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How can caregivers overcome sleep problems?
Interview with Sleep Physiologist Stephanie Romiszewski
We asked Channel 4 sleep expert Stephanie Romiszewski about the impact of poor sleep, and how caregivers can break unhealthy sleep cycles.
There are many ways caring for a loved one can impact your sleep. At night time you may feel like you need to stay on high alert, so that you can react to your loved one if they need help. You may find yourself staying up after everyone else has gone to bed in order to have some time to yourself. Or, you may simply find the day to day worries of caring difficult to switch off from.
Whatever the reason, poor sleep can cause longer term problems if left untreated, particularly when it comes to your ability to look after yourself and others. We spoke to Sleep Physiologist and the founder of Sleepyhead Clinic Stephanie Romiszewski, to understand more about the science of sleep.
Aside from feeling tired, what are the warning signs that someone may not be getting enough quality sleep?
There are actually a bunch of things that come along with, for example, insomnia, that you wouldn’t really expect. One of them is actually feeling really lonely, because when you’re up all night and you can’t sleep, you can start to get quite isolated from your community during the day time.
You can also begin to feel out of control of your own body. So when people aren’t sleeping well, they start to feel like there’s something wrong with them, but that it’s something that they have no control over. If you think about it, sleep is something we do every night, so when you’re unable to sleep night after night you can start to get a bit of a complex that something is very wrong with you.
This can make you start worrying about what’s going to happen if you don’t sleep well. So the anxiety levels go up quite high.
And then, it’s actually really abnormal for people to feel sleepy when they’re lacking good quality sleep, but they will start to feel very fatigued.
Fatigue doesn’t always look like the ability to nod off, it can just make you feel like you don’t have much motivation to do stuff, for example you don’t really have any motivation to or energy to see friends or be social.
Research has shown that family caregivers are already at an increased risk of loneliness, so does that mean a sleep disorder can increase this risk even further?
It makes it much worse. It’s an entirely different game caring for someone and then developing a sleep problem.
The sleep problem can literally take over your life – worse than anything else. If you think about it, sleep affects everything and everything affects sleep. That’s not something in any other area of medicine that’s quite as prolific and strong. We do it for a third of our lives. There’s no getting away from it.
One thing that sleep can have a big impact on is our mental health, and vice versa. How can a carer break this negative cycle?
So, if you’re having a problem sleeping, but it’s only been happening for about a week, making some changes to your environment, and taking some time to relax will probably improve it a little bit.
However if it’s been going on for a longer time, most people will focus on their mental health, and look at resolving those issues first. But here’s the problem. Once you’ve had any sleep problems for longer than three months, it doesn’t matter what the trigger is, whether it’s mental health issues and life stressors, or something else like hormones – after three months, it’s ingrained, it’s a habit.
So this means your brain doesn’t even need that trigger. Even if you were to fix your mental health the sleep problem would still be there.
This means you’re likely to see the mental health issues come back at some point too, because the sleep problem will keep you feeling low. This is why when you treat the sleep problems first, the rates of relapse for mental health problems go down – because you’re treating the bit that is continuously affecting you every single day.
The way we do that is with something called cognitive behavioural therapy for insomnia. It’s different to CBT for depression or anxiety or chronic pain, and is all the best strategies that we know are proven to influence your window for getting quality sleep.
It’s very successful, but it does need to be done by a professional, or you need to do a programme or read a book that’s been written by professionals, because it’s essentially reprogramming your brain through your own behaviour.
It’s probably not what people think it’s going to be like either. For example, there’s no point spending hours trying to relax when there’s no evidence that relaxation is going to fix your sleep disorder. Think about it this way – if it takes three months for poor sleep to become a habit, it’s going to take you at least about three months to change it.
What are the long term implications of not seeking help for a sleep problem?
So here’s the thing – there’s a difference between insomnia and chronic sleep deprivation.
Insomnia isn’t sleep deprivation. It’s true that sometimes when you have insomnia, you can go through times where you have a little bit of sleep deprivation, but it’s not the kind of chronic sleep deprivation that you hear lots of worrying studies about. Insomnia is literally having a problem with the quality and the timing of your sleep.
If you are chronically sleep deprived it’s actually quite easy to fall asleep because your body needs it. It’s much more complex with insomnia. Whilst you think ‘I’m only getting one hour sleep when I used to get eight’, your body sort of goes into this strange survival mode and gets used to it.
Most people with insomnia try to go to bed earlier, or lie in longer too, so they’re actually spending much more time in bed and get little snippets of sleep, but they’re horrible.
This is partly because the brain is now used to surviving on small bits of sleep, and also because it treats this behaviour as a new pattern. When you think, ‘oh, I didn’t sleep well last night. I better lie in.’ your brain thinks okay, let’s start making her sleep around this time now, because she wants to have two hours of sleep here.
It’s sad because poor sleep can make you feel rubbish, but the thing is, if you give in to that and think, ‘Right, I’m going to cancel the gym, I’m going to not do anything today, and hope that will encourage my brain to sleep.’ It’s actually going to do exactly the opposite. Not only are you changing the window of sleep, but your brain doesn’t understand how to build a nice, strong sleep drive for you because you’re constantly moving the signals and goalposts.
People with insomnia can then get very anxious about their sleep. And, when you get anxious your heart rate goes up, your temperature goes up and you’re less likely to be able to wind down for sleep. Then you’ve got your adrenaline levels and your cortisol levels to contend with and you don’t realise that they’re not just randomly firing. It’s all to do with our own behaviour and this horrible, vicious cycle.
Do our sleep needs change as we get older?
You begin to grow into your sleep needs as a young adult, and then they should stay pretty stable for most of your life.
But as we get older, we get introduced to more illness and more medication and it gets harder to maintain these needs, especially now, in our Western society with technology and connectivity thrown into the mix.
Then, on top of that we actually naturally become morning people as we get older, so it gets harder to maintain the second half of the night’s sleep. It’s in the second half of the night, you’re more likely to have REM sleep where you dream.
There are things you can do to help with that – adapting, rather than forcing your brain to do things that it naturally doesn’t want to do is important. So if you’re getting up at 6am now, accepting that it may become 5am will often work out fine, because you’ll likely feel like going to bed earlier too.
It’s the people that are trying to keep the late nights and also try to stay asleep in the mornings that tend to experience problems. They start napping during the day, and don’t realise they need to use that sleepiness to build back a healthier sleep drive at night.
What can a family caregiver do to improve their own sleep behaviours, alongside the person they’re caring for?
So the ways we all can help with building better sleep, and especially as we get older, is first of all to maintain a wake time. People love lying in, but it’s the wake time that matters and we should be waking up and getting up at exactly the same time every day.
It’s also important to get plenty of light exposure. Light exposure is your absolute best friend and it’s free and available to all of us. Light exposure is key in the first two thirds of the day, especially when you wake up in the morning.
Make sure you’re eating and you’re exercising or moving as consistently as possible each day too. You can’t metabolise and sleep at the same time, so if you’re consuming calories close to when you want to sleep, you’re going to notice that your brain’s not recognising your sleep signals.
Try and get ready for bed early, and do everything you need to do so nothing’s going to distract you later on. Then when you are sleepy – tired – nodding off in your chair, go and take yourself to bed because that’s all you’ve got to do.
If you do wake up in the night and you can’t sleep, leave the bedroom and just say to yourself, ‘Do you know what? There’s nothing to worry about here. Clearly, my drive to sleep is not that strong. That’s OK. I’m not going to make this a long term problem because I’m going to leave the bedroom and I’m going to distract myself with a nice, enjoyable activity. I’m still going to wake and get up at my usual time, I’m not going to make it later, and I’m not going to start napping during the day.’ Eventually, your brain will get back on track.
Often, people are so afraid of sleepiness and fatigue that it can take over and stop them doing the things that will make them feel better. I think we believe that not feeling ‘up to it’ is like a physical ailment, when actually we’re just being a little bit lacklustre in motivation.
Exercising, seeing our friends, and eating regular, nutritionally balanced meals, are going to bring back our energy levels. But of course, we don’t like that. We like to presume that our brains and our bodies are very mysterious and we have no control over them.
And finally, it’s important to remember that actually, you’re OK – even if you’re struggling with your sleep, or feeling anxious about it, you’re still alive and you’re still thriving because your brain is super smart and able to adapt.
I treat people who have had insomnia for 70 years, they don’t have serious chronic health issues because of the lack of sleep. It’s the fear and anxiety around it that plays the biggest part.
As a Sleep Physiologist, Stephanie Romiszewski helps people to incorporate sleep treatment into their everyday lives. She is highly skilled at turning complex sleep medicine into easy to understand strategies, and alongside running Sleepyhead Clinic, regularly shares advice and practical tips on radio and TV.
To find out more click here.
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