Getting enough sleep is one of the tenets of staying healthy and aging well. But what to do when you get into bed and can’t fall asleep? The Science Times section of The New York Times this past Tuesday offered an interesting solution from Emergency Physician, Joe Whittington.
“Now I Lay Me Down to Play,” written by Christina Caron, explains the doctor’s technique. It’s called cognitive shuffling, and it is designed to calm a busy brain sufficiently to allow sleep. While he had tried deep breathing, meditation and melatonin, to no avail, the following strategy works for him. Incidentally, he has 750,000 followers on Instagram.
“Cognitive shuffling,” according to the Times, “is a mental exercise that involves focusing your mind on words that have no association with one another, as a way of signaling to your brain that it’s time to fall asleep. The task is meant to be engaging enough to distract you from the thoughts that may be impeding sleep, but not so interesting that your brain perks up.”
So how do you do cognitive shuffling?
Take a random word, any word, like “adobe.” Then think of all the words that you can, beginning with that same first letter, like apple, arrow, across, attire. Visualize each word, then move on to the next. When you no longer can think of any more words beginning with “a” go on to the next letter, “d” and do the same thing: dog, depart, done, dope, detritus, and so forth. Again, visualize each word before moving on.
Luc P. Beaudoin, a cognitive scientist at Simon Fraser University in Canada, developed the cognitive shuffling strategy, and he suggests that as people drift off to sleep their minds have distant thoughts or vivid images. This technique is intended to mimic that process.
“These images don’t create a clear story line and may help your brain to disengage from problem solving or worry loops,” said Dr. Beaudoin, who conducted a study in 2016 using various sleep inducing techniques. He himself suffered from insomnia. The study was then discussed at the Associated Professional Sleep Societies conference in Denver, written up in Forbes magazine, then circulated widely online.
It can’t hurt to try cognitive shuffling.
I can tell you what I do to fall asleep. First, with full disclosure, I confess not to often having a problem falling asleep. In fact, I’m like a teapot. Just tip me over and pour me out. Usually, all I need is to get horizontal on a mattress and doze off. However, lately I have been waking up around 4 a.m., feeling rested and not able to resume sleeping. But I know if I get up and start my day at that hour, I will pay for the remaining lack of sleep in the late afternoon. I’m an 8 1/2 hour a night sleeper. So here’s what I do after 20 minutes of tossing and turning.
I get out of bed, put on a lamp that offers dim light and read until my eyes get tired. I am selective in my reading choice: not a page turner. Then I shut off the light, get back into bed and usually fall right back to sleep.
It’s not a researched and tested technique but for me, it works. I enjoy sleeping and require the restorative effects in order to enjoy my waking hours. Hope these strategies work for you.
Have you been waking up thinking at night? There is so much to think about, even to be deeply concerned about. There is COVID-19, of course. No one wants to get the disease, and if you already had it, you don’t want to get it again, as some people reportedly have. You also don’t want any of the long-hauler symptoms to afflict you: fatigue, brain fog, aches and pains, trouble breathing, dizziness, headache, and at least nine more on a reported list. In fact, the list is so comprehensive, it’s enough to give you anxiety, especially if you already have had the illness. Oh yes, and anxiety is also one of the symptoms.
Then there is the Ukraine. Normally a country that was somewhere in Eastern Europe, in the same general area as “Fiddler on the Roof,” now its whereabouts as Russia’s western neighbor are known around the world. We watched as Putin sent more than 100,000 soldiers to overrun its borders. Poor little Ukraine, horrid bully Russia. We are sending them an unprecedented amount of money and military aid, and we have lowered our national oil and gas supplies. Will we have enough resources if we are attacked? Even as we cheer the valiant resistance and success of the victims of naked aggression, we worry about Putin’s possible use of nuclear arms. He has over 2000 small such weapons, apparently, and it’s the Cold War all over again.
The problem of immigration was brought right to our door with the arrival of immigrants sent by southern governors of border states. They have been literally deposited here by the thousands via buses, and they have been humanely received, if we are to accept what we are told by the media. As I have written in this column before, they can represent an opportunity as well as a challenge for areas in need of Help Wanted. Indeed, I am now reading that some of the immigrants are put to work cleaning up the devastation wrought by hurricane Ian in Florida. They are even being sent back down there to help. Who knows what to believe?
If you are going into New York City, how likely are you to ride the subway? The reports of incidents underground are frightening. So are horrible, unprovoked attacks on the streets. Now, I grew up in the city, and I am used to all sorts of miserable statistics concerning crime there, but I somehow never felt fearful. With some eight million people, crime is unfortunately inevitable. And NYC isn’t even statistically the worst. New Orleans is. But somehow, these recent incidents seem more violent.
Climate change has finally penetrated national conversation. The destruction and deaths in Puerto Rico and now in Florida and the Carolinas caused by the last two hurricanes have made those of us who live on islands and along the shores more conscious of future threats. While there have always been hurricanes, some with even legendary force, the prospect of more and stronger blasts due to climate change has prompted scary instruction about emergency bags and escape routes.
Inflation and its direction are also of grave concern. Going to the supermarket now seems to net about half as many bags of groceries for the usual food budget. Restaurants have decidedly become more expensive, as they have to pay more to function. And home values seem to have stopped rising and begun to cool. The stock market, while it is not the economy, has dropped like a rock. That negates the “wealth effect” homeowners and investors feel that encourages them to spend more freely.
Heck, I even worry about the New York Yankees. Yes, they have won their division, and you might say, “handily.” That’s exactly the problem. The last time they won by a big margin, they lost their competitive edge, along with the series, remember? It even happened this year right after the All-Star break. Teams do better when they have to fight until the last minute.
Though statistics vary widely, about 30 percent of Americans are affected by insomnia, according to one frequently used estimate, and women tend to be affected more than men (1). Insomnia is thought to have several main components: difficulty falling asleep, difficulty staying asleep, waking up before a full night’s sleep and sleep that is not restorative or restful (2).
Unlike sleep deprivation, patients have plenty of time for sleep. Having one or all of these components is considered insomnia. There is debate about whether or not it is actually a disease, though it certainly has a significant impact on patients’ functioning (3).
Insomnia is frustrating because it does not necessarily have one cause. Causes can include aging; stress; psychiatric disorders; disease states, such as obstructive sleep apnea and thyroid dysfunction; asthma; medication; and it may even be idiopathic (of unknown cause). It can occur on an acute (short-term), intermittent or chronic basis. Regardless of the cause, it may have a significant impact on quality of life. Insomnia also may cause comorbidities (diseases), including heart failure.
Fortunately, there are numerous treatments. These can involve medications, such as benzodiazepines like Ativan and Xanax. The downside of these medications is they may be habit-forming. Nonbenzodiazepine hypnotics (therapies) include sleep medications, such as Lunesta (eszopiclone) and Ambien (zolpidem). All of these medications have side effects. We will investigate Ambien further because of its warnings.
There are also natural treatments, involving supplements, cognitive behavioral therapy and lifestyle changes.
Let’s look at the evidence.
Heart failure
Insomnia may perpetuate heart failure, which can be a difficult disease to treat. In the HUNT analysis (Nord-Trøndelag Health Study), an observational study, results showed insomnia patients had a dose-dependent response for increased risk of developing heart failure (4). In other words, the more components of insomnia involved, the higher the risk of developing heart disease.
There were three components: difficulty falling asleep, difficulty maintaining sleep and nonrestorative sleep. If one component was involved, there was no increased risk. If two components were involved, there was a 35 percent increased risk, although this is not statistically significant.
However, if all three components were involved, there was 350 percent increased risk of developing heart failure, even after adjusting for other factors. This was a large study, involving 54,000 Norwegians, with a long duration of 11 years.
What about potential treatments?
Ambien: While nonbenzodiazepine hypnotics may be beneficial, this may come at a price. In a report by the Drug Abuse Warning Network, part of the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of reported adverse events with Ambien that perpetuated emergency department visits increased by more than twofold over a five-year period from 2005 to 2010 (5). Insomnia patients most susceptible to significant side effects are women and the elderly. The director of SAMHSA recommends focusing on lifestyle changes for treating insomnia by making sure the bedroom is sufficiently dark, getting frequent exercise, and avoiding caffeine.
In reaction to this data, the FDA required the manufacturer of Ambien to reduce the dose recommended for women by 50 percent (6). Ironically, sleep medication like Ambien may cause drowsiness the next day — the FDA has warned that it is not safe to drive after taking extended-release versions (CR) of these medications the night before.
Magnesium: The elderly population tends to suffer the most from insomnia, as well as nutrient deficiencies. In a double-blinded, randomized controlled trial (RCT), the gold standard of studies, results show that magnesium had resoundingly positive effects on elderly patients suffering from insomnia (7).
Compared to a placebo group, participants given 500 mg of magnesium daily for eight weeks had significant improvements in sleep quality, sleep duration and time to fall asleep, as well as improvement in the body’s levels of melatonin, a hormone that helps control the circadian rhythm.
The strength of the study is that it is an RCT; however, it was small, involving 46 patients over a relatively short duration.
Cognitive behavioral therapy
In a study, just one 2½-hour session of cognitive behavioral therapy delivered to a group of 20 patients suffering from chronic insomnia saw subjective, yet dramatic, improvements in sleep duration from 5 to 6½ hours and decreases in sleep latency from 51 to 22 minutes (8). The patients who were taking medication to treat insomnia experienced a 33 percent reduction in their required medication frequency per week. The topics covered in the session included relaxation techniques, sleep hygiene, sleep restriction, sleep positions, and beliefs and obsessions pertaining to sleep. These results are encouraging.
It is important to emphasize the need for sufficient and good-quality sleep to help prevent, as well as not contribute to, chronic diseases, such as cardiovascular disease. While medications may be necessary in some circumstances, they should be used with the lowest possible dose for the shortest amount of time and with caution, reviewing possible drug-drug and drug-supplement interactions.
Supplementation with magnesium may be a valuable step toward improving insomnia. Lifestyle changes including sleep hygiene and exercise should be sought, regardless of whether or not medications are used.
References:
(1) Sleep. 2009;32(8):1027. (2) American Academy of Sleep Medicine, 2nd edition, 2005. (3) Arch Intern Med. 1998;158(10):1099. (4) Eur Heart J. online 2013;Mar 5. (5) SAMSHA.gov. (6) FDA.gov. (7) J Res Med Sci. 2012 Dec;17(12):1161-1169. (8) APSS 27th Annual Meeting 2013; Abstract 0555.
Insomnia is frustrating because it does not necessarily have one cause.
Untreated insomnia can have long-term health effects
By David Dunaief, M.D.
Dr. David Dunaief
Insomnia is an all-too-common complaint. Though the statistics vary widely, about 30 percent of Americans are affected, according to the most frequently used estimate, and women tend to be affected more than men (1). Insomnia is thought to have several main components: difficulty falling asleep, difficulty staying asleep, waking up before a full night’s sleep and sleep that is not restorative or restful (2).
Unlike sleep deprivation, patients have plenty of time for sleep. Having one or all of these components is considered insomnia. There is debate about whether or not it is actually a disease, though it certainly has a significant impact on patients’ functioning (3).
Insomnia is frustrating because it does not necessarily have one cause. Causes can include aging; stress; psychiatric disorders; disease states, such as obstructive sleep apnea and thyroid dysfunction; asthma; medication; and it may even be idiopathic (of unknown cause). It can occur on an acute (short term), intermittent or chronic basis. Regardless of the cause, it may have a significant impact on quality of life. Insomnia also may cause comorbidities (diseases), two of which we will investigate further: heart failure and prostate cancer.
Fortunately, there are numerous treatments. These can involve medications, such as benzodiazepines like Ativan and Xanax. The downside of these medications is they may be habit forming. Nonbenzodiazepine hypnotics (therapies) include sleep medications, such as Lunesta (eszopiclone) and Ambien (zolpidem). All of these medications have side effects. We will investigate Ambien further because of its warnings.
There are also natural treatments, involving supplements, cognitive behavioral therapy and lifestyle changes.
Let’s look at the evidence.
Heart failure
Insomnia may perpetuate heart failure, which can be a difficult disease to treat. In the HUNT analysis (Nord-Trøndelag Health Study), an observational study, results showed insomnia patients had a dose-dependent response for increased risk of developing heart failure (4). In other words, the more components of insomnia involved, the higher the risk of developing heart disease.
There were three components: difficulty falling asleep, difficulty maintaining sleep and nonrestorative sleep that is not restful. If one component was involved, there was no increased risk. If two components were involved, there was a 35 percent increased risk, although this is not statistically significant.
However, if all three components were involved, there was a 350 percent increased risk of developing heart failure, even after adjusting for other factors. This was a large study, involving 54,000 Norwegians, with a long duration of 11 years.
Prostate cancer
Prostate cancer has a plethora of possible causes, and insomnia may be a contributor. Having either of two components of insomnia, difficulty falling asleep or staying asleep (sleep disruption), increased the risk of prostate cancer by 1.7 and 2.1 times, respectively, according to an observational study (5).
However, when looking at a subset of data related to advanced or lethal prostate cancer, both components, difficulty falling asleep and sleep disruption, independently increased the risk even further, 2.1 and 3.2 times, respectively.
This suggests that sleep is a powerful factor in prostate cancer, and other studies have shown that it may have an impact on other cancers as well. There were 2,102 men involved in the study with a duration of five years. While there are potentially strong associations, this and other studies have been mostly observational. Further studies are required before any definitive conclusions can be made.
What about potential treatments?
Ambien: While nonbenzodiazepine hypnotics may be beneficial, this may come at a price. In a report by the Drug Abuse Warning Network, part of the Substance Abuse and Mental Health Services Administration (SAMHSA), the number of reported adverse events with Ambien that perpetuated emergency department visits increased by more than twofold over a five-year period from 2005 to 2010 (6). Insomnia patients most susceptible to having significant side effects are women and the elderly. The director of SAMHSA recommends focusing on lifestyle changes for treating insomnia: by making sure the bedroom is sufficiently dark, getting frequent exercise and avoiding caffeine.
In reaction to this data, the FDA required the manufacturer of Ambien to reduce the dose recommended for women by 50 percent (7). Ironically, sleep medication like Ambien may cause drowsiness the next day — the FDA has warned that it is not safe to drive after taking extended-release versions (CR) of these medications the night before.
Magnesium: The elderly population tends to suffer the most from insomnia, as well as nutrient deficiencies. In a double-blinded, randomized controlled trial (RCT), the gold standard of studies, results show that magnesium had resoundingly positive effects on elderly patients suffering from insomnia (8).
Compared to a placebo group, participants given 500 mg of magnesium daily for eight weeks had significant improvements in sleep quality, sleep duration and time to fall asleep, as well as improvement in the body’s levels of melatonin, a hormone that helps control the circadian rhythm.
The strength of the study is that it is an RCT; however, it was small, involving 46 patients over a relatively short duration.
Cognitive behavioral therapy
In a study, just one 2½-hour session of cognitive behavioral therapy delivered to a group of 20 patients suffering from chronic insomnia saw subjective, yet dramatic, improvements in sleep duration from 5 to 6½ hours and decreases in sleep latency from 51 to 22 minutes (9). The patients who were taking medication to treat insomnia experienced a 33 percent reduction in their required medication frequency per week. The topics covered in the session included relaxation techniques, sleep hygiene, sleep restriction, sleep positions and beliefs and obsessions pertaining to sleep. These results are encouraging.
It is important to emphasize the need for sufficient and good-quality sleep to help prevent, as well as not contribute to, chronic diseases, such as cardiovascular disease and prostate cancer. While medications may be necessary in some circumstances, they should be used with the lowest possible dose for the shortest amount of time and with caution, reviewing possible drug-drug and drug-supplement interactions.
Supplementation with magnesium may be a valuable step toward improving insomnia. Lifestyle changes including sleep hygiene and exercise should be sought, regardless of whether or not medications are used.
References: (1) Sleep. 2009;32(8):1027. (2) American Academy of Sleep Medicine, 2nd edition, 2005. (3) Arch Intern Med. 1998;158(10):1099. (4) Eur Heart J. online 2013;Mar 5. (5) Cancer Epidemiol Biomarkers Prev; 2013;22(5):872–879. (6) SAMSHA.gov. (7) FDA.gov. (8) J Res Med Sci. 2012 Dec;17(12):1161-1169. (9) APSS 27th Annual Meeting 2013; Abstract 0555.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
