News Special Report

America's Sleepless Nights: In Pursuit of Rest

photo of man sitting on edge of bed

March 27, 2019 -- It’s 3 a.m. on a Wednesday, and I’m flat on my back, eyes closed but mind racing, counting backward from 300 by 3s.

A sleep specialist once recommended this way to count sheep, assuring me that the math would distract my busy brain from work deadlines and family drama and literally bore me to sleep.

I used to drift off before I got to 250. But now that perimenopause has set in, it’s not working anymore.

I glance at the clock -- 3:20 a.m. -- make a trip to the bathroom, and climb back into sweat-soaked sheets, grumbling to my husband: “Why can’t I sleep?”

On any given night, millions of people share my pain.

About 70 million in the United States have sleep problems, and 60% of those have a chronic sleep disorder like insomnia, sleep apnea, or restless legs syndrome, or RLS. On average, we’re sleeping about an hour less than we did in the 1940s, with 1 in 3 adults now failing to get even the minimal 7 hours of nightly sleep experts recommend. A quarter of us are so tired, we have trouble concentrating by day; 9% say sleep deprivation interferes with our job; and, frighteningly, 5% say they’ve nodded off at the wheel in the last 30 days.

This lack of shut-eye can take a serious toll on our health, leaving us more vulnerable to infection and boosting our risk of obesity, heart disease, diabetes, mood disorders, and Alzheimer’s disease. And it doesn’t take long for damage to start to kick in.

Recent research has shown that deep sleep -- sometimes called the brain’s washing machine -- serves to wash out metabolic byproducts that gum up the brain and lead to cognitive decline. After just one night without it, the plaques and tangles associated with Alzheimer’s disease can rise as much as 50%.

One sleepless night can also boost levels of ghrelin, aka “the hunger hormone,” leading us to eat more and crave sleep and fat. And it makes our body less able to use insulin to metabolize that sugar, leaving more in our blood and boosting our risk of getting type 2 diabetes.

One recent study found that people who slept less than 6 hours per night for a week and were then exposed to a cold virus were four times more likely to get sick.

All this has prompted the CDC to begin referring to sleeplessness as an “epidemic” public health crisis. But sleep specialists stress that all sleep problems are not created equal. Researchers have identified at least 88 distinct sleep disorders, many fueled by genetics. Age, gender, and a more stimulating nighttime environment also play key roles.

“There are many different flavors of sleep problems, and people need to stop thinking about them as just one thing,” says Michael Breus, PhD, a Los Angeles-based clinical psychologist who offers customized sleep programs for celebrities and elite athletes. “To find lasting relief, you have to know what your root causes are.”

Here’s a look at some possibilities:

Born This Way

If you, like me, grew up listening to horror stories about your parents’ sleepless nights, chances are your problem may rest partly in your genes.

“There are many genes involved in sleep, and almost all sleep disorders run in families,” says Rafael Pelayo, MD, a professor of psychiatry at the Stanford Center for Sleep Sciences and Medicine.

Scientists have pinpointed dozens of gene variants associated with sleep problems, linking them to everything from nighttime teeth grinding to not being able to let go of tension.

Restless legs syndrome -- which causes “creepy crawly” feelings in the legs at night -- has been linked to genetic variants that make it hard to absorb iron in the brain and tissues. As the thinking goes, people are born with the genetic mutation but often don’t have symptoms until something changes (a vegan diet, heavier periods) to drop their iron levels below a critical threshold. Because iron is a key ingredient for the movement-regulating neurotransmitter dopamine, tremors can arise when it’s in low supply.

“Sometimes people start to experience RLS symptoms, you treat it with iron supplements, and it works,” notes Pelayo.

Another set of genes, known as “period” genes, influence our “chronotype” -- or whether we tend to be morning larks, night owls, something in between, or insomniacs.

“Your genes impact the master biological clock in your brain as well as all the clocks around your body that dictate when hormones are produced and physiological processes occur,” says Breus, whose book The Power of When outlines how to live more in line with our chronotype. “Not everybody’s clocks keep the same time.”

While sleep apnea is often associated with obesity, it, too, is largely rooted in genetics. About half of the people who have it are of normal weight.

Some people are born with a small jaw, narrow face, and/or high-arched palate that make it hard for the tongue to fit snugly in their mouth. As a result, the tongue slips backward during sleep, blocking breathing and causing fits of waking, says Pelayo.

On the flip side, researchers recently discovered a gene that leads to high levels of a protein that stimulates arousal. Some lucky people who have it can go to bed at midnight and pop out of bed, refreshed, at 5 a.m.

The science is young, and there’s still a lot to learn, cautions Breus.

But genetic testing companies like 23andMe have already begun sharing sleep-related genetic information with clients. And Breus uses it as one tool for creating personalized sleep plans.

He and others say knowing that your genes make you more susceptible to sleep problems often motivates people even more to change the things they can.

“Your genetic tendencies are not your destiny,” says Pelayo.

You’re Getting Older

Genetics aside, age also comes with a host of new sleep challenges.

“When you’re young, you can fall asleep in the car and sleep for hours, but as an adult, it gets harder,” says Christine Won, MD, medical director for the Yale Centers for Sleep Medicine.

Studies show total sleep time declines from as much as 14 hours a night in childhood, to between 6.5 and 8.5 hours a night in young adulthood, to between 5 and 7 hours a night in your late 50s, where it tends to plateau.

That’s in part because as we age, the pineal gland in our brain, which produces the sleep-promoting hormone melatonin, begins to shrink and calcify, says Pelayo. (That’s why melatonin supplements can be an effective sleep aid for the elderly.)

Sleep patterns also begin to shift in middle age, leaving us with shorter fits of lighter sleep, less restorative deep sleep and active dreaming (REM sleep), and a tendency to wake up earlier.

Both men and women also tend to gain more weight in their neck area in middle age, which can boost the risk of sleep-disordered breathing, Won notes.

For women, perimenopause, the 3-5 years before menstruation ceases and official menopause kicks in, can make things worse.

“Even women who have slept soundly for years find themselves struggling in new ways during perimenopause and menopause,” says Breus.

A recent CDC survey found perimenopausal women were the most likely of any age group surveyed to sleep less than 7 hours, and a whopping 49.9% said they wake up tired 4 days a week.

The reasons: Progesterone and estrogen levels shift during perimenopause, and sleep becomes more fragmented. Hormone therapy can help some women with disturbances that are related to hot flashes during perimenopause and after.

The overall silver lining: Waiting it out may help.

Breus says sleep often normalizes after menopause (defined as one year after the last menstruation) as hormones level out.

And some research suggests that after about 60, we adapt and learn to function a little better on a little less sleep: One small study comparing women ages 20 to 30 with those ages 55 to 65 found that the older group did better on a battery of tests of motor skills after 3 nights of sleep restriction. Another survey of 10,000 adults found that adults over age 65 complain less of insomnia than those who are younger.

Your Environment

No discussion of sleep problems would be complete without a mention of the radical shift in the American lifestyle in the past few decades.

“People are expected to be available 24-7 now, and sleep can sometimes be viewed as lazy or unproductive,” says Pelayo. “Technology has accelerated this.”

As you’ve probably heard, that blue glow coming from cellphones and tablets can be a serious sleep killer. Special cells in our retina are finely tuned to respond when hit with that short-wavelength light (which happens to be about the same wavelength as morning sun) and signal the brain that it’s time to stop making melatonin and wake up.

One 2014 study found that people who read from a tablet before bed saw melatonin levels plummet 55%. Another 2018 study found that preschoolers -- who are believed to be more vulnerable to the sleep-disrupting blue rays -- had melatonin shut down almost completely when exposed to bright light an hour before bedtime.

Fortunately, many companies have begun to offer apps that automatically shift the light to a calmer, less disrupting hue as night falls.

But that alone won’t save your sleep, says Kathy Sexton-Radek, PhD, a professor of psychology and sleep researcher at Elmhurst College in Illinois.

“The content on that device is a problem too,” she says, noting that a work email or text before bed can stir our emotions and get our mind racing.

The advent of Netflix and other streaming services, which tempt the viewer to watch episode after episode and leave them thinking about what will happen next, even after they shut it off, is also a factor, she notes. One recent survey of 423 people ages 18 to 25 found that 81% identified themselves as “binge viewers.” When researchers asked about sleep patterns, they discovered that about one-third of cases of chronic insomnia were related to binge-watching.

“The narrative complexity of these shows leaves viewers thinking about episodes and their sequel long after viewing them,” the authors note.

Other studies have suggested that light-pollution outside our homes could be having an impact. A study of 52,000 adults 60 or older found that those who live in more brightly lit neighborhoods are more likely to take prescription sleep medications.

We’re also eating dinner later, which is a problem, since digestion revs up the body and it takes about 4 to 6 hours to move a meal through your system, says Sexton-Radek.

Then there is worry.

“I see a lot of adults today who are worried about finances, teens who are worried about being accepted at school or getting into the college they want, and seniors who are worried that they are not sleeping and it’s going to affect them cognitively,” says Sexton-Radek, noting that in these cases, psychotherapy may help.

But amid this sleeplessness epidemic, she says she also is beginning to see a positive cultural shift. After decades of being dissed as a low priority, sleep is slowly becoming trendy again.

“I believe we are in transition,” Sexton-Radek says. “Thanks to the public health and media messages, people are starting to recognize the value of sleep and the serious consequences of not getting enough and seek help.”

WebMD News Special Report Reviewed by Neha Pathak, MD on March 25, 2019

Sources

SOURCES:

Michael Breus, PhD, clinical psychologist; diplomate, American Board of Sleep Medicine.

Rafael Pelayo, MD, professor of psychiatry, Stanford Center for Sleep Sciences and Medicine.

Christine Won, MD, medical director, Yale Centers for Sleep Medicine; director, Yale Women’s Sleep Health Program.

Kathy Sexton-Radek, PhD, professor of psychology, Elmhurst College.

News release, American Academy of Sleep Medicine.

News release, Gallup.

News release, University of California, San Francisco.

Journal of Clinical Sleep Medicine: “Insomnia in the Elderly, a Clinical Review.”

CDC: “Sleep Duration and Quality Among Women Aged 40–59, by Menopausal Status, September, 2017.”

Physiological Reports: “Sensitivity of the circadian system to evening bright light in preschool‐age children.”

Journal of Clinical Sleep Medicine: “Binge Viewing, Sleep, and the Role of Pre-Sleep Arousal.”

Journal of Clinical Sleep Medicine: “Outdoor Artificial Nighttime Light and Use of Hypnotic Medications in Older Adults: A Population-Based Cohort Study.”

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