By Misti J. Norton, PhD, DBSM

The American Heart Association recently included sleep health as one of eight factors that define “Life’s Essential 8” (LE8), a metric to assess ideal cardiovascular health.¹ Sleep duration is associated with a greater risk of cardiovascular disease. Insomnia, particularly difficulty falling asleep and non-restorative sleep, is associated with increased cardiac events.

Insomnia vs. Insufficient Sleep

Many patients in cardiac and pulmonary rehabilitation have sleep difficulties.² More broadly, the National Institutes of Health estimates that 50-70 million Americans suffer with sleep problems. Insomnia and insufficient sleep are distinct issues, and both cause problems with daily functioning. Individuals with insomnia have the opportunity to sleep but cannot fall asleep or stay asleep. They may try hard to sleep and may spend lots of time in bed tossing and turning and worrying about their sleep loss. This happens to most people on occasion, but if it occurs at least 3 nights per week for at least 3 months, a diagnosis of insomnia is appropriate. On the other hand, individuals with insufficient sleep could almost certainly sleep if given the opportunity but may be awakened repeatedly due to caregiving or have a short sleep window due to work schedules. Some people simply sleep less than their body needs but because of the demands of their day, they want more time for themselves when they should be sleeping. Sleep needs vary from person to person, but the National Sleep Foundation generally recommends 7-9 hours per night for adults.

The gold-standard treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I), which focuses on increasing the sleep drive at bedtime while strengthening the body’s circadian clock with a regular rise time each day. First, individuals are taught to improve sleep efficiency by limiting their time in bed to what is needed for sleep and then gradually increasing time in bed until their sleep needs are met. They are also taught to associate the bed with sleep by using the bed only for sleep and sex and by sleeping only in the bed. Participants also learn skills to relax their bodies and quiet their minds. Individuals needing help with insomnia can find a provider on the International List of CBT-I providers.  

Do’s and Don’ts for Better Sleep

There are also some general rules to keep in mind:

• Caffeine. This stimulant interferes with sleep and stays in the body for several hours, so individuals should aim to restrict caffeine at least 6 hours before bedtime.
• Nightcaps. Many people use alcohol as a sleep aid. Although it does help with falling asleep, it interferes with staying asleep; therefore,  people often find that their sleep is fragmented and unrefreshing later in the night. If having alcohol, it’s best to keep it to 1-2 drinks and stop 2 hours before bedtime.
• Noshing. Aim to eat larger meals at least 2 hours before bed, but a light snack at bedtime can be helpful. Try to avoid sugary foods and instead choose something with a mix of carbohydrates and protein, such as cheese and crackers. 

Whether one’s problem is insomnia or insufficient sleep, a consistent nightly wind-down routine is extremely beneficial. Use this time to:

• Relax
• Read
•  Listen to soothing music
• Journal
• Engage in gentle yoga or stretching

A key consideration for both insomnia and insufficient sleep is to listen to the body. Individuals with insomnia often say they go to bed “with my spouse” or “when I think I should.” Those with insufficient sleep may go to bed “when everything is done.” Ultimately, the decision to retire for the night should be based on sleepiness cues, such as heavy eyelids and yawning.

Work Out a Better Sleep Regimen

Insufficient sleep can occur for a variety of reasons, and addressing it typically involves changes in scheduling and support. Caregiving is a common reason for sleep interruption and insufficient sleep. Individuals benefit greatly from stretches of uninterrupted sleep and are encouraged to coordinate with other caregivers so that both can get at least 5 hours of consolidated sleep.

Although both night shifts and swing shifts are difficult for workers, swing shift is especially damaging to health, and employers are urged to allow workers to consistently work either daytime, evening, or night shifts. Individuals who work night shift and need to sleep during the day should create a quiet, dark space for sleep and should set firm boundaries around interruptions from others. White noise may help drown out daytime sounds.

Interestingly, individuals who follow erratic sleep schedules will experience the same physical and mental effects as people who work swing shift or are jet-lagged. For example, many people will get up early for work on weekdays but sleep several hours later on weekends. They may have been at home the whole time, but their body feels like they have traveled from the United States to Europe and back over the weekend! Many people balk at the idea of getting up early on non-workdays, saying, “But that’s my day to sleep in!” It can be helpful to think of other ways you can relax and enjoy your day off while getting up at your usual time. You may be rising from bed early, but you don’t have to rush out the door to work! You can enjoy your coffee and read or watch a favorite show or go outside for some morning sunlight.

At least one small study has adapted a behavioral treatment for sleep disturbance to patients participating in cardiac rehabilitation.³ The intervention was well-accepted, but larger-scale studies are needed to demonstrate efficacy in CR.

Is Sleep Apnea the Problem?

Disorders such as sleep apnea can also lead to insufficient sleep. Sleep apnea occurs when breathing pauses and associated loss of oxygen occurs because of airway obstruction or issues with the parts of the brain that control respiration. Although a person may appear to sleep a sufficient amount, they may have short awakenings throughout the night as the body fights for oxygen. Many people with sleep apnea feel very sleepy during the day and note that they can fall asleep anywhere. If one is experiencing frequent snoring, daytime sleepiness, and morning headaches, they should request a referral to a sleep physician for a full evaluation and sleep study. Untreated sleep apnea also carries significant risk for cardiovascular disease, and those living with it are often surprised at how much better they feel once treated. Continuous positive airway pressure or CPAP is the gold-standard treatment for sleep apnea, but there are other options as well.

Overall, there is much to be gained from improving sleep quality! Professional help for sleep disorders is readily available if sleep problems persist despite the recommendations discussed in this article.

References:

National Sleep Foundation’s updated sleep duration recommendations: final report. Hirshkowitz, Max et al. Sleep Health: Journal of the National Sleep Foundation, Volume 1, Issue 4, 233-243

Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 3, Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19961/

1¹Lloyd-Jones DM, Allen NB, Anderson CAM, et al. Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation. 2022;146(5):e18-e43. doi:10.1161/CIR.0000000000001078

2²Tighe CA, Buysse DJ, Weiner DK, Beehler GP, Forman DE. Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT. Journal of cardiopulmonary rehabilitation and prevention. 2022;42(5):316-323. doi:10.1097/HCR.0000000000000694

3³Tighe CA, Phares A, Weiner DK, et al. Adapting and Evaluating the Feasibility and Acceptability of a Behavioral Intervention to Promote Sleep Health in Cardiac Rehabilitation. Behavioral sleep medicine. 2024;22(6):894-909. doi:10.1080/15402002.2024.2386602

Misti J. Norton, PhD, DBSM, is a licensed clinical psychologist who is board-certified in Behavioral Sleep Medicine.