Article by Jordan Rosenfeld
A few nights of poor sleep are more than just a hassle; new research finds lack of sleep may shorten the duration of a person’s life. However, healthcare providers can use sleep habits to improve outcomes in patients with chronic diseases.
The Journal of the American Heart Association found that middle-aged people living with chronic health conditions—high blood pressure, Type 2 Diabetes or heart disease—who slept less than six hours a night were twice as likely to die from stroke or heart attack as those without these conditions.
The problem is that many chronic diseases are also comorbid with poor sleep, according to sleep expert Michael Grandner, PhD. Short sleep duration may aggravate or worsen cardiovascular, metabolic, and inflammatory dysfunctions in individuals with chronic conditions, increasing the risk of stroke, heart attack, dangerous arrhythmias and even cancer.
At the same time, Grandner, who oversees the Sleep and Health Research Program at the University of Arizona College of Medicine, said people with chronic disease often experience more sleep disturbances, insufficient sleep and insomnia.
“Sleep is an effect modifier making [the condition] worse,” he said. “It’s not the sleep itself that is driving the increased mortality.”
But while sleep may not be the core of the problem, the research suggests that sleeping less than six hours per night is a risk factor that can help a healthcare provider design a treatment approach by, for example, helping patients make lifestyle changes.
“It’s not just that sleep problems are inevitable. They’re treatable,” Grandner said.
What causes sleep disturbance
Chronically ill patients, like many individuals, may not realize they are sleep deprived because cultural factors promote bad habits, according to Jagdish Khubchandani, a professor of health science at Ball State University in Indiana.
“Sleep is a big problem in American society,” Khubchandani said. “There’s a large portion of people who don’t sleep enough.”
He recommended that providers guide their patients toward better sleep hygiene, including sticking to a sleep schedule, exercising daily, avoiding the use of technology in the bedroom, steering clear of alcohol, tobacco and coffee in the evening (or at all), and seeking out forms of stress management. “Then later, if these things aren’t working, patients may want to consider medications and other therapies,” he said.
He finds that “one of the best medicines for people with chronic illness is exercise.”
Exercise not only can help address physical problems, but mental health ones as well, he said.
When it comes to helping patients make changes, Grander said he finds there are two main areas where providers should start when addressing patients struggling with sleep.
First, he encourages patients to give themselves enough time to wind down. “Your brain isn’t a light switch, you can’t just turn it off, especially if you have a lot that your body’s attending to,” he said.
Second, it’s important to prevent awakenings at night, especially in older adults and those with chronic illness. “The most important sleep tip you can give anybody is that they don’t spend excessive amounts of time in bed awake. Sit up. Get up. Then try to get back to sleep.” Staying in bed awake is tantamount to training your brain to stay awake, he said.
Sometimes, the level of sleep disruption goes beyond lifestyle factors such as caffeine or the lack of a schedule. Recognized sleep disorders can occur alongside other chronic conditions, exacerbating their effects.
Some sleep disorders get plenty of attention because they are more common, such as sleep apnea. Grandner said sleep apnea is fairly easy to diagnose and treat—risk factors include loud snoring, daytime tiredness, observed apneas during the night, hypertension, a BMI over 33 and over the age of 50. However, there are other sleep disorders that may be flying under the radar due to the chronic health issues, he said.
One of the less treated sleep disorders is insomnia, Grandner said. “Insomnia can be a symptom, but it crosses the line into a disorder.”
He said a good rule of thumb is to ask the patient if it takes them at least 30 minutes to fall asleep at the beginning of the night, or whether they are awake for at least 30 minutes during the night three or more times per week. If the answer is yes, they should be treated for insomnia.
“Most physicians do not know that the main treatment for insomnia is CBTI—cognitive behavioral therapy for insomnia,” Grandner explained. This treatment helps a patient become aware of negative thoughts and replace them with positive ones.
He recommended that when the physician isn’t sure what is causing a patient’s lack of sleep, it doesn’t hurt to refer to a sleep specialist for further evaluation. “Worst case scenario, they don’t have a sleep disorder,” he said. “Best case scenario you were able to treat something that was standing in the way of treatment progression.”
But when in doubt, he suggested physicians consult the American Academy of Sleep Medicine for guidelines in treating sleep disorders.
Finding a solution
Khubchandani acknowledged that sleep problems can be complex and even confusing to physicians, because the provider may not know whether “the patient has a lifestyle issue or a sleep problem.” Patients may ask for medications and sleep aids to address the challenge, or self-medicate themselves through alcohol and over-the-counter medications, but these often just mask a larger problem, he said.
“The challenge for physicians is how to bring about so many changes in one person when they have limited time,” Khubchandani said. “It takes a lot of evaluation, monitoring and lifestyle modification.”
Rather than feeling overwhelmed by the challenge of helping a patient improve health and sleep quality, he encouraged having a positive attitude and remembering to refer to other practitioners, such as a dietitian or health coach, who can help patients adopt healthier lifestyle habits.
“Physicians have to see the patient as a full picture, and not just a person with a chronic illness,” he said. “Dive deeper and approach every case comprehensively. Sleep disorders will require an integrated approach.”
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