption up to 16 hours before sleep might significantly decrease sleep quality and impair sleep-wake regulation (26).

Recommendations

To help your clients/patients to improve their sleep, the optimal strategy would be to help them develop a healthy sleeping routine gradually. Initially, this routine should include a few basic steps, and more can be added gradually. To incorporate the routine efficiently into the lifestyle, it should be perceived by a client/patient rather as a journey, not as a heavy burden. To ensure the progress is noted, ask your client/patient to keep a journal with notes on estimated sleep quality (can be marked on 5-point or any other convenient scale) and sleep duration.

The possible recommendations are listed below:

• Limit consumption of caffeine-containing beverages to the morning hours;
• Physical activity is beneficial for sleep quality, but any exercises should be done at least two hours before sleep (27);
• Put a special sleep alarm approximately 1 hour before sleep. This alarm will serve as a reminder to stop all the daily tasks, eliminate the stressors, start unwinding and preparing for sleep;
• If possible, ventilate the room to ensure the optimal sleeping temperature;
• If needed, the air can be additionally humidified to reach optimum 40-60% humidity (28)
• Shift devices to the “Night mode” (with less blue light emitted) and/or stop using any light-emitting devices at least 15 minutes before sleep;
• Use sleep mask or black-out curtains to avoid excessive light exposure during sleep;
• To reduce the environmental noise, use either earplugs or a neutral background sound (i.e., white noise);
• Help your client to choose one of the available range of consumer wearables to monitor their sleep and track the progress (29);
• Another thing that can improve sleep quality is choosing a comfortable and functional mattress (30)

A range of supplements was significantly connected with the quality of sleep, and may also ease the sleeping problems of your patients/clients. Those include:

• Magnesium intake showed improved quality of sleep and sleep duration in the longitudinal analyses (31);
• Bioactive peptides, derived from milk and fermented dairy products, were reported to enhance sleep and relieve stress due to an affinity for gamma-aminobutyric acid (GABA) receptors (32,33);
• l-theanine intake was shown to decrease stress and improve sleep quality (34);
• An increase in intake of both natural and biosynthetic GABA showed systematic sleep-enhancing effects in multiple studies (35)

All these recommendations are targeted at healthy individuals who experience sleep problems due to their lifestyle. Vasodilation techniques should not be recommended if a client has cardiovascular problems. If nothing from the listed above helps, your client/patient may require additional insomnia treatment or experience other related medical problems.

Conclusions

The prevalence of sleep problems worldwide has led some clinicians to the discussion as if insufficient sleep disorder should be classified as a major non-communicable disease. Most sleep problems are caused by flaws in lifestyle and sleep hygiene and can be fixed by developing a healthy sleep routine.

References

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