Chronic and acute pain often interferes with sleep. Since a third of our lives are spent sleeping or trying to sleep, having an issue getting good sleep can be a major issue. There are many problems that interfere with sleep, and many pain patients have difficulty sleeping. Sleep is similar to pain, in that it is a complex process, and many things can affect our sleep. Sometimes the solution to better sleep is simple, but more often the problem and solutions are complex.
Why Recent Guidelines on Sleep Fall Short
The latest issue of JAMA came in the mail today and had two articles related to sleep. The first was on chronic insomnia and the new guidelines for its management. The second article was on restless leg syndrome (RLS). The “guidelines” were put out by the American College of Physicians (ACP) and written by primary care physicians and health care administrators. To be valuable, guidelines really need to be written by experts in the field of the guideline, and sleep specialists can be credentialed in Neurology and Internal Medicine with a specialty of Respiratory Medicine. These experts were not the ones to write these guidelines. If a patient wants only entry level advice on sleep, these may be okay, but for those suffering from chronic sleep issues, consulting an expert would serve most patients significantly better. It is shame that leading national organizations like the ACP and JAMA publish minimally useful information.
Since I have been in practice for a number of years, learning some some of the basic treatment options to improve sleep is not difficult. If a patient is having difficulty sleeping, always start with a good history and physical exam. The history often tells significant information with regards to the nature of the sleep problem. Treating sleep is usually more complex than guessing the right medications. The most important first step is good habits prior to going to sleep. The easy things involve reducing caffeine intake, especially in the afternoons and do not drink it at night. Alcohol also does not help with sleep; it often will wake one up in the middle of the night. Technology is also a horrible actor; the blue light of cellphones and computers as well as television will stimulate people and prevent sleep. Lastly, do not exercise vigorously in the evenings; this also wakes up most people.
Solving Sleep Problems
If a person has addressed the simple sleep issues and they are still having sleep problems, then finding a solution will often require some expert intervention. Since there are many problems that affect sleep, obtaining a medical sleep consult by a specialist is worthwhile. Problems like sleep apnea are often an issue. Finding medical problems that need management can reduce interference with sleep. If nothing is found to be a problem by an expert, then solutions to what seems to be reducing sleep can be initiated. Many people cannot relax enough to go to sleep, and psychological based treatments like mindfulness or cognitive behavioral therapy are indicated. Few patients may need some sort of medications, but these need to be closely monitored for side effects.
Most experts have not found that a particular type of bed or pillow makes any significant difference. If I am asked about whether a person should buy a new bed, it is probably only necessary if the current one is totally broken. Pillows are really a matter of personal preference, but they need to keep the neck in a neutral spine position. Usually spending lots of money on beds and pillows is not a good solution for improved sleep.
The patient with chronic pain is often no different from any other patient with sleep difficulties. Correct the simple things with regards to sleep hygiene first. If a person continues to have sleep problems, they should see a sleep specialist who can often help find the most appropriate intervention. Expensive beds and pillows are not usually a good investment. If you need a new bed, buy either a bed with a memory foam type top, or an air adjustable bed so the firmness can be adjusted depending on how you feel. Beds with adjustable frames that raise the head are sometimes good for those with breathing problems at night. Most importantly, good sleep hygiene is the first issue to solve, and if the problems persist, ask to see a sleep expert.
Thomas Cohn, MD
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