How can we improve? The non-pharmacologic approach.

The Basics: Sleep Hygiene

Getting started, it is important to respect the basics- which frequently get talked about. I like to equate it with setting the mood. Develop a nightly routine as you start to prepare for sleep. Similar to driving a car, you won’t slam on the brakes to stop the car but coast to a stop. Do the same for yourself- develop a routine of meditation, reading, or stretching which can start to put you in the right headspace for sleep. If possible, try to sleep at the same time every day (seems crazy in an article about shift work, but if you can, it helps). Avoid large meals or alcohol before bed (more on this later) and remove any clock faces that may cause anxiety when you have difficulty sleeping. Avoid screens or sources of bright light immediately before bed. Finally, limit sleep avoidance, the time you spend staying awake late to reward yourself for a stressful day or delaying sleep for the satisfaction of social interaction.

Control the Light

Attempt to remove any significant sources of light from your living space at least two hours before you plan to sleep. Bright light will limit the production of physiologic melatonin. You may continue to use warm and dimmed lights or candlelight. Once asleep, make sure you are in as dark of a room as possible. Even small amounts of light can frequently result in reduced sleep efficiency and metabolic disturbance.²³ Similarly, you can use bright light to drive your circadian rhythm. Once awake, viewing bright, outdoor light within 30-60 minutes will strengthen your circadian rhythm and help with sleep the following night.

Temperature

Studies have shown that not only do our bodies drop their temperature during the night while we sleep, but it is this 1-3 degree decrease in temperature that helps us stay asleep as well.²⁴ Cooling a room to between 60-73 degrees Fahrenheit may help support this. If you’re having trouble or can’t afford AC, try utilizing a fan or removing the covers.

Limit Caffeine Intake

Caffeine functions as a competitive antagonist for the adenosine receptors in our brain. While it does not inhibit the receptors, it outcompetes adenosine and functionally inactivates those pathways. This tricks our brain into thinking it is awake (because it can no longer receive signals from that aspect of sleep pressure). The half-life of caffeine is 5-7 hours and a cup of coffee may remain present in the body for up to 12 hours. While caffeine itself is not bad, it can prevent you from experiencing the sleep pressure that puts you to sleep if it remains in the system. Beyond this, if you are able to fall asleep, your sleep efficiency will decrease and will be less restorative, even if you subjectively feel rested.²⁵ For this reason, try to avoid any caffeine intake 8-10 hours before you plan to sleep.

Napping

Napping is great and restorative when done during the day. Frequently, people find no difficulty with napping (even though they are troubled at night) because of the “extra credit” feeling to a nap. If they can’t do it, it’s fine because it’s extra. This reduction of anxiety frequently allows people to have reduced sleep latency. Even NASA has found the benefit of short naps and demonstrated that a 26 minute nap improves performance by 36%.²⁶ In general, naps should be limited between 20 minutes to 90 minutes to avoid encroachment on the typical sleep pressure that will help you fall asleep at night. As a side note, if you already experience insomnia, preferentially napping and not sleeping in the evening may make this worse.

Noise Machines

If you find that your sleeping environment is unfortunately disturbed by loud noises, then noise machines may offer a chance to deal with some of that. Noise machines function by producing noise along a spectrum of frequencies,providing auditory masking. That is, your brain adapts to the steady noise and only reacts to those significant changes in peaks of volume.²⁷ You can do a deep dive into the different color spectrums of noise options (white, pink, brown, gray, etc.), but perhaps that’s a paper for another day.

Sleep Strategies

If you’re in bed and having difficulty falling asleep, it helps to have an approach to help remove the anxiety people feel from not sleeping or to at least make the time awake more restorative. Have some strategies in your back pocket that can distract or reduce the cognitive load of “trying to sleep”. Dr. Harvey from UC Berkeley frequently discusses that simply counting sheep doesn’t cut it. Instead, it will result in difficulty with emotional suppression. It is far more useful to picture and develop a calming scene in your mind. You can take this one step further- since visualization of activities actually improves performance of that task, you can spend this time setting up a scene and visualizing a low-frequency procedure to both practice it and help you fall asleep.

Other simple techniques you can try include practicing 4-7-8 breathing (a meditative technique where you inhale 4 seconds, hold for 7 seconds, and exhale for 8 seconds) or playing a naming game to distract your brain (choose a theme and go through the alphabet).

How can we improve? The Possible Pharmacologic Approach

Melatonin

Melatonin works wonderfully for jet lag and resetting a circadian rhythm back to a stable time zone. Unfortunately, there have been mixed results for the utility of this supplement beyond that. Recent studies have found only minimal improvement in chronic use of about 4 minutes of increased sleep duration. There may be some indications for use, that is in elderly adults who may have reduced endogenous hormone production or to support dropping core body temperature and staying asleep. One difficulty is that melatonin dosing is frequently inconsistent within supplements ranging from -83% to +478%.²⁸

Magnesium Threonate

Built off of a theory in patients with insomnia and low magnesium receiving improvement from magnesium supplementation, there has been a growing trend towards its use in supporting sleep efficacy and duration. Threonate is favored for the theoretical ability to cross the blood-brain barrier. A recent meta-analysis found that while there was evidence for some mild support in specific situations, overall there is not enough evidence and multiple high-bias risk studies comprise the data.²⁹ At this time, without well structured RCTs, it’s difficult to say if there is improvement with magnesium supplementation.

What should we avoid?

Alcohol

Alcohol once metabolized forms aldehyde as a metabolite. Unfortunately, aldehyde has been found to actually prevent the ability of the body to enter REM sleep. Even doses as low as one glass of wine may exhibit this effect. While this allows for physically restorative sleep though N3 sleep, it prevents the mood, emotional, and memory benefits of REM sleep from occurring.

Marijuana

There is limited data on the use of marijuana for sleep outside of subjective reports. It is important to also separate THC, the psychoactive component, from CBD. Limited studies in THC demonstrate a block of REM sleep with an element of tachyphylaxis as well. CBD may have some benefit in speeding up sleep latency, but has not yet been fully studied to determine the mechanism or side effects.

Sleeping Pills

Sleeping pills are wonderful and produce sedation which may feel restful, but does not provide the same benefits of true N3 and REM sleep. Sleeping pills may also result in daytime drowsiness and increase the risk of stimulant use. There has also been an association with increased mortality, even in those taking up to 18 pills per year.30 Given the addictive nature and significant side effects, it may be best to avoid these as sleep aids.

I hope this gives you a basis to start your sleep journey and improve your sleep given the significant damage on chronic health issues that our shift schedule predispose us to. As a caveat, if you are having true sleeping difficulties and cannot find improvement, it may be beneficial to speak with your primary care doctor and receive a referral to a specialist.