Sleep improvement strategies

30/05/08: NRAS

Taken from NRAS magazine, Spring 2008

This is based on a session at the ACR (American College of Rheumatology) 2007 meeting moderated by Sue Oliver, NRAS Chief Nurse Advisor

The two presenters who were both psychologists presented evidence that suggested ten to fifteen percent of the general population suffer from sleep problems. When it comes to those with RA 50% report problems, for fibromyalgia sufferers the figure is higher at 75% and those with lupus 80%.

The speakers advised that it was important to assess a patient’s sleep status first. Keeping a sleep diary or log for a week is a useful way to start. Questions concerning the following can establish how big a problem exists for the individual concerned:

  • Bedtime
  • Naps taken during the day
  • Normal daily schedules
  • Difficulty falling asleep
  • Awakening regularly during the night
  • Quality of sleep (how refreshed you feel when getting up)
  • Snoring/leg movements/sleep apnoea
  • Lifestyle (occupation, social, commuting)

Getting enough sleep is often not treated as being as important as it should. ‘Volitional chronic sleep deprivation’ brought on by stress or a hectic lifestyle is when individuals ignore symptoms and put up with sleep deprivation due to the pressures of everyday life.

Cognitive Behavioural Treatment

There are various strategies for the improvement of sleep patterns. Sleep medications like Tylenol PM are available. The use of meditation and yoga may also help. However, cognitive behavioural treatment looks at non pharmacological ways of improving sleep patterns in a different way under the following headings:

1) Sleep Hygiene

Making a comfortable bedroom environment is important – firm mattress, quiet, dark room (no clock ticking etc). You need 16 hours of wake time to build up sleep debt (going to bed too early can worsen the problem). Following this regime you may feel worse before you feel better. Set alarm in the morning so no sleeping in to make up for lost sleep. Exercise 4-6 hours before bedtime. Increase light exposure early in the day. Use wind down time to help prepare for sleep (warm bath/reading/music). Avoid nicotine/chocolate/caffeine after lunch and alcohol after dinner. Snack carefully and moderate fluid intake before bed.

2) Controlling stimulus that will encourage wakefulness

Modern bedrooms have become entertainment centres where we eat and watch tv or use a computer etc. There are far too many stimuli. Only go to bed when feeling drowsy. Do not nap or nap less than 45minutes in the early afternoon.

3) Sleep Restriction

Aim to reduce the time you spend in bed not sleeping. Consolidate your sleep. Set a fixed wake up time and decide the number of hours you think you have asleep on a typical night. Then go to bed to achieve it using the fixed wake up time. If you feel deprived move the time you go to bed back by half an hour. Continue to do this until sleep efficiency improves.

4) Cognitive Restructuring (re-educating the mind about previous negative experiences)

When we have problems sleeping we often have negative thoughts about the need to fall asleep and its importance with the next day fast approaching. Everyone else seems to be able to get to sleep more easily. Change your negative list into positive by telling yourself you will fall asleep sooner or later and that good sleepers have bad nights.

5) Relaxation Training

Set up a good routine and practise relaxation at times other than bedtime (3 minutes is plenty to start with).

6) Continued Assessment

75% of people can improve their sleep patterns using cognitive behaviour treatment techniques and monitoring the process can help to reinforce success.

People with RA often experience pain and stiffness in their joints and are likely to be on anti-inflammatory drugs. The non pharmacological sleep strategies described here are known to help a percentage of those experiencing sleep problems.