Sleep is not simply time when the body and brain “shut down.” It is an active biological process essential for memory, mood, immune function, metabolic health, and cardiovascular health.
Regularly sleeping less than 7 hours per night is associated with increased risks of numerous health conditions. The American Academy of Sleep Medicine recommends that adults obtain a goal of 7-9 hours of sleep per night.
Habits that protect sleep
Several habits can help protect sleep:
Maintain a consistent sleep and wake schedule
Seek morning daylight and exercise regularly
Limit caffeine later in the day and alcohol near bedtime
Keep the bedroom cool, dark, and quiet
CBT-I: the first-line treatment
Cognitive behavioral therapy for insomnia (CBT-I) is strongly recommended as the first-line behavioral treatment for chronic insomnia and has been shown in numerous randomized trials to improve sleep quality, sleep onset, and nighttime awakenings.
One evidence-based principle from CBT-I is particularly useful for nighttime awakenings. If your mind starts making tomorrow's to-do list at 2 a.m., don't engage with it. Keep a notepad beside your bed and briefly write down anything you are afraid you'll forget. Then remind yourself, “It's written down; I can deal with it tomorrow.” Even better, spend 10 minutes before bed writing down tomorrow's priorities and any unresolved concerns. This gives your brain a designated time for planning—and helps keep your bed a place for sleep, not problem-solving.
If you remain awake and frustrated, get out of bed and do something quiet in dim light until you feel sleepy, then return to bed. This “stimulus control” approach helps reinforce the association between bed and sleep rather than bed and wakefulness.
If insomnia continues
When good sleep habits have been established and CBT-I has been completed but insomnia continues, it may be worth discussing possible underlying medical conditions with your physician. First, look for conditions that may be contributing to poor sleep.
Obstructive sleep apnea
Can cause loud snoring, gasping or choking during sleep, morning headaches, and excessive daytime sleepiness.
Restless legs syndrome
Causes an uncomfortable or “crawling” sensation in the legs, often accompanied by an urge to move them, particularly at night.
Anxiety and depression
Can also contribute to persistent insomnia.
Sleep medications
If these conditions have been treated or ruled out, medication may be an option. Sleep medications work in several different ways. Some reduce nighttime hyperarousal by calming the brain, while others help reinforce the body’s natural circadian sleep signal. A newer class of medications works differently: rather than broadly sedating the brain, they reduce the brain’s wakefulness signal, allowing sleep to occur more naturally.
Benzodiazepines
Among the oldest sedative-hypnotic medications. They enhance the effects of GABA, the brain’s primary inhibitory neurotransmitter, thereby reducing hyperarousal. Different benzodiazepines, Ativan and Xanax for example, vary in their degree of sedation, anxiety reduction, muscle relaxation, and duration of action. Although they can be effective in the short term, their use is limited by concerns about tolerance, dependence, cognitive impairment, and changes in normal sleep architecture, including reductions in deep and REM sleep.
Z-drugs
Such as zolpidem (Ambien), also act through GABA receptors but are more specifically directed toward sleep. They can reduce the time it takes to fall asleep and increase total sleep time. Unlike benzodiazepines, they are not intended to treat anxiety. Potential risks include next-day impairment, memory problems, and unusual or complex sleep behaviors, such as sleepwalking.
Dual orexin receptor antagonists (DORAs)
A newer class of sleep medications. Rather than broadly sedating the brain, they block orexin, a chemical system that promotes wakefulness. By reducing this wakefulness signal, DORAs, such as Dayvigo and Quvivo, may allow the brain’s natural sleep processes to take over. They support healthy sleep architecture and have fewer cognitive effects than traditional sleep medications. Early research suggests that they may even help the brain clear harmful proteins like amyloid beta and tau.
Medication should complement—not replace—good sleep habits, treatment of underlying conditions, and CBT-I. When medication is appropriate, the goal should be to use the lowest effective dose for the shortest appropriate duration.
The bottom line
Treat sleep as a health priority—not leftover time at the end of the day. If you’d like to talk more about your sleep, your primary care physician is the best person to connect with.
Harley A. Simeone, MD Clinical Director of Primary Care
