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Unquiet Spirits III

Sleeping Well

We’ve spent the last couple of months talking about sleep; both good and bad, and how important it is for our health and safety. The old Scottish poet Joanna Baillie, from whom I got the title of the articles, would have loved Abba’s song from a while back, “I Have a Dream,” which sums it all up with a catchy line, “I have a dream...to help me cope with everything.” The DoD would also agree.

A recent report from the Pentagon says, “Sleep may be the most important biological factor that determines Service member health and combat readiness.” Based on our discussion for the last two months, we could paraphrase that to read, “Sleep is the most important biological factor for our safety in the sky.” Let’s wrap up our deep dive into sleep physiology this month and talk about what you can do to get that critical good night’s sleep.

A couple of things need emphasis even before we get to all the fancy ways to fall asleep and stay asleep for a restful night. The first is that it’s imperative to fix any issues you might have with one of the most common sleep disorders, Obstructive Sleep Apnea (OSA), which we talked about last month in Part II. It’s also clear from all the sleep literature that the seeds for a good night’s sleep are sown during the day. Get as much natural sunlight or bright light during the day as possible. Recent studies show that 2 hours of sunlight improves time and quality of sleep by 75-85%. Exposure to light during the day is beneficial, but nighttime light exposure has the opposite effect. Light, especially the blue light that’s found on TV screens, computer monitors, and cell phones, tricks your brain’s circadian rhythm center (the pineal gland we talked about) into thinking it’s still daytime so your devices need to be shut off at least 2 hours before bedtime. Bedrooms are a pretty popular place to watch TV, but it might keep you up later than you want. Avoid daytime naps since sleep is sleep and it all counts; the more you sleep during the day means the less you’ll sleep at night.

Another thing you can do is to set up a daytime routine that you stick to. Wake up at the same time in the morning and go to bed at the same at night to program your brain into a consistent cycle of wakefulness and rest. Make sure you’re physically and mentally active during the day so you’re mentally and physically tired at bedtime. We already talked about diet, caffeine, nicotine, and alcohol, but also pay attention to when you eat. A large late-night meal suppresses melatonin secretion and will keep you awake far later than an early dinner. To promote restful sleep you also need to control your environment, and there are lots of important things that are actually pretty simple. Generally, a cooler temperature is more conducive to rest than a hot, dry room. Make sure your bed and mattress are comfortable for you and rest on pillows to support you in your favorite sleeping position. Use earplugs and an eye mask if you live in a noisy urban area to minimize outside stimuli to your brain while you power down.

When you’re getting ready for bed, prioritize relaxation. Try making a checklist of the things you want to get done tomorrow so you don’t stay awake tonight worrying that you might forget something important. Consider a few relaxation techniques to ease the stress and anxiety you built up during the day; one thing you can use is relaxation imagery. Think of a place where you feel grounded and at ease. It can be an imaginary place or a peaceful place that you know. Include all your senses as you create this relaxing imagery by using sights and sounds that are relaxing. This place you have created can be there for you to return to each time you are getting ready to sleep. We’ve talked about these types of skills and relaxation methods before in the post on “Focus” and also in the post on “Stress,” which are both worth another read if you’re having trouble falling asleep.

There are a number of other relaxation techniques out there that are grouped into “focused attention exercises” and “progressive muscle relaxation.” The NIH provides a nice guide to the various methods at this link you can check out. As you go through these types of exercise techniques, focus first on muscle relaxation, and your mental relaxation will follow. Concentrate especially on your facial muscles and masseter muscles of the jaw. Jaw clenching is a common stress reaction, so really relax those muscles and let your mouth fall open a bit. Also focus on relaxing your abdominal muscles, since the “butterflies” we feel in our stomach with stress are from clenching and tightening of the muscles of your abdominal wall. Here are some more basic methods you can try:

  • Breath in and out, feel your belly rise and fall with each breath, count each breath, once for each time you inhale and exhale
  • Continue counting from 10 back to 1; if you lose count or get distracted start again
  • Tense your left leg and foot and then release
  • Tense your right leg and foot and then release
  • Keep doing this for your arms and hands
  • Tense and hold your face muscles and then release
  • Then combine the two—tense and relax all your muscles while you inhale and exhale

Some pretty reputable medical institutions like Johns Hopkins have advocated the practice of yoga as another method you can use to promote relaxation and sleep. The idea is the same and uses both muscle and breathing exercises that can help you relax so you sleep better. There are also a few commercially available relaxation techniques that have been shown to have health benefits and aid with restful sleep. One is Transcendental Meditation, which takes its origin from ancient Indian traditions dating back thousands of years. There are good peer-reviewed studies that show this technique has positive effects on relaxation and overall well-being. It has also been shown to reduce blood pressure, both systolic and diastolic pressures, to a “clinically meaningful” level in a 2017 meta-analysis. The takeaway from these studies is that any good relaxation technique that works for you to unwind daytime stress will promote sleep health and that’s clearly beneficial.

There’s a whole pharmacy full of chemical sleep aids, both over-the-counter and prescription, but as I cautioned in the last post, be careful with these meds as they can have paradoxical reactions that cause more anxiety than relaxation and also become addictive. The study published in 2015 that I mentioned before states that almost 80% of people who use sleep medication experience unpleasant and potentially dangerous side effects. But lots of people take various sleep meds and find that they can help when used right and for a short time period. Last month we also talked about how melatonin secretion initiates the sleep cycle; it makes sense that taking an extra dose of melatonin would help, and it does for many people, but it also has some side effects. There’s a prescription melatonin agonist called Rozerem (Ramelteon) that has a similar effect as the over-the-counter variety but is more potent. Other prescription meds are also available from your physician. The more common ones are meds like Restoril (Temazepam), Ambien (Zolpidem), and Lunesta (Eszopiclone), which are all benzodiazepines (very popular for abuse on the street and known as “benzos”) that act as chemical relaxants. They can work short term in certain situations but are controlled substances and they have serious side effects that make their use dangerous and potentially addictive. This class of meds is also on the FAA DNF (do not fly) list of drugs and not permitted within 24 and sometimes 48 hours prior to flight. That number is calculated as 5 times the pharmacological half-life of the meds in your system. Check the FAA web site for bans on these and a number of non-prescription sleep aids, as many of them are also on the DNF list that require cessation a day or two prior to operating an aircraft.

With all the options to help you relax and sleep well, you’ll have to try some of these and find out what works best for you. It’s easily overlooked, but as we covered in all these posts, good sleep is one of the most important aspects of our health, safety, and well-being. Take it seriously and work as hard at your rest and brain health as you do on your pilot skills; you can’t have one without the other. Next month we’ll continue on the topic of stress and how it affects your health, so stay tuned, relax, sleep well, and fly safe!

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in principles of aviation safety and has adapted those lessons to healthcare and industry for maximizing patient safety and minimizing human error. He also writes and teaches pilot and patient safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery/surgical critical care and general surgery. Dr. Stahl holds an active ATP certification and a 25-year member of the AOPA with thousands of hours as pilot in command in multiple airframes. He serves on the AOPA Board of Aviation Medical Advisors and is a published author with numerous peer reviewed journal and medical textbook contributions. Dr. Stahl practices surgery and is active in writing and industry consulting. He can be reached at [email protected].

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