Natural Habits that Promote Sleep
by Dr. Zoë Kelly Linkletter
Insomnia is a common condition involving:
dissatisfaction with the quality or quantity of sleep
difficulty falling sleep or staying asleep
daytime impacts from poor quality sleep such as fatigue, cognitive impairment, irritability, or overstimulation
It can be triggered by various reasons and can have negative impacts on our sleep efficiency and health overall.
What is Sleep Efficiency?
Sleep efficiency is the clinical measurement used to determine quality of sleep. Simply put, it is the percentage of time that you spent in bed during which you are actually asleep. 85% or above is considered good quality sleep. If you are using a wearable device to monitor your sleep this is a great time to check and see if it calculates sleep efficiency or if you can calculate it from the metrics it is tracking.
If you have experienced difficulty falling asleep or wake up during sleep and have a hard time falling back asleep you are familiar with the experience of lying awake in bed.
Why improve sleep efficiency?
It’s the measurement used by sleep specialists to quantify severity of insomnia. Research shows that lower sleep efficiency is linked to conditions such as depression, lack of concentration during the day, fatigue, weight issues, inflammation, and more. So, addressing sleep can often be the root of our larger symptoms or a necessary step to improve these.
Mechanisms of natural sleep
When we are looking to support sleep quality, it is helpful to understand how our natural sleep cycles work. There are two drivers of the sleep-wake cycle
Our circadian rhythm which governs our alertness or “awakeness”
Our homeostatic drive which governs our need for sleep and increases our “sleepiness” or sleep drive.
We fall asleep because our homeostatic drive is high (high need for sleep after a long day) and we stay asleep during the night because our circadian alertness is low. Feeling awake and well rested during the day is the opposite of this because we experience high circadian wakefulness and low homeostatic sleep drive.
Either of these drivers of sleep can be affected leading to insomnia. Stress, anxiety or depression, big life events, medications, shift work can all alter the way these two drives function to promote sleep during the night and wakefulness during the day. Sleep medications, including specifically designed meds, antihistamines and other medications that cause sleepiness like gabapentin increase the homeostatic drive - the feeling of sleepiness, but aren’t as good at decreasing nighttime alertness from overactive circadian drive toward wakefulness. Medications work well for falling asleep but aren’t as good at preventing nighttime awakenings.
So, what are the more naturally supportive habits and interventions to improve sleep?
Behavioral Approaches:
Cognitive behavioral therapy for insomnia (CBTi) is a habit-focused approach to improving sleep efficiency by increasing nighttime sleepiness AND decreasing the nighttime wakefulness that can break through our best efforts at sleep and lead to wake-ups at night.
CBT-I is recommended as the first line treatment for insomnia by the American College of Physicians. CBT-I is behavioral therapy specifically for insomnia and has been shown to be superior to sleep medications for the long term maintenance of good quality sleep.
CBT-I includes three main approaches: sleep hygiene, stimulus control, and sleep restrictions
Let’s talk about some practical and natural habits that you can use to start implementing the principles of CBT-I as a tool to improve your sleep efficiency.
Sleep Hygiene
Implement the following sleep hygiene habits into your regular routines:
Create the appropriate bedroom environment - no light, cool temperature, quiet
Remove or hide time-pieces from the bedroom (or from view the in the bed, see below for further details)
Avoid screens before bed - discontinue screens about an hour before you wish to fall asleep
Avoid caffeine after lunch
Avoid alcohol which disrupts sleep
Stimulus control
This is especially important for changing HOW we think about sleep and the associations we have with sleep. Stress, worries, and long standing insomnia itself increases our wakefulness during the night. An association can form between the bed/bedroom and lying awake, feeling distressed about not sleeping. To control this “stimulus” CBTi recommends :
Use the bedroom only for sleep - avoid doing work, stressful activities or other wakeful activities, in the bedroom. This includes lying awake in bed while trying to fall asleep either at the start of the evening or in the middle of the night, early morning. The recommendation is to leave the bed and the bedroom all together when unable to sleep. Instead, If you can't get back to sleep right away, leave the bedroom and do a quiet activity in the living room such as reading, listening to music, having a cup of tea until you are sleepy again. Then return to bed.
Avoid falling asleep on the couch and later transferring to the bed or napping on the couch. This fosters an association with the couch for sleep, rather than the bed and promotes nighttime awakenings.
Remove time pieces from the bedroom (or from view while in bed). This could include turning the alarm clock away from the bed or covering up the time on your clock. Commit to avoiding looking at the time during 5hr night. This helps decrease nighttime stress around what time it is and the pressure to fall back asleep.
Create a bedroom space that is designed just for sleep. Rearrange furniture, lighting, etc. so that the bedroom functions primarily for sleep and, if available, setting up your living space so that non-sleep activities can happen in a different room.
Sleep restriction
The above sleep restrictions and recommendations help improve the sleepiness drive. In addition, it can be helpful to:
Choose a wake time that you can consistently get up each day (for work, etc) and working back to determine bedtime.
Total hours are determined by how many hours of sleep you are currently getting plus 15 or minus ins
No sleeping outside this restricted window of sleep (such as daytime napping, going to bed early, sleeping in late)
I hope these tips are helpful to you! If you’d like more guidance or support in your sleep, I invite you to schedule a visit with myself or one of our other providers in clinic.
To your sleep and your health!
Dr. Zoë