Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilton , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilton .

Speaker 2: 0:18

Hey everybody, it's David Hilden and welcome to episode 24, the final episode of Season three of the Healthy Matters podcast. Thanks for joining us today. We're gonna talk about insomnia and the most effective treatment for insomnia, which is cognitive behavioral therapy for insomnia, otherwise known as CBTI . To help me out today, I have Mark Rosenblum. He is a doctor of psychology and an expert in insomnia and the treatments of insomnia. He is a colleague of mine here at Hennepin Healthcare in downtown Minneapolis in our sleep center. Mark, thanks for being here. Well, thank you

Speaker 3: 0:52

For having me. I appreciate it. So

Speaker 2: 0:53

You've been doing sleep medicine for some 20, 30 years, I don't know, a long time. Mm-hmm , <affirmative> and treating patients who experience insomnia. So could you start us out, lay the groundwork, the basics of insomnia. What is insomnia? How is it defined, and what are the various types?

Speaker 3: 1:09

Well, when we break down insomnia, we , we break it down between the symptom versus the condition. The symptom of insomnia is something that most people are familiar with. Troubles falling asleep, trouble staying asleep, or troubles waking up too early in the morning. When it transitions to a condition, usually it involves a few more factors. First of all, you start having some daytime consequences. A person is struggling more at work, maybe at school , um, in their relationships. Secondary is it ha it takes on a chronic feature to that. For example, most people, upwards to 50% of people will have insomnia symptoms At times. They may be there for a day or two and they resolve in contrast the condition which goes on and on until it's treated. We think even upwards to 10% of the population struggles with that. Yeah,

Speaker 2: 1:53

I can imagine that darn near everybody listening says, yeah, I had trouble falling asleep last night, or I woke up at 2:00 AM and I was anxious about something. So, so I think it's something that a great number of people have experienced. But you're distinguishing that with, when's it a problem that you need to have addressed? That's what you mean by a condition. Yeah,

Speaker 3: 2:09

So, so a symptom oftentimes, like I said, could be for a single night here or there. There are sometimes though the symptoms can go on and on because they're secondary to another situation. So for example, let's say someone's going through a lot of stress in their life, a relationship stress, job stress. That would still be an insomnia symptom though that could go on for a while . And in those situations treating it still has some value typically. But like you said, the condition is really that one that just seems to go on and on and on until it's resolved or treated.

Speaker 2: 2:38

Could you break down these types of insomnia's force ? Are they caused by different things? So what , what do they look like? So

Speaker 3: 2:44

Troubles falling asleep. The , the way we demarcate it from let's say just a , a normal night of sleep is anytime it takes more than a half hour to fall asleep. And if this happens more than three times a week, we now consider that a problematic type of insomnia here. Oftentimes what you see associated with that is some situational stress. Again, we all have stress. Stress is a normal thing, but sometimes that stress is so high that it seems to interfere with our ability to fall asleep. Middle of the night insomnia is a little more complicated. People are waking up. Again, it's a similar time duration for more than 30 minutes. But this can involve again, regular stress too. But there can be other sleep conditions that seem to fuel that, that would always need to be teased out when that occurs. And the early morning insomnia is kind of interesting too, 'cause we'll sometimes see people again with the stress, but also a little depression tied into that as well. So

Speaker 2: 3:32

How does that differ the waking up too early from just the middle of the night one ? Do they have a different pattern to them?

Speaker 3: 3:38

Well, what differentiates them typically is just about the person's ability to get back to sleep because it is normal to wake up during the night. Most people do, but for some reason, some people have a harder time getting back to sleep in the middle of the night, whereas other people have a harder , harder time to get back to sleep if they wake up too early. You know, and , and one of the features of that oftentimes is when someone is aware that it's, let's say, within an hour of their expected wake up time, that seems to put them in a kind of a dynamic where either they give up trying to sleep or they feel a lot of pressure get back to sleep, which then interferes with it.

Speaker 2: 4:08

And listeners, don't worry in just a short bit on this episode, we're gonna talk with Dr. Rosenblum about ways to manage these conditions and what treatments are available. So stay tuned for that. So let's go back to the first kind for just a little bit if we could, I bet there's a medical name for that. When you can't fall asleep.

Speaker 3: 4:25

Well, in , in the name of insomnia has evolved over the years. Back in the day we used to refer to like this chronic insomnia or troubles falling asleep as a primary insomnia. And then if it was caused by some other factor, we'd call it a secondary insomnia. These days, to be honest with you, we really kind of lump it all together because it doesn't seem to affect how we treat it as long as it's a chronic condition. So you

Speaker 2: 4:46

Said 30 minutes. I tell you, if I'm lying there for 30 minutes and can't fall asleep, I'm gonna be pretty anxious. Just on that fact alone, I think last night , uh, my head hit the pillow and I was out in about 30 seconds. So what is considered normal? How long are you supposed to lie there before you fall asleep? Is 30 minutes the time <laugh>.

Speaker 3: 5:04

So anything under 30 cons minutes is considered within normal limits. And that sometimes is something that, that people react with . Similar to what you said, it , it feels too long. And then it triggers some anxiety about the sleep itself, which then feeds into the insomnia. So anything under 30 minutes. And actually when it's a a few minutes, what that suggests to us is you are really sleepy when you go to bed. Most people take at least five to 15 minutes to fall asleep. So kudos to, you're going to bed when you're in a really sleepy stage. Well that's

Speaker 2: 5:32

'cause I was up till 1:00 AM the past four nights for work thing <laugh> . So I think maybe it's my own fault. Which brings up a question. Uh , bring , uh, what to what degree do your own behaviors contribute to this type of insomnia? You know, is it something you could have done something about or is it just a fact of your life that you can't fall asleep? Well,

Speaker 3: 5:51

We can see a variety of behaviors that increase the risk of that. So for example, you have some people burning the midnight oil, like that's

Speaker 2: 5:57

What I've been doing all

Speaker 3: 5:57

Week. Yeah. And you see this a lot for college students, for example, who are are studying for their finals up until, you know, the middle of the morning. Also, sometimes what you'll see is people that don't really have a regular routine and there's something about the aspect of routine that seems to feed into the better chance of falling asleep at night. We see when people have a lot of variety in their routine, they can have a little more difficulties. And then the last trap that I think that people get into are people who are watching TV in bed or on their phones in bed as they try to sleep at night. And what is interesting about that is oftentimes the reason they're initially doing it is they think it's gonna help them sleep. And at some point it probably was, but over time it weakens the association between bed and sleep and actually feeds into the insomnia. So

Speaker 2: 6:38

Me watching a very intense episode of The Bear last night on TV where they're yelling and screaming at each other that maybe didn't help either. It

Speaker 3: 6:45

It may have not helped

Speaker 2: 6:46

<laugh> <laugh> . So there are some things and we , we will delve into that a little bit more. What about the middle of the night business? Maybe I'm wrong in this, but it sounded a little bit more sinister or it sounded just a little bit more like that might represent some other conditions that you have to deal with. Is that, am I missing that or? Well,

Speaker 3: 7:02

Troubles falling asleep is typically insomnia when people wake up in the middle of the night. There can be a variety of other sleep disorders that also lead to that behavior. You see people who have things like restless leg syndrome , uh, sleep apnea to name a few here. So there could be , uh, numerous reasons why people wake up. But if there is also troubles getting back to sleep, that would be more the traditional insomnia. So essentially there could be situations that are multifactorial with the middle of the night insomnia. Yeah.

Speaker 2: 7:27

And I, I treat adults. I'm an internal medicine doctor and so I treat mostly adults and , and even a subset of adults I treat mostly older adults. Is it true or is it not true that, that your sleep shortens or gets different as you get older? Because I can tell you that darn near every adult man over a certain age gets up in the night to go pee. They had , they have to urinate and then usually they get right back to sleep. But is it true that older adults experience insomnia more or if an older adult is not sleeping as well, is that something they should have looked at?

Speaker 3: 7:58

Yeah, it , it is more common and I really liked how you phrased it. Does their sleep change as they age? There used to be this myth out there that people would just need less sleep as they age. So kind of kinda whitewash all these sleep needs or sleep health concerns as people age. But as people age, there are a variety of reasons why they have more sleep issues. You named one for , for males they feel like they have to get up more to go urinate, but there could be other reasons as well too. As people age, the more sedentary, which isn't helpful for sleep , uh, oftentimes they lose the structure. Let's say they had a career and they were go waking up the same time each day, going to bed at the same time each day, wrapping that around their career and sudden that's lost. So there's a variety of reasons and then also we, we do find that people seem to spend less time in their deep restorative sleep as they age as well too. So there's a host of reasons why sleep just becomes more problematic as we age versus the myth that it's people just don't need as much sleep. Is

Speaker 2: 8:49

There a correct number of hours to sleep? I get to ask this all the time.

Speaker 3: 8:52

Yes and no. Like a lot of things, right? So we used to have this number of eight hours that was around and I suspect everybody's certain , well you need eight hours of sleep as an adult. But it wasn't really backed by anything empirical. It was more anecdotal, if anything. And I suspect what was based on the idea as an adult , uh, your sleep cycles last about one and a half to two hours. So some people were going through four sleep cycles and it turned out to be eight hours. When we look at the data for adults, the average adult obtains about 7.3 hours of sleep a night. That's

Speaker 2: 9:21

Pretty specific there, Dr. Rosenberg.

Speaker 3: 9:22

Well that's what I'm saying. It's not , not saying

Speaker 2: 9:24

It's optimal. 7.3 hours is what the average adult gets.

Speaker 3: 9:26

Yeah. Based on our, our , well the data we have now, again, that is always evolving, but um, it doesn't mean that's optimal. That's just what is happening. A big thing that we pay attention to within sleep health is just not how much sleep a person is getting, but how are they feeling in the morning? I'd rather have a patient get six and a half hours of sleep and feel rested in the morning than get 8.00 hours of sleep and feel lousy. Yeah ,

Speaker 2: 9:48

That makes perfect sense. I think I would go for 10 hours if I could <laugh> and I never had that in ages, but I, I think I need more than I'm getting. Do you , is that a over generalization or, or it sounds like maybe people need to get a little bit more than they are in general. Oh

Speaker 3: 10:02

Yeah. I mean there , there is a, a widespread understanding that in today's society, in western society we're not getting enough sleep and we're now looking at it in the same light that we look at, let's say with obesity , uh, smoking cigarettes. In that as people do these things chronically and repeatedly, they oftentimes can pay a , a price in their health or their mental health or even how they function on a day-to-day basis. What

Speaker 2: 10:25

Does the medical science support about the long-term effects of poor sleep?

Speaker 3: 10:30

Well, if we're just gonna simplify it, I talk about insomnia or insufficient sleep. We know there's a greater risk for heart disease, there's a greater risk for diabetes, there's a greater risk for obesity. There's a bidirectional relationship between untreated insomnia and substance use disorders, especially alcohol. Um, there's a bidirectional relationship between depression and insomnia. You mean

Speaker 2: 10:52

It's causative and it's a result?

Speaker 3: 10:54

Yep , it's a loop and as well as generalized anxiety disorder. And then if we take it a step further, it affects us how we function on a day-to-day basis. We find that people have lower work productivity, a greater risk for motor vehicle accidents. So as I was mentioning earlier, it really cuts through a lot of different areas of health in a similar weight as smoking or or obesity. Before

Speaker 2: 11:13

We get into CBTI , which I'm gonna do in just a moment, is the amount of sleep that is required differ by age of life. We've talked about older adults, but then we always hear about teenagers and kids. Just, I don't wanna skim over that. Is it different based on age, how much a person might need? Everyone knows their teenager slept in until noon <laugh> may . Is it maybe not the teenager's fault? Do they need more sleep or is your kid just a slacker,

Speaker 3: 11:37

<laugh>? Well, you know, it's possible to be both. It doesn't have to be one or the other . Your

Speaker 2: 11:41

Kid can be a slacker and it's still necessary, but ,

Speaker 3: 11:43

But we are finding that teens need about nine hours sleep a night. That's what the data is supporting. And in fact, there's been a movement nationally to shift star times in high schools to accommodate that, which I think is a terrific concept because what what was happening before and it still happened a lot of times you're having these sleep deprived teens go to school, they're tired, they're probably more irritable, more down, harder time focusing far from optimal as a learning environment. Yeah .

Speaker 2: 12:08

Cut your teens some slack maybe a little bit. Hey Mark , I got a question once from a listener about napping. And personally I could take a nap anytime , any day I could fall asleep anywhere. And I, and this listener asked , what's the ideal length of time for a nap? So

Speaker 3: 12:24

Like a lot of things it , it's a more complicated answer even though it's a simple question. When we talk about naps, the thing we we wanna be mindful of is the state of sleep we're in. So it takes about 30 to 40 minutes before we get into the deeper sleep in , in most cases. So anytime a nap under that , that 30 minute threshold for most people, they're okay. Where we always wanna be careful is we don't wanna net sleep too much or nap too much where we're using up the deep restorative sleep. 'cause that's the one that can have an impact on the following night. Okay,

Speaker 2: 12:52

So you don't wanna sleep too long because you don't wanna get into the deeper sleep in your neck . Correct. So the ideal length is what

Speaker 3: 12:58

I usually say 20 to 30 minutes.

Speaker 2: 13:00

You talked about the states of sleep , I would call the the napping the state of bliss is what I'd call it. We're gonna take a quick nap. I mean we're gonna take a quick break and when we come back I'm gonna ask Dr. Rosenblum to share some success stories that he's had with his patients and also to share some practical tips that you can use right now if you're having trouble falling asleep or staying asleep. So stick around, we'll be right back

Speaker 4: 13:25

When head up in healthcare says we are here for life. They mean here for you, your life and all that it brings. Hennepin Healthcare has a hospital HCMC and a network of clinics both downtown and across the west metro. They provide all the primary care and specialty care you would expect to find. But did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis? Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 14:03

So we're back talking with Dr. Mark Rosenblum about insomnia. Mark, what might people not know about insomnia who are really worried about it?

Speaker 3: 14:12

Well what we're finding, one of the key features that underlies the perpetuation chronic insomnia is people often develop an anxiety or fear about not sleeping. We all have a bad night of sleep now. And then for the person with the sleep anxiety that we're referring to, that sleep anxiety gets higher or stronger the longer this insomnia goes on. So after two nights the sleeping anxiety is at one level, but by three nights it's even higher and it just keeps building and building. And oftentimes people, while they're aware they're having it, they're not always aware that's the reason or one of the main reasons they're not sleeping.

Speaker 2: 14:46

Let's shift a bit now to the treatments and we're gonna introduce the concept of CBTI , which stands for cognitive behavioral therapy for insomnia. What the heck is that?

Speaker 3: 14:56

So cognitive behavioral therapy for insomnia is really the outcome of the development of a variety of different insomnia , uh, treatments that focus on behavioral or cognitions. And they all were developed in different schools. And so the main techniques that make up cognitive behavioral therapy for insomnia now include something called sleep restriction , uh, stimulus control, cognitive restructuring. And we find each of them on their own empirically show improvements in sleep. And when we pull 'em together, we have an approach that has outcomes that are typically better than even the prescription sleep medications.

Speaker 2: 15:30

The thing that I get asked for almost the most in my primary care practice is can you give me a pill to go to sleep? And listeners, CBTI is a more effective treatment than anything that comes in a pill form. So that was some kind of eggheady terms you used in there, some technical terms <laugh> about, you know, about all the parts of CBTI . Let's break those down. Sure.

Speaker 3: 15:48

So sleep restriction typically involves condensing the window of sleep temporarily and shifting the bedtime later temporarily. And taking advantage of the fact that as we restrict ourselves our sleep, we naturally get sleep. Here it's not essentially rocket science, but it , it seems to be a very effective way to enhance our sleepiness. And what happens then is people start going to bed in a sleepier state and having better success, we can see a pretty quick turnaround in how quickly they're falling asleep and how much they're sleeping through the night. And once a person has better sleep quality and also feels more in control of their sleep, well then gradually and incrementally move that bedtime earlier.

Speaker 2: 16:25

So how long do you have to do that? The sleep restriction?

Speaker 3: 16:29

I will see improvements between session one and two if someone implements sleep restriction along with maybe a few other , uh, sleep really

Speaker 2: 16:35

Right at me In between sessions one and two with you?

Speaker 3: 16:37

Yeah. And and the way I've, over the years, because I've been doing this now for almost 20 years now, towards the tail end of the first week after the first session, you start seeing a trend in improvement. And by the time they come back for the second session, which is usually a week or two later, we're oftentimes already seeing improvements in a person's sleep.

Speaker 2: 16:52

Wow. Wow . That that would be wonderful because you don't see that in anything else. Okay. That's sleep restriction. What's the second component? So

Speaker 3: 17:00

Stimulus control is essentially an adult version of sleep training. So to understand stimulus control, it's best to understand how we learn to sleep when we're infants 'cause we all went through that to some capacity or we, we took care of our own kids. 'cause there's a transition phase where an infant goes from having an irregular and erratic sleep schedule to sleeping through the night with scheduled naps. And it's largely based on different learning theories we have in psychology while steal mis control borrows from these same learning concepts and essentially retrains an adult to sleep , meaning that they're going to bed and they feel drowsy naturally as they go to bed and then they fall asleep in a timely way. So

Speaker 2: 17:37

Just gotta emulate your six month old .

Speaker 3: 17:39

Basically though though we tend to be a little more complicated than the six month old ,

Speaker 2: 17:43

I would imagine

Speaker 3: 17:44

Because of what goes on between our ears, essentially we , we tend to think our way in and out of , in a lot of things in life, including sleep.

Speaker 2: 17:51

So in CBTI , you talk this through with your patients about ways that they can retrain themselves.

Speaker 3: 17:58

Absolutely. And, and then there is a third component that that ties into this stuff really nicely called restructuring our sleep reframing. And we find for the vast majority of people with chronic and repetitive insomnia, they start thinking about the sleep and insomnia while they're awake at night in a way that makes it even harder to sleep. So they start getting increasingly frustrated or panicked or irritated or they become really preoccupied about the next day , gosh, what's work gonna be like? So with cognitive restructuring or essentially teaching people how to think differently about the insomnia while they're in the midst of it, and then I'll add to that is I'll teach 'em about how sleep works and as they start getting, you know, an understanding of how this all comes together, they can have what we call like an aha moment and it , and it kind of can pull this together and you can see that sleep anxiety drop and then they start sleeping better again.

Speaker 2: 18:43

So compare that if you will to medications. So people in our society, it's not their fault. Our society is kind of into medications. That's what I do for a living more than I wish I did. How does sleep medications work and then how does that differ from what you do? Well

Speaker 3: 18:59

And so first I wanna to defend these people because by the time they come to their provider, there is that anxiety or panic about not sleeping. So they're desperate. Mm-hmm . <affirmative> and , and medications is probably what they're more familiar with. But the interesting thing is when we compare the data and we've had uh, numerous times they've done comparisons. There's an organization called the Agency for Healthcare Research and Quality. A federal agency back about seven or eight years ago ran some data and they found the medications work about 60 to 65% of the time

Speaker 2: 19:27

Sleep medicines do . Yeah , yeah .

Speaker 3: 19:28

And in contrast, when we look at the data for CBTI , we're at about 75 to 80%. So one of the points that is helpful I think to convey is that our data is better, but what is also helpful to understand is really what the medications are doing. And that's usually one of two things. They're either creating a drop in a person's anxiety or arousal or they're creating more sedation. And these are two things we can do without medications. I can make my patients more sleepy by just having them go to bed later temporarily. Mm-Hmm, <affirmative> . Okay . I can make them more relaxed by doing the cognitive reframing or sometimes we'll also integrate some relaxation techniques. So the CBTI can actually target the same things though though it does take a little more work, but overall it tends to be more effective and healthier.

Speaker 2: 20:10

That's really interesting to me. You said you can make people more, you know, you so you can address the sleepiness issue that the medications kind of claim to do. And the most popular sleep aid medicines that you can buy at your local drugstore are antihistamines. You know, they're just, we're using 'em for some side effect and they, they might make you more sleepy or they reduce your, they sedate you kind of, or they make you less anxious. You can do all those things without a medication and have better success than any of those pills. And the data supports that.

Speaker 3: 20:38

Yeah . And the data supports that. And also, you know, medications have a different target than cognitive behavioral therapy for insomnia. The target for a sleep aid be at the antihistamine or the prescription sleep aid is to address a single night of sleep. Mm-Hmm . Okay . So if someone has maybe acute insomnia or just a single night, perhaps that's a good fit. But when it's a chronic problem, people are now using a one night at a time approach for a chronic problem. And as such, people are taking these sleep aids indefinitely for years. But

Speaker 2: 21:05

These also have lots of side effects too. Uh, there's all kinds of side effects too. Uh, even the over the counter ones, folks, you could , there are side effects to over the counter sleep aids. Older adults can have troubles with their bowels, they can have troubles with B and dehydrated all from these sleep aids. And the prescription ones also have quite a few side effects. Some of them are legendary that you might have read about. We're not gonna get into that in much more detail, but is there a downside to the CBTI that you're talking about? I mean, what would the side effect be? Is there a downside?

Speaker 3: 21:35

Well, there are what we call contraindications and what a contraindication means is this somewhat has some other health issue that maybe some aspect of CBTI should not be done. So sleep restriction, which is one of the tools we don't typically recommend it for some of the they history of bipolar disorder , um, seizures or we call parasomnias. Um , in all those situations, if we do something that amplifies sleepiness, be it through sleep restriction or a medication, you can increase those symptoms or those health risks. What's

Speaker 2: 22:04

A parasomnia?

Speaker 3: 22:05

That's a terrific question. So that's

Speaker 2: 22:07

A whole nother episode, isn't it? That's

Speaker 3: 22:08

A whole nother episode. But so our body is supposed to do certain things while we're awake and do certain things while we're asleep. And in a parasomnia these signals get crisscrossed. Probably the most common example that people are familiar with is someone who sleepwalk, we're not supposed to walk while we're sleeping. We're our muscles are supposed to be flacid and we're not supposed to be moving. But there's a variety of other conditions too where our body kind of gets the signals get crisscrossed and we find when someone does anything that amplifies sleepiness, like sleep restriction or the sleep medications, you can get either an occurrence of it or a more frequency if it's already existing. And, and for people that sometimes heard of some of these sleep medications, some of these stories that you're talking about, oftentimes that's what's happening is they're amplifying their, how sleepy they are and then you're triggering these parasomnias and so they're out walking in their sleep or driving their car or what have you. Little

Speaker 2: 22:52

Practical things about CBTI before I ask you to give some tips for what people can do right now, but when you do engage in CBTI , what can you expect? You talked about sessions. Is this an ongoing thing? Does it go forever? How many sessions is it? How do they access it? Things like that.

Speaker 3: 23:07

So even though most of the time it's administered by a psychologist, it it , it's gonna have a much different feeling or structure to it in comparison to traditional therapy, which can go on for months, even years. CBTI is a brief treatment. Um, it usually takes somewhere between three to six sessions and when you get in with a sleep psychologist, you're not gonna be delving into , uh, your deep history typically. Usually it's as a behavioral treatment, people are assigned recommendations or homework. Uh , oftentimes they'll track their sleep using a sleep blog and when they come back we review it and keep modifying it so it moves pretty quickly. And, and like I said, usually takes between three to six sessions. The , the target for CBTI and we don't always reach the threshold is actually to cure the insomnia to resolve it. And so, you know, I tell people what if I , when I try to like kind of simplify it, I simplify it as basically we're retraining you to sleep. So just like it can take a little time with a treating an infant and it's <laugh> , it's sometimes a little frustrating. It doesn't always happen right away, but it has a lot of the same goals. We're trying to retrain someone to sleep and as such we could , we can actually get to the point they don't need further treatment

Speaker 2: 24:13

And you can access that through your healthcare system if you happen to be in Minneapolis. I encourage nobody more than the sleep psychologist at Hennepin Healthcare right here in downtown Minneapolis. Okay. Practical tips. If someone's having sleep problems right now, they're not yet engaged in CBTI . What, what tips could you give people who are listening if they're having some trouble falling asleep, what behavioral things could they do?

Speaker 3: 24:36

Well, I find it's helpful to, to think about this in the same way you think about how you'd want your own kids to sleep if you have kids. So for example, with our kids, we want them to go to bed and wake up at the same time each day. Well , we wanna do the same thing for ourselves because our sleep operates a lot like our need for food. And just like if we ate meals at all different times of the day, our appetite would be irregular. If we sleep at all different times, it's gonna create a , an irregularity of when we're sleepy. The second thing is to limit to what we do in bed to sleep and intimacy. If we think back again how sleep training works for an infant, we wouldn't give our infant all these different things to do in their bath , in our crib in an effort to intimate sleep or we actually discourage that . So you really wanna be only in bed for sleep and intimacy at night. And, and the third one, and this is more of I think a, a modern manifestation is really get off the internet in that hour or so before bedtime. And, and this ends up not just affecting insomnia, but we're seeing now people staying on their phones for hours and hours, which at that point they're not getting enough sleep. Not because they can sleep, but they're just not using their opportunity to sleep.

Speaker 2: 25:39

Those are great tips and I, I don't think I do any of 'em. Mark , I think I have something to work to do on there. You know, regular schedule , um, uh, the bed for sleep and intimacy only and less screen time right before bed. Those are fantastic tips. What about alcohol and exercise right before bed? Those are two things I get asked a lot. You shouldn't drink right before bed, you shouldn't exercise right before bed. True. Or is that a myth? So

Speaker 3: 26:01

Let me get into the weeds a little if I may. You may. Um , <laugh> . So for alcohol, yeah, we don't wanna drink alcohol close to bedtime, which ironically at one point, and this is maybe 15 years ago or so, it was one of the most common ways people on their own try to rectify their insomnia. And while at times it can help fall asleep a little bit with a small amount, alcohol is a depressant. So what happens is it messes with our respiratory systems of sleep and we tend to have a lower quality of sleep, more awakenings and feel less rested in the morning. So usually the benchmark we say is we encourage no alcohol within two hours of bedtime. Exercise is interesting because back in the day, old sleep hygiene discouraged any exercise in the evening. And this was largely based on the idea that when we exercise our body's physiology changes in a way that makes it less likely to sleep. But where we've evolved in that over time is a little bit, first of all, it doesn't take our body a full evening to cool down . For most people it takes a couple hours. Second exercise, especially cardio is in a very effective tool to deal with stress. So we're now actually encouraging some of our patients, if they have a lot of day-to-day stress is to do some modern intense cardio two to three hours for bedtime. That's a great bit of , uh, advice to give. Thank you for all of that. Before I let you go, mark , what final thoughts would you leave with our listeners? Well , what I'd really suggest for people is to think of their sleep health in the same light that they think of weight loss and smoking. In that if you take care of your sleep health proactively ahead of time, that will help you across the board in so many areas of your health. So what I'd really encourage people is not wait to the point that you need to see a sleep specialist, but see what you can do now to really make sure that you get the quality and quantity of sleep you need to maintain good sleep health. I feel so fortunate to get to work with colleagues across medical specialties. Mark , thank you so much. This has been an incredibly helpful show. Thanks for being with us and thank you for having me. Well, that's a wrap on season three of the podcast and I can't stress enough how thankful I am for all of you who are listening and supporters of the podcast, three seasons in the books. Thank you for downloading. Thank you for listening. Thank you for telling your friends about the Healthy Matters podcast and don't lose any sleep. We'll be back for season four in the next two weeks with a new episode. So please join us for that. Thank you for listening and in the meantime, be healthy and be well.

Speaker 1: 28:23

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden. To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show , email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan , CTO and Christine Hill . Please remember, we can only give general medical advice during this program and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.