- The Sound Sleeper | Webinar
Devices in the dark: helpful or hindrance?
Our electronic devices are always with us — even in the bedroom. While using certain devices at bedtime can make it difficult to sleep, some may be useful for sleep tracking. Our chief medical officer, Dr. Jeffrey Durmer, demystifies devices in this free webinar.
Dr. Durmer: Thank you, Jessica. And thank you all for joining us this morning for another in our series of webinars. Today’s webinar, as Jessica mentioned, is about wearables. Something that is a little ubiquitous to all of us. The first thing I want to do before we jump into the wearable discussion is really focus on the sleep aspects of this discussion. Because a lot of us use wearables to tell us about our sleep, and also to give us some input in terms of how we function during the day and if we’re prepared for the day.
So I want to start off with just the fundamentals of what healthy sleep means to you. And I want to break it down into three elements. And if you’ve been part of the SleepCharge program, you probably have heard about the duration, timing and quality of sleep, or what we call the DTQ™. This is the fundamental neuroscience behind sleep, how we teach our residents, fellows in medicine, about sleep and how we do research in the different realms of sleep and circadian neurobiology.
The first one is sleep duration, which seems pretty straightforward, right? It’s the number of hours of sleep you get in a single day. It’s an area that has a lot of research around it, it tends to be the area that we know most about. And we even talk about it ourselves with our friends and family. And there are lots of recommendations from many organizations like the National Institutes of Health, the Centers for Disease Control and Prevention, about our total number of hours that are recommended on a day-to-day basis.
The second one is sleep timing. And this is looking at when you sleep across the 24 hour period or cycle of our day. And the natural rhythms you have related to when you sleep and when you wake are yours, they’re intrinsic to your brain and your body. And how you match those up to the day-to-day activities like going to work or sleeping at night or taking care of family or loved ones. That’s about the rhythm connection or the synchronization between you and that rhythm of the world. That’s a second component of sleep, and often not remembered by most people.
The last one is sleep quality and sleep quality is not necessarily something that we have our fingers on the pulse of on a day-to-day basis as just regular folks because sleep quality is something about the natural progression between sleep stages as you go to bed and wake in the morning. In that period of time, we go through a natural process of sleep cycles. And those sleep cycles are what cause us to feel refreshed in the morning and also prepared to go into the next day. So quality is often the black box of sleep that we, often in sleep medicine as physicians, help people with and do things like sleep testing or polysomnography.
So we’re going to continue the discussion today around DTQ but also integrate into this discussion our use of technology. What we know about the use of technology in the United States is that we’re in a 24/7 culture, and around 90 percent of Americans use technology within the first hour before they go to sleep. And this includes kids, by the way. Sixty percent of Americans watch television within that hour before asleep. Seventy-two percent of adolescents — high school kids — use their smartphones within that hour.
It’s actually an issue that we haven’t really had to talk too much about, up until the last 20 years or so. Because we’ve found from a lot of research that the more interactive the device is, like a television program that’s really interactive — I don’t know if anybody’s watching Squid Games. That’s a very interactive, and it’s kind of a little bit traumatic television show, but it interacts with you and it gets you excited. Those kinds of interactions are what creates the impact on falling asleep and getting refreshing sleep. You may remember, you know your mother saying don’t watch a scary movie before you go to bed because you’ll wake up or you’ll have nightmares. Well, it turns out it’s not just about nightmares, it’s about actually getting your sleep started and keeping your sleep going in that natural progression during the night.
And these are a couple of reasons why. Because technology itself arouses parts of the brain that makes it difficult to fall asleep and stay asleep. Because light itself, just the light, but not just the light, also the novelty of what you’re watching activates parts of your hypothalamus that are associated with wakefulness, not only does it activate wakefulness, but it also shuts off areas of the brain that are responsible for starting sleep. So if you’re sitting there watching television or something that’s very exciting, very important, like doing work at night for your job. That’s something that will deactivate your sleep centers. And that’s what leads to the reduction in duration and quality of sleep. And also can delay the timing of your sleep as well. So it really affects all three, your duration, timing and quality.
Now, we’ve got a lot of data, over the last 20, 30 years, of significant technology use in the home. Thanks to things like the home computer and all the other bright lights that we put in our environment. We do have people wearing these wearables all across the United States. And this is a study that actually was conducted by Jawbone in their UP band, which is still available out there. And looking at how and when people go to sleep. And this is a time zone study. And you can see the time zone lines, the one between the East Coast and the Midwest, you can see that bright red line, people to the east of that bright red line at the end of the Eastern Time Zone, go to bed much, much later. And if you look at people just on the other side, at the beginning of the Central Time Zone, go to bed much, much earlier, probably about the same time as the folks on the other side, but because of the time change difference at that line, it’s a much earlier bedtime, and you see that across the Midwest, going to the Mountain Time Zone into the western or Pacific Time Zone, too. That’s one thing that was detected by this, but the other thing that was detected was cities, themselves, where you see places like New York, Washington, Denver, Minneapolis, Los Angeles, all across the map, those areas have the latest bedtimes and that’s not just because they may be on a timeline, which not all of them are, it’s because there’s so much light in the environment of those cities, creating a later bedtime. So these are things that we’ve seen with technologies but also light.
Another thing that’s amplified our problem, as a group with technology, has been COVID-19. And the pandemic causing a lot of quarantining, working and living from home but also changing our behaviors. And one thing I want to point to on the right hand side here in this picture, is that if you are looking at people whose sleep was disrupted, percentage-wise disruption versus improved during the pandemic.
And this is a large study actually looking at athletes across the United States. What they found is that screen time before bed, electronic screen time and indoor light, were all significant predictors of disruption of sleep. And that makes all the sense in the world given what we were just talking about biologically. One thing, though, that was kind of interesting is that outdoor daylight predicted improved sleep. So I’ll talk a little bit more about that because that’s an important component of modulating your normal circadian rhythm so your timing is correct, which helps you fall asleep at the right time and stay asleep.
The one thing that’s also been associated with this change and this disruption in sleep is that a lot of folks have had incredible amounts of anxiety, depression and stress. And it’s directly related to the populations that have had the screen time, the electronic indoor lighting. And that’s a really great signal for us to understand that these changes that happened during COVID-19 and the stress we all sort of felt, but also the anxiety and depression that came about, is directly tied to some of the behavioral changes that we have control of, like using light and maintaining our bedtimes.
So, it is notable, of course, that technology itself and light itself are not bad things. And I mentioned earlier that light in the daytime is a good thing. The one thing that I can tell you about technology before bed is that anything really that you put into your environment where you sleep that causes activation, that causes you to look at things like your phone, that’s a problem.
But wearables because they’re there on your body, you’re not actually always looking at them, they’re kind of in the background, that they actually can provide you with some interesting physiologic metrics. In all wearables, there’s something called actigraphy, which is the ability to determine movement, even force of movement, in three dimensions. And that’s often used with algorithms to detect your sleep and wake times, not specifically sleep and wake, but your movement times associated with that. Certainly, you can fool the watch by lying still.
And, also, some people who move at night may also fool the watch into thinking that they’re awake. But there are other metrics that have been brought into watches and rings and bedside units that give us physiologic metrics of your heart rate, heart rate variability, your respiratory system, your breathing rate, your blood pressure, as well as even the rhythms of your heart that may be associated with things like A-Fib. And these watches and rings and sensors are really useful in some ways, because they have the ability to be there with you for days and weeks and months. And we can get a lot of information about how things have changed over time.
They are all consumer devices at this point. And at this point, also, they really can give us some metrics around when we fall asleep, when we wake up. But they’re really limited in their ability to detect things like sleep quality. Remember, I talked a little bit about REM and non-REM. The good thing is that a lot of people are using these wearables. So we’re getting a lot of data. Twenty-one percent of Americans currently use wearables on a regular basis. And this is how we got there.
Lots of data has been collected since around 2010 when the first wearables hit the marketplace, with the Fitbit Ultra as the first one really. Before that there were wearables for sure, but they were not commercialized as they are now. So it really started at the beginning of 2010. And all through the teens, the 20 teens, we saw the introduction of a number of different watches, including smartwatches. One of the first was the Jawbone UP, which I mentioned and showed you the data and millions of users were using UP. There’s been Google Glasses presented to us in the midst of the 2012-13 year, the Nike FuelBand, Fitbit Flex, all the different devices all the way up to even the Apple Watch most recently, which has the ability to detect arrhythmias, and a number of other devices that have been developed that are not even on your wrist, but that are on your fingers. And those are so much newer that they didn’t even make this list.
But you can see that this has become a ubiquitous concept, that we should be able to measure our sleep and wake and our behaviors and daytime function with any of these different devices. The one thing, though, that’s really important to know is that there are some pros and cons to wearables. The pros are that, yeah, they give us a decent awareness about our sleep duration and timing, which we talked about. Those two are the main focus of sleep and understanding your sleep. And they may be able to help you monitor your behavior so you can actually change your behaviors. You start seeing you’ve been going to bed later. The devices themselves may prompt you to go to bed earlier. And you may see that that’s an issue for you. So it helps you to monitor your behaviors.
It also can connect those behaviors to the outcomes of your sleep. If you start feeling that you’re more rested, you could look into what behaviors you did. Did you meditate the night before? Did you reduce the lighting? Did you avoid alcohol and a heavy meal? What helped you to result in feeling rested? And that’s really what they’re good at. They can show the impact of your behavior changes, too, and provide you positive reinforcement. Some of these devices even give you readiness scores to tell you how ready you are the next day, given the sleep you got in the evening prior. That’s something that can be a pro.
On the other side, it doesn’t measure sleep stages. Whatever they tell you from the algorithm, light sleep, deep sleep, REM versus non-REM, it’s not really measuring that. It’s measuring a downstream change that happens in your physiology, often heart rate or some of them look at oxygenation, some of them look at movement, and combine those in an algorithm — that’s really secondary, those are not primary measures of sleep when we do a sleep test. So it can’t give you really the fine detail of sleep quality that is necessary to understand at this point.
And it’s also an unreliable metric for people with a sleep disorder. So at this point, we’ve seen studies where folks with sleep apnea or restless legs syndrome or insomnia will have a wearable. And it’s not as accurate in detecting their sleep and wake times. And that’s largely because untreated sleep disorders are so disruptive to sleep and also change your wake behaviors, make you sleepy, that you start to see discontinuities in your sleep patterns that the devices can’t pick up. And so you get inaccurate results.
The other thing that we’ve seen recently, especially during COVID, is that some folks that wear these devices on a night-to-night basis get a little competitive with themselves, and can actually get into this preoccupation of getting their sleep wearable data to look better. And it can even lead to something we call orthosomnia — it’s using a device regularly to see if you can get a better result and focusing on your data too much. And that causes people to not sleep well. So definitely not everything is positive.
So, again, back to the DTQ concept in this wearable discussion, the duration of your sleep. Only a few of the devices on the marketplace are readily able to demonstrate sleep and wake times that approximate what we see in a polysomnogram, which is the gold standard for sleep and wake testing. There are devices that are better at this than others that have different algorithms. Again, the problem with these consumer devices is that the algorithms change, the firmware gets updated, and all of a sudden the metrics change. So we can’t rely on them medically at this point, or clinically, but they can help us a little bit if you have one that’s more accurate in terms of sleep and wake detection. Timing, again, is another benefit to using a wearable because you can see when wake and sleep occur on a general pattern across time.
One study actually showed that after 175 days of use, half of the people using trackers themselves — rings, watches, bed devices — stop using them. At 320 days, only about 16 percent in this study actually continued using their device. And this may be due to the fact that these devices give you information, but they don’t give you something oftentimes that you can do about it or make things better. So that’s part of the issue that’s a plus-minus with wearables. And I think there are some that are getting better at this that are able to integrate back to you some recommendations to improve your sleep. Quality of sleep is really not, as I mentioned, measurable with our current wearables that are on the market.
You might see that your patterns of sleep change. And if you see dramatic changes in the patterns from your wearable, like all of a sudden you’re having no REM sleep, or there’s a lot of wakefulness in your sleep time. That’s a chance for you to maybe say, hey, this isn’t right, I’m getting these really bad scores, but my duration and timing seem to be on, perhaps there’s a quality issue that you can then talk to a professional, talk to a sleep medicine physician about, and then they may test you with polysomnography.
So these are useful concepts of using wearables, but only for specific aspects of your sleep. Now, no wearable in the world will help you make the changes necessarily that you need to make that are specific to you. They’re very general in their ability to detect these physiologic metrics. But they can’t really just tell you about your environment, which actually oftentimes has significant impact on your day-to-day sleep and wake function. So here are some recommendations that I have for you — we’re going to go through a couple of slides of recommendations — that will go along with the use of wearables that can help you to benefit from them.
One is to remove light and light-emitting devices from your bedroom. As I mentioned earlier, the physiologic impact of light in your brain and novelty in your brain is to arouse the wake centers and to shut off the sleep centers. That’s true of light itself. And what we know is that also using lower light emitting devices, like using a dimmer switch in your bathroom for instance at night, is very helpful because it reduces the amount of light that you’re getting in the midst of the night if you happen to get up to go to the bathroom. Also, natural levels of light, things that come from fire, you’ll get a candle or a fireplace, they’re orangey, reddish color yellow light that is less alerting to the body and brain than bright white light, or what we call blue-green light.
Another thing you can do is to make sure that you’re wearing your glasses at night if you’re reading or you’re doing some work. If you have problems with your vision, get it corrected, get your cataracts taken care of, because the better your vision, the less light you need to actually see.
And then, additionally, there are simple things that we all can do like putting room darkening shades in your bedroom, to reduce the impact of light that is incidental and that happens in most cases, unless you live out in Montana on a farm, or ranch I guess you’d call it in Montana.
The other thing, and this is actually echoed by that study I mentioned, that during COVID, getting light into your day is something that can really help to improve the sleep-wake cycle. So if you think about it, like a roller coaster, as the roller coaster climbs up during the day to a high height, the higher it goes, the faster and lower it can go. And that’s where sleep happens. So if you can really activate, like, make a really steep activation of light in the daytime, the roller coaster of sleep and wake, you’ll get a decently dark, downwards sleep period that’ll be very deep. So you’ll have brighter wakefulness and you’ll have deeper sleep.
There are things you can do to help that. One is to avoid using sunglasses in the morning. Now, I’m not talking about people driving into the sun not using sunglasses. But if you can just use that as a general rule of thumb because often we get in the car and throw our glasses on. It’s often something that you can do easily to increase the amount of light you’re getting, especially in the morning. And that’s important — sunlight in the morning is what starts your day and activates your circadian rhythm and starts that sleep-wake cycle. So take outdoor breaks during your work day, get some more light, get out of the cave that we call our offices.
And then at night, what can you do? Well, one thing I like to talk to people about is the concept of a bedroom. As you notice, I don’t use the word “bedroom,” I use the term “sleep sanctuary.” And that’s because if you think about where you’re going to go at night to lay down and sleep, it’s really not just a room with a bed, it’s an area that is sort of your area to sleep and get away from everything so that you don’t have interactions with the day, you don’t have interruptions.
And part of your sleep sanctuary is to make it cool, and smart house thermostats are one way to do that. Cooling pads and having airflow is another way to do that. Because we know from research that sleep is helped, it’s induced, by cool. And it’s also maintained when your body temperature is in a cooler state.
Also, using background sounds, that’s another thing to quiet the environment like a ceiling fan or a natural wind-water-wave device. These are things that help us to stay in our natural sleep cycles during the night and cancel out some of those interruptions that might occur especially in urban settings where we saw a lot of people going to bed so late in the Jawbone study.
Another thing to do is add things to your sleep period. Before you go to bed, do a guided relaxation or a meditation. And we have these in our Sleep Life Learning Center™ within SleepCharge. And there are a number of ways to use different programs that are out there, the different apps, whatever seems to work for you is the one thing that you should do, but use it on a regular basis so you know what it does to your physiology and helps you to relax that sympathetic nervous system that seems to be ready to go at all times.
The other thing is your bedroom itself — physically remove things like televisions, computers, smartphones. Move them to another room in your house, get them out at least at night, get them out of the room. I’ve talked to a number of younger adults who have small apartments or studios. They live in their kitchens basically. But, you know, you can actually turn off a lot of things and create that darkness in that sleep sanctuary just about anywhere.
Another thing to do is improve your bedding. A lot of us don’t even think about it. We just kind of plop on the bed that’s been there for how long and it’s like eight years later, and the bed feels lumpy and uncomfortable, but yeah, it’s just a bed, no big deal. If you think about how often you use your bed, it’s a lot more than your shoes. It’s a lot more than anything else that you spend money on. And it is one of the things that could improve your life in general. So think about your bedding.
Also make your space clear and peaceful, try to not make it about entertainment. People put TVs in their bedrooms all the time thinking about that as an entertainment focus. And it’s really important to separate your sleep sanctuary from the daytime activities, and try to make it a peaceful sanctuary.
So here are the 10 — I’ve used this slide in a number of different venues. But these are just 10 things you can do to maximize your ability to sleep and some I’ve already kind of mentioned, but just wanted to put them in one slide for you.
The first is to follow a regular routine. Have a morning routine, like we all usually do. You know, get up in the morning, take a shower, brush your teeth, whatever you do, have a cup of coffee. That’s your morning routine. You need one in the evening, and we call it the “downshift” here at SleepCharge. So the downshift of the day-to-night transition is a good half hour to up to an hour of time. That’s really about you preparing for sleep, because sleep has that much of an impact on your day-to-day function. It’s thinking about, it’s not the end of your day, it’s the beginning of tomorrow. So if you think of it like that, prepare for it, you want to keep it consistent. So you go to bed about the same time, you wake up about the same time.
There’s something called social jetlag where folks go to bed later on the weekends and wake up much later on the weekends. If you think about that, that’s kind of like traveling across time zones. Not a very effective way to spend your weekend, especially when you have work coming up.
Get seven to nine hours of sleep. That’s your general recommendation from the CDC and the NIH in terms of hours of sleep for average adults in the United States.
Exercise daily because, like getting light in the day, exercise itself also helps to activate that roller coaster of wakefulness so that you can go to sleep in a deeper state later.
Set time aside in the early evening to reflect on your day. And this is actually something that goes into the downshift concept. If you can take your pen and paper or you can use your electronic notes and create a list of the things that you’re interested in doing tomorrow or that are important that are on your mind, you can take them out of your mind, put them on paper, put them in your note app and allow that to live there. That way you don’t have to take it to bed with you. And even at night, if that happens, you wake up and you can’t stay asleep, you’re thinking about something, go and do that, write it out, put it down on paper, get it out of your brain and allow it to be there ready for you the next day when you’re ready to go.
Number six is avoid alcohol and caffeine. Now, these are sort of ubiquitous in our society. But both of them have direct activity within the brain. So alcohol activates GABA receptors, which may help you feel sleepy and a little giddy first. That activation of GABA receptors has a significant impact on the cycles of your sleep. And it can actually cause you to fall asleep quicker in some cases, but then wake up multiple times because it’s also a potent rapid eye movement or REM sleep inhibitor. And if you inhibit your REM sleep, it’ll pop back later and wake you up constantly, and you’ll end up going to the bathroom and all kinds of activity that you don’t want to have. So avoid alcohol if you can in the two to three hours before bed.
The other is caffeine. Now this is even more ubiquitous. This is something that has become ritualistic with all of us, across the United States, and many places around the world as a stimulant. And it’s not just a stimulant, it actually works in the brain to directly inhibit the signals, adenosine signals, of sleep. And that has a long-acting effect, it can actually continuously impact our sleep activation system for up to eight hours in some cases. So think about caffeine as something in the morning. Yeah, that’s great, it kind of knocks out the hangover of adenosine that didn’t get reabsorbed overnight, and makes you feel a little bit more ready to go. But later in the day, if you start to feel that low in the middle of the day, which is normal, get some sunlight, because sun, the light itself, is going to activate wakefulness much more effectively than caffeine, which is really not activating wakefulness, it’s shutting down sleep, and it could impact you later when you want to go to sleep.
Number seven is avoid heavy, complex food close to bed. This is something I think we’ve all probably experienced one time or another, maybe even Thanksgiving. You feel sleepy. Yeah, it can make you feel a little sleepy to have a big meal, but it will wake your physiology up. If you look at the number of neurons in your gut, it’s equal to your cerebellum. So it’s a very large nervous system, the second largest in your body. You don’t want to activate that at night, especially with a spicy or hot food, where heavy foods will activate that more so.
Take time to relax and wind down before bed. We talked about that earlier with the wind-down.
Number nine, create that dark, cool, sleepy environment that’s quiet, as we mentioned. And then avoid those electronic screens in the bedroom. That’s when you take your iPhone or your iPad or your Android and you just basically put it on silent like you’re traveling on an airplane and flip it over with the alarm set for the next day. That’s all you really need.
If you want to learn more about how to get specific advice about your sleep in particular, or learn more about wearables for yourself, you definitely should go to our checkup, the Sleep Checkup™ at SleepCharge, where we can give you a personalized sleep assessment. And then if you have issues, we can get you in touch with a sleep physician directly through our app. And we can provide you with all the therapies and testing, anything that’s necessary to get your sleep to where it needs to be. And learn more about your own DTQ by taking the Sleep Checkup, and also sign up for our Sound Sleeper, which is our regular newsletter that comes out electronically. And you can sign up for that at sleepcharge.com/sound-sleeper.
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