Solutions for Sleep
By Bruce Campbell
Regardless of the number of hours slept, sleep is usually not restorative, meaning that people wake up tired rather than refreshed. This is likely due to an insufficient amount of the deepest and most restorative type of sleep, called delta sleep.
Other sleep problems include
In addition, many people with ME/CFS and FM experience intensified fatigue, achiness and mental fogginess that lasts one to two hours after rising.
Addressing sleep problems is a good initial focus for symptom management because treating sleep can both improve quality of life and reduce other symptoms. Sleep management plans usually include a combination of strategies from three categories:
1) Sleep Environment and Habits
Most people with ME/CFS and FM can improve their sleep by changing their sleep habits and their sleep environment, matching a solution to a problem. Common problems include:
A starting point for better sleep is to address these and other aspects of your sleep hygiene.
Have a Comfortable Environment. Provide yourself with an environment conducive to good sleep by using a good mattress, and by exercising control over light, noise and temperature. Many feel most comfortable sleeping in a recliner, which can reduce back pain.
Establish a Routine. Go through the same routine each night and have a consistent bedtime. Prepare for sleep by gradually reducing your activity level in the several hours before bedtime and by having a regular routine you go through consistently at the same time each night.
Use Relaxation and Distraction. If you find it difficult to fall asleep, consider listening to quiet music or distracting yourself in some other way. If you are still unable to sleep, get up and engage yourself with quiet activities such as reading or listening to soft music or relaxation tapes until you are sleepy.
Control Stress and Worry. Stress often leads to muscle tension, which makes falling asleep more difficult. Practicing relaxation methods can help you ease tense muscles.
If you have difficulty falling asleep because you are preoccupied with problems, consider setting aside a "worry time" each night before going to bed.
Get Up at the Same Time. If you are going to bed later and later, setting an alarm so that you get up at the same time each day may help you adjust gradually back to more normal hours. Usually, you may not need to compensate by changing your bedtime to an earlier hour; your body can adjust itself.
Use Pacing. Being too active during the day or early evening can create a sense of fatigue combined with restlessness called feeling "tired but wired." Keeping activity within limits and having a winding down period before going to bed are antidotes.
Limit Daytime Napping. Sometimes daytime napping interferes with nighttime sleep. If you nap during the day and find that you have trouble falling asleep at night, or your sleep is worse than usual when you nap, you might consider sleeping only at night.
Avoid Caffeine, Alcohol & Tobacco. Consuming too much caffeine, drinking alcohol and smoking can make getting good rest more difficult. Avoid products with caffeine, such as coffee, tea, soft drinks and chocolate, for several hours before going to bed.
Check for Medication Side Effects: Drugs taken for other issues may affect sleep or create sleep-related problems. For example, drugs can produce a feeling of grogginess in the morning. Also, medications taken for problems other than sleep may interfere with sleep if they contain substances like antihistamines or caffeine.
If you think medications might improve your sleep, first consider over-the-counter (non-prescription) products like melatonin and valerian, simple antihistamines such as Benadryl (diphenhydramine) and Tylenol PM and Advil PM, or doxylamine (used in Nyquil and ZzzQuil).
If you prefer prescription medications, a reasonable approach is to find a physician willing to work with you to find what helps in your unique situation. Because no one drug is consistently helpful for treating sleep in people with CFS and FM, you may have to experiment to find what helps you.
In patients who have trouble both falling asleep and staying asleep, a particularly useful combination is Klonopin (clonazepam) with a dosage of 0.5-1mg to initiate sleep together with trazodone (25-50mg) or a tricyclic antidepressant to help maintain sleep.
Next step would be a non-hypnotic medication such as Lunesta (eszopiclone), Rozerem (ramelteon), or Sonata (zaleplon). These work to naturally stimulate the sleep center of the brain, and are not thought to be addicting.
The hypnotic drug Ambien® (zolpidem) is useful for both sleep initiation and maintenance. Zolpidem increases the depth of sleep but users may adapt to the drug over time, and some people experience amnesia and/or sleep walking.
Analgesics and/or non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain and often benefit sleep as well.
Xyrem (socium oxybate) has some appealing properties, because it increases slow wave sleep and restores rapid-eye-movement (REM) sleep.
While medications can improve sleep, they can also make it worse. Some drugs disrupt sleep by reducing slow wave sleep or causing restless legs and periodic legs movements.
High doses of opioid pain relievers such as morphine and oxycodone can disrupt sleep. Ultram (tramadol) has the potential to interfere with sleep (even at low doses) because of its antidepressant-like action.
3) Sleep Disorders
If your sleep doesn’t improve despite better sleep hygiene and the use of medications, consider asking your doctor for a referral to a sleep specialist, who can examine you for sleep disorders.
Sleep apnea, meaning absence of breathing during sleep, occurs when a person's airway becomes blocked during sleep and he or she stops breathing. An episode can last from a few seconds to a few minutes.
Apnea is a treatable condition. A common remedy is the use of a CPAP (continuous positive airway pressure) machine. The patient wears a mask through which a compressor delivers a continuous stream of air, keeping the airway open and thus allowing uninterrupted sleep.
Restless legs syndrome (RLS) involves "twitchy limbs," strong unpleasant sensations in the leg muscles that create an urge to move. The problem is often at its worst at night.
Self-management techniques that may help include reducing consumption of caffeine and other stimulants, establishing a regular sleep pattern, doing exercise that involves the legs, distracting yourself by immersing yourself in activity, using hot or cold baths or showers, and taking supplements to counteract deficiencies in iron, folate and magnesium.
Several categories of medications may also help, including sedatives, drugs affecting dopamine, pain relievers and anticonvulsants. Three of the more commonly used drugs for RLS are the pills Requip and Mirapex, and the patch Neupro.