simple strategies for better sleep · • do not stay in bed unless asleep - if not asleep in 20...

“Medically Ready Force…Ready Medical Force”

Simple Strategies for Better Sleep

Anne C. Dobmeyer, Ph.D., ABPP CAPT, US Public Health Service

Primary Care Behavioral Health Directorate Deployment Health Clinical Center

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

1

Disclaimer

“Medically Ready Force…Ready Medical Force” 2

The views expressed are those of the author and do not reflect the official policy of the Department of Defense (DoD), the U.S. Public Health Service, or the U.S. Government.

Overview

• What is “a good night’s sleep”?

• Barriers to good sleep

• Six strategies for better sleep

• Getting help when needed


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What is a “Good Night’s Sleep?”

• Sleeping a specific number of hours per night?

• Falling asleep quickly?

• Quality of sleep?

• Feeling rested upon awakening?


In the public domain. http://www.clipartlogo.com/image/alarm-clock-clock-and-stopwatch-vector_87157.html

Polling Question #1

• How many hours of sleep do you need each night to feel rested?

a) 5 hours

b) 6 hours

c) 7 hours

d) 8 hours

e) 9 hours

f) 10 hours


Recommended Sleep Duration

• National Sleep Foundation Recommendations:¹

- Young adult (18-25 years)

• Most need 7-9 hours (range of 6-11 hours)

- Adult (26-64 years)


- Older adults (65+ years)



¹Max Hirshkowitz, Kaitlyn Whiton, Steven M. Albert, Cathy Alessi, Oliviero Bruni, et al. “National Sleep Foundation’s sleep time duration recommendations: methodology and results summary,” Sleep Health 1 (2015).

Polling Question #2

• What is considered a “normal” or “typical” amount of time to fall asleep at night?

a) Within 5 minutes

b) Within 10 minutes

c) Within 20 minutes

d) Within 30 minutes

e) Within 45 minutes


Sleep Onset and Duration

• American Academy of Sleep Medicine identified common complaints of clinical insomnia, including:¹

- Taking longer than 30 minutes to fall asleep

- Being awake during the middle of the night for more than 30 minutes

- Having less than 6.5 hours of total sleep per night (when trying to sleep longer)

- Being asleep less than 85% of the time one is in bed


¹Sharon Schutte-Rodin, Lauren Broch, Daniel Buysse, Cynthia Dorsey, & Michael Sateia, “Clinical guideline for the evaluation and management of chronic insomnia in adults,” Journal of Clinical Sleep Medicine 4 (2008): 487-504.

Insufficient Sleep is Associated With¹…

• Decreased attention and concentration

• Increased risk taking

• Mood changes

• Decreased motivation

• Feelings of physical exertion

• Impaired performance on tasks

• Increased health problems


¹Charles M. Morin and Colin A. Espie, Insomnia: A Clinical Guide to Assessment and Treatment (New York: Kluwer Academic/Plenum Publishers, 1993).

Barriers to Good Sleep

Photo in the public domain. http://www.defense.gov/media/photo-gallery?igphoto=2001141696


Factors We Cannot Control

• Age

• Genetics

• Adverse childhood events

• Some sleep disorders, medical conditions, medications


Factors We May Be Able to Control

• Amount of time we allow for sleep

• Sleep environment

• Nighttime behaviors

• Bedtime worry

• Getting treatment for sleep disorders


Potential Military Spouse Factors

• Partner’s bedtime schedule - Shift work

- Early or late work hours

• Managing multiple demands on the home front

• Worry about Service member during deployments or temporary duty


Six Strategies for Better Sleep


Allow Enough Time for Sleep

• Prioritize sleep

• Evaluate whether your typical bedtime and wake time allow enough time for the sleep you need

• Minimize frequent late-night diversions

- Late night social/recreational activities

- Working

- Cleaning, paying bills, preparing for next day


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Keep a Consistent Rising Time and Bed Time¹

• Arise at the same time each morning

- Regardless of how poorly you slept

• Strive to keep the same bedtime each night

- But… don’t go to bed if you are not sleepy


¹Wendy M. Troxel, Anne Germain, & Daniel J. Buysse, “Clinical management of insomnia with brief behavioral treatment (BBTI),” Behavioral Sleep Medicine 10 (2012): 266-279.

Use a Relaxing Wind-down Routine

• 30 to 60 minutes prior to planned bedtime

• Engage in relaxing (or boring) activities

• Avoid activating activities

• Keep it consistent each evening


Photo in public domain. http://www.photo-public-domain.com/2016/08/21/reading-glasses-atop-pages-of-open-dictionary-book/

Prepare a Good Sleep Environment

• Quiet

• Dark

• Not too cold or hot

• Comfortable bed

• Minimal interruptions

- Pets?

- Bed partner?


DOD photo by Donna Miles. http://www.defense.gov/media/photo-gallery?igphoto=2001099448

Train your Mind and Body to Associate the Bed with Sleep¹ ²

• Only use bed for sleep and sex

• Do not stay in bed unless asleep

- If not asleep in 20 minutes, get up

- Do something relaxing or boring

• Avoid turning on lights or electronics

• Do not lie in bed while worrying

- Use meditation or relaxation

- Use “worry time” earlier in evening

- Get up if not asleep in 20 minutes


¹Charles M. Morin, Annie Vallieres, Bernard Guay, et al, “Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial,” JAMA 301 (2009): 2005-2015. ²¹Wendy M. Troxel, Anne Germain, & Daniel J. Buysse, “Clinical management of insomnia with brief behavioral treatment (BBTI),” Behavioral Sleep Medicine 10 (2012): 266-279.

X Photo in public domain. http://www.photos-public-domain.com/2015/03/15/empty-email-inbox/

Breathe2Relax and CBT-I Coach

In the public domain. http://www.ptsd.va.gov/professional/ materials/apps/ cbticoach_app_pro.asp


In the public domain. http://t2health.dcoe.mil/apps/breathe2relax

Minimize Substances and Activities that Promote Wakefulness¹

• Caffeine

• Nicotine

• Alcohol

• Heavy meals before bed

• Excessive fluid before bed

• Exercise within 4 hours of bed

• Electronic devices (phones, tablets, etc.) before/in bed


¹Paul Harsora & Jennifer Kessmann, “Nonpharmacologic management of chronic insomnia,” American Family Physician 79 (2009): 125-130.

Photo in the public domain. http://www.defense.gov/media/ photo-gallery?igphoto=2001136822

When More Help is Needed: Sleep-Wake Disorders¹

• Insomnia disorder

• Hypersomnolence disorder

• Narcolepsy

• Breathing-related sleep disorders

• Circadian rhythm sleep-wake disorders

• Nightmare disorder

• REM sleep behavior disorder

• Non-REM sleep arousal

• Restless leg syndrome

• Substance/Medication-induced sleep disorder


¹Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association, 2013.

Symptoms of Sleep Disorders

• Obstructive sleep apnea

- Snoring

- Pausing in breathing at night

- Gasping for air

- Morning headaches

- Morning dry mouth

- Daytime sleepiness



• Restless Leg Syndrome

- Legs have “crawling” or “aching” feeling at night

- Urge to move legs

• Periodic Leg Movement Syndrome

- Legs jerk, kick, or twitch at night

- Cramps in legs upon awakening

- Covers kicked off



• Insomnia Disorder¹

- Dissatisfaction with quality or quantity of sleep

- Difficulty initiating or maintaining sleep, or awaking in early morning with inability to return to sleep

- Significant distress or impairment in functioning

- Occurs at least 3 nights per week, for at least 3 months

- Present despite adequate opportunity for sleep

¹Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association, 2013.


Getting Help

• See your primary care provider

- May order labs or sleep study

- May refer to sleep medicine or behavioral medicine

- May prescribe medication

• Follow through with evidence-based treatments

- Cognitive Behavioral Therapy for Insomnia (CBT-I)

- Brief Behavioral Therapy for Insomnia (BBT-I)

- Positive Airway Pressure (PAP) treatment

- Medications


A Personalized Plan

• Select one (or two) areas to target for improved sleep

• Set a SMART goal

- Be Specific

- Make it Measurable

- Achievable

- Realistic

- Timeline


A Personalized Plan: Example #1

• Sam’s Situation:

- Staying up until 2300 or 2330

• Straightening up house, packing kids’ lunches

• Paying bills

• Using email/social media

- Falling asleep quickly (within 15 minutes)

- Arising at 0530 with alarm

- Obtaining about 6 hours sleep per night

- Feeling tired throughout most of the morning


A Personalized Plan: Example #1 Allow Enough Time for Sleep

• SMART Goal: Be in bed for 7 hours, 4 nights per week - Bedtime 2230, Arising time 0530

- Sunday, Monday, Wednesday, Thursday

• Strategies to help: - Post on fridge: 3 reasons why more sleep is important to me

- Schedule bill paying on Saturday morning

- Ask family to help straighten up house right after dinner

- Stop other tasks at 2130 (set alarm for reminder)

- Keep track of progress on a chart kept by bedside

- After 2 weeks of success, expand to 5 nights per week



• Mark’s Situation:

- Going to bed around 2230

- Reading eBooks or online news for 30-45 minutes

- After lights are out, worrying about not falling asleep

- Falling asleep around 2400

- If awakened, taking up to 60 minutes to fall sleep again

- Awakening (with alarm) at 0545

- Feeling tired during day


A Personalized Plan: Example #2 Train Body to Associate Bed with Sleep

• SMART Goal:

- Decrease reading and screen use in bed (from 7 to 2 nights/ week)

- Get out of bed if not asleep in 20 minutes. Sit in recliner in living room; listen to music. Return to bed only when sleepy.

• Strategies to help:

- Get hard copy books from library (to substitute for eBooks)

- Put bathrobe/slippers near bed, making it easier to get up at night

- Read in living room starting at 2230; go to bed only when sleepy



• Lara’s Situation:

- Talking on phone with distant friends/family until 1100 most nights

- Quickly brushes teeth and changes into PJs

- In bed with lights out by 1110

- Doesn’t feel tired; often awake for an hour or more

- Tired when awakens with alarm at 0600


A Personalized Plan: Example #3 Use a Relaxing Wind-down Routine

• SMART Goal: Use a 30-minute wind-down routine

- Beginning at 1030, follow a consistent set of boring/relaxing activities:

• Take a warm shower and brush teeth

• Sit on couch and pet the dog

• Read magazine or book (on couch)

- Plan to get in bed at 1100. If not sleepy, stay on couch and read longer

- Goal: Follow plan 4 of 7 nights the first week; then increase

• Strategies to help:

- Schedule time to connect with others earlier in day

- Set alarm for 1030 to end phone calls

- Post list of wind-down routine in bathroom

- Have ‘unexciting’ books and magazines available near couch


Summary/ Q & A

• Six strategies for better sleep

- Allow enough time for sleep

- Keep a consistent rising time and bedtime

- Use a relaxing wind-down routine

- Prepare a good sleep environment

- Train mind and body to associate the bed with sleep

- Minimizes substances and activities that promote wakefulness

• If problems persist, seek help from your primary care or mental health provider


simple strategies for better sleep · • do not stay in bed unless asleep - if not asleep in 20...

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