How to wake up feeling more refreshed

by Dr Deborah Lee, Dr Fox Online Pharmacy

Unrefreshing sleep is surprisingly common. Around 11% of us wake up each day feeling groggy and unrefreshed. That’s around 1 in 10 people. The medical term is non-restorative sleep (NRS).

Getting seven hours of good quality sleep per night is vital for human health. I’m focusing, in this post, more on quality, rather than quantity, of sleep. Why is it that we sometimes get into bed and wake in the morning, feeling no better than the night before? What should we do? How can we improve it?

What is non-restorative sleep (NRS)?

One working definition is ‘difficulty getting started in the mornings and/or feeling rather or completely unrested on waking every day, despite a normal duration of sleep for your age and gender.’

What causes it?

NRS can occur due to difficulty initiating sleep (DIS) or difficulty maintaining sleep (DMS), or it can occur in those who show neither of these features.

A wide range of issues as causes of NRS. Anything that increases sleep latency (time taken to get to sleep), or disrupts sleep, causing night-time awakenings. Sometimes we may be aware of these factors and sometimes we may not.

Here’s a list  –

• Chronic medical conditions – Fibromyalgia, chronic fatigue syndrome (CFS), heart and lung disease, chronic pain and autoimmune diseases. Prostatic disease in men and bladder disturbance in women.
• Sleep disorders – Sleep apnoea, restless leg syndrome, narcolepsy and Circadian rhythm disorders.
• Medication – Decongestants such as pseudoephedrine, asthma medications  – B2 agonist inhalers, blood pressure meds such as B-blockers and ACE inhibitors, some types of diabetes meds such as glipizide, dementia meds – cholinesterase inhibitors, antidepressants/antianxiety meds such as SSRIs, SNRIs and NDRIs, opioid painkillers, amphetamines and steroids.
• Mental illness – Anxiety switching on the sympathetic nervous system (SNS), which is the opposite of what is needed for sleep. Stress and anxiety lead to raised cortisol levels which also cause insomnia. Depression is frequently linked to poor sleep.
• Lifestyle factors – Alcohol, caffeine, nicotine, shift work and jet lag all worsen sleep.
• Environmental factors  – Sleep is disrupted if the bedroom too hot, too cold, too noisy, or there is too much light.
• Hormonal – In the perimenopause, hot flushes and night sweats are triggered by rapid fluctuations in oestrogen and FSH, and wake women from sleep. However, there are additional reasons sleep is affected by menopause. Thyroid disorders also frequently disrupt sleep.
• Inflammation – Research has shown NRS is linked to an  increased level of systemic inflammation. Raised proinflammatory cytokines (chemical messengers of the immune system), such as  interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumour necrosis factor α (TNFα) are present in NRS. Sleep deprivation also increases levels of these molecules.
• NRS as a sleep disorder – This could possibly be a sleep disorder in its own right.

A 2010 study studied those with NRS, DIS and SMS. The authors used polysomnography (PSG) to monitor sleep and brainwaves. NRS was found to occur in those with DIS and DMS, but it was also noted in those without either, showing it can occur as a distinct entity. The authors did find slightly less stage 3 and 4 sleep in those with NRS, which is deep restorative sleep, but this was only a short duration of around 10.8 minutes and the significance is unknown.

Risk factors

Studies show those with NRS is more likely in the following

• Young age
• More common in females than males
• Being generally dissatisfied with sleep
• Stress, anxiety, depression and bipolar disorder
• Having a physical illness

Symptoms

Those with NRS often suffer the following symptoms –

• Daytime fatigue and sleepiness
• Impaired daily functioning at work and at home
• Cognitive impairment
• Irritability
• Increased sensitivity to pain
• Tinnitus

What to do if you have it?

If you think you have it, here’s what you can do to fix it yourself.

Set a sleep schedule –Make time for seven hours sleep a night as part of your daily routine. Ou also need enough time to wind-down for sleep and to wake up the following morning. Set a bedtime and a wake-up time and stick to it.

Keep a sleep diary – This will help a lot to see what is happening and where you could make improvements. Record what time you went to bed, what time you woke up, how many times you woke in night or went to the bathrooms, how you felt when you woke up, any alcohol and caffeine consumption, exercise etc … You can download the Sleep Foundation Sleep Diary here. Take this with you if you need to see your GP.

Improve your sleep hygiene – You need a dark, cool, quiet bedroom. Plus, a comfortable bed/mattress and pillows. Wind-down for 1 -2 hours before sleep, dim the lights, take a warm bath or shower and do something relaxing such as reading, gentle yoga or mindfulness/meditation. Don’t use any electronic devices for at least 1 hour before bedtime. Don’t have caffeine within 6 hours of bedtime or alcohol within 4 hours.

Eat a healthy diet, take regular exercise – You are what you eat. Your body needs the correct nutrients to produce the correct hormones and neurotransmitters to induce sleep. Your body also needs to be used. Taking daily exercise improves sleep.

See your GP  – If you find after 4 weeks of making the above improvement, you are not feeling better, you should see your GP.

How to improve NRS

Your GP will do a sleep assessment and consider all aspects of your personal medical history. An accurate diagnosis is required to improve your sleep. They might use the Epworth Sleepiness Scale to work out the severity of your symptoms.

One very important condition not to miss is sleep apnoea. 80% of cases are undiagnosed. To exclude this means having sleep studies and you may need a referral to a local sleep clinic.

Treating NRS

This largely depends on the cause  of the problem –

• Z drugs  –  Zopiclone can be used in the short term to help restore sleep patterns.
• Sleep apnoea  – This can be treated with either Continuous Positive Airway Pressure(CPAP) or a mandibular device. Both the use of CPAP, and a mandibular device have been shown to significantly improve sleepiness scores and can be life-changing.
• Other sleep disorders  – Specific medication may be required. Restless legs can be treated with drugs such as pregabalin. Narcolepsy is treated with a stimulant such as methylphenidate. Melatonin may be prescribed for those aged 55 and over with insomnia.
• Non medication options  – Cognitive Behavioural Therapy (CBT) is a type of talking therapy that can be highly beneficial for those with many different types of insomnia. The NHS recommends Sleepio. CBT is often effective for those with mental health conditions and has been shown to improve menopausal symptoms.
• Chronic medical conditions – These need to be managed optimally. A medication review needs to be undertaken to ensure medication that doesn’t interfere with sleep is used wherever possible.
• Chronic pain – Non medication options for treating chronic pain include hot and cold therapy, massage, acupuncture, hydrotherapy, CBT and the use of a TENS machine.
• Menopausal symptoms  – HRT is the most effective way of eliminating hot flushes and night sweats. However, there are nonhormonal options for women who cannot take or prefer not to take HRT.
• Lower systemic inflammation – You can do this by eating a Mediterranean Diet. This contains a large number of  anti-inflammatory foods including oily fish, unsaturated fats such as olive oil, and large quantities of fruit, vegetables, nuts and seeds which contain large amounts of antioxidants. Other things that lower inflammation include taking regular exercise, not smoking, not drinking alcohol, losing weightso your BMI is in the normal range 21-25, and lowering stress.

Final thoughts

We all need to wake in the morning refreshed after a good night’s sleep. This is so important  for good health. What’s the point of sleep if it doesn’t achieve this objective? If you feel you are experiencing NRS, it’s time to take steps to make it better. But if things are not improving, don’t perseverate  – see your GP.

I always say that getting the right amount of good quality sleep every night is an emergency  – it’s not an optional extra!