Sleep

Our sleep doctor, a pulmonologist, gave us a wonderful update talk on sleep in early 2009.

He said, “First of all, I hate that blue butterfly.” For those who do not watch tv or read magazines in the United States, the blue butterfly was in advertisements for a sleep medicine.

“The blue butterfly lies,” he said. “Eight hours sleep is NOT normal and NOT average.”

He said the average amount of sleep for an adult is 7.5 hours. Some people need more, some people need less. I need 6 to 6.5 except on the first day of menses, when my body prefers 10-11 hours. Too much information?

“Catching up is a myth.” He said that we don’t catch up on sleep after the first night. I get people all the time in clinic who say that they haven’t slept for a month and “need to catch up.” The first night with a sleep medicine, people catch up some but that is it. After that, their body returns to their average.

Alcohol is bad for sleep. Yes, I know, it makes you fall asleep faster. However, it is not normal sleep and you will wake when it wears off, in 3-5 hours. And you may be a bit jittery and anxious, especially if you have more than 2 drinks a night routinely. Hello, I said that is the alcohol wearing off. Are you partly addicted? Tell me you can’t fall asleep at all without it? Want a pill instead?

Sleep pills are really alcohol in pill form. Really, really, really. We use benzodiazepines — that is, valium, ativan, librium, etc. for alcohol withdrawal because it has the same mechanism of action. In other words, we are substituting the benzo for the alcohol and then withdrawing you more slowly. Withdrawing from heroin or narcotics makes the pain receptors go completely gonzo, but it doesn’t kill you. It just makes you writhe with pain and wish you were dead. Withdrawing from alcohol can cause the blood pressure to go too high and can cause a stroke or seizures and kill you. So how enthusiastic am I about adding that lovely blue butterfly sleep pill to the 3-5 alcoholic drinks that someone has at night? NOT. Gosh, if we get the dose high enough, mix of alcohol and benzodiazepines the person could throw up and drown in their own vomit or just become sedated enough to stop breathing entirely and die, or just enough for brain damage. That’s fun.

And we don’t know if sleep pills are safe long term. Read the fine print. Ambien is tested and approved for use for two weeks. Right. Not 10 years. We don’t know what the hell they do to your brain if you use them for 10 years. One sleep pill has been tested for longer term use: that is, six whole weeks. Sonata. So I am stingy when it comes to sleep pills. I give people 8. Yes, 8, and tell them not to use them more often than once every three days because I am NOT going to give them 30 a month. I am going to give them 8 a month and that with reluctance. That is a conservative approach to long term use. And if they drink anything over 1-2 drinks a night, they have to cut that down first.

“But doctor, I wake up in the night!” And you are between 40 and 60 years old? That would be normal. Yes, I said normal. NORMAL NORMAL NORMAL. Ok, here’s the story. Little babies wake 4-5 times a night, right? Really. Ask any new mom or dad. Eventually they “sleep through the night”. No, actually they don’t really. They still wake 4-5 times a night but they fall back asleep really quickly and without howling. They keep doing this as children, teens, young adults, adults…..and then sometime in the 40-60 year old range the wake up periods get a little longer. And we remember them. It is normal. It is ok. Do not drug it.

“But I can’t go back to sleep.” Ok, here are the sleep hygiene rules. No violent tv or any screen time (yes, that includes computers, you addicts) for the last hour before bed. No caffeine after noon. Bed is for sleeping and sex only. If you want to read, get out of bed. A cushy armchair by the bed is fine, but get out of bed. Sorry, but you asked. Music is ok before bed and so is radio. The visual light in any screen activates weird parts of the brain, so that’s why no screen. Don’t listen to music or radio that sends your blood pressure through the roof. Exercise is best at least 4 hours before you are trying to drop off. A cool bedroom turns out to be better for sleep than a really warm one: turn down the heat and save money. Warm milk actually works.

“But doctor…” Ok, I know, you CAN’T do some part of the above. Do what you can.

“My teenager falls asleep in classes all the time.” Ah, teens are interesting. The brain essentially melts when puberty hits, at around 12, and is done with major hormonal rewiring by age 25. Teens need MORE sleep than kids or adults. 10-12 hours. They are working hard on puberty. Our sleep doctor said that the time the teen wakes up on the weekend indicates their real circadian rhythm. So, if a teen wakes at 1 pm on Saturday and Sunday, and is going to bed at two, that is where their circadian rhythm is set. Of course they are groggy as heck when they get up at 7 and trundle off to school and that history teacher is boring and drones in a monotone. How do we reset the rhythm? It takes time. The teen has to set an alarm on the weekend and get up progressively earlier. And they STILL need 10-11 hours so guess what? If the goal is 7 am, they should be going to bed by 9 pm. “HA, HA, HA, HA!” laughs the parent. Most teens are not getting enough sleep and are not catching up on the weekend. Parents can have influence. The sleep needs start to decrease as teens are entering their 20s.

Also, no screens in kids’ bedrooms. No tv, no computer, and the cell phone stays in another room. Start this with small children. Why? Kids are up texting at 2 am. Or surfing the net. Or watching whatever. It is a good sleep habit to get out of bed if you can’t sleep and go read something or listen to music. Out of bed, not in bed. Set a good example for your kids and get your television out of the bedroom….ok, now you hate our sleep doctor, not me.

What medicines do I use to help people sleep? I don’t like the benzodiazepine related drugs, which is most of the advertised New Fancy Expensive sleep medicines. I do use old medicines: antidepressants in low doses, very low. Trazodone, amitriptyline and nortriptyline. They are cheap and we are actually using the side effect; that is, they make people drowsy. I prescribe at doses way below the theraputic dose for depression.

Geriatrics. Well, it’s a difficult group. It’s not good to make someone drowsy who needs to get up at night twice to urinate and is a bit shaky on their pins and who won’t turn on the light for fear of disturbing someone. If I make them drowsy they trip and then we have a hip fracture. Mostly it is education: yes, they are waking up, maybe more than once and it’s normal. I have had people really cheer up once we’ve had this discussion. Oh, they say, I’m normal. They’ve been confused by that damn blue butterfly.

Sleep well.Moderate your alcohol, caffeine, television, computer, and cell phone; exercise, eat right, drink enough water and put your doctor right out of business. And the blue butterfly too.

revised. previously published on everything2 November 2009