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By: Brandon R. Peters, MD on August 12th, 2020

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Using CBTI Techniques to Ease Insomnia During Sleep Testing

There are few things as frustrating in the sleep lab as a patient who can’t — or won’t — sleep. Barring the use of a sleeping pill, how can this situation be avoided? Consider the role of cognitive behavioral therapy for insomnia (CBTI) techniques and how these may ease insomnia during an overnight sleep study.

Preparations to Make Before Arrival

In some cases, it is what happens before the patient arrives at the sleep laboratory that determines how easily he or she may be able to sleep. Education by the referring provider, or a set of clear instructions sent out ahead of time, may be helpful. There are a few considerations that should be prioritized.

The ability to fall asleep is highly dependent on two factors: the homeostatic sleep drive and the circadian alerting signal. The sleep drive can be enhanced by observing an earlier wake time, avoiding daytime naps and going to bed feeling sleepy.

The circadian alerting signal may dictate when a patient should schedule a sleep study. Accommodations should be made for people who have delayed sleep phase syndrome, or for shift workers, so that the timing of the test corresponds to their typical sleep patterns. In many cases, this will require daytime staffing and efforts to preserve a quiet and dark sleep environment.

Caffeine consumption should be discouraged the day of the testing. Alcohol use should reflect typical usage patterns, and moderation may be encouraged. Normal activity levels, including exercise, should be maintained.


Establishing a Sleep Sanctuary

Upon arriving to the sleep lab, the patient should be made comfortable. Reasonable requests for accommodation should be met. The bedroom should be kept cool and quiet, with the lights appropriately dimmed.

Ideally, the same optimal sleep hygiene habits promoted at home should be recommended in the sleep lab. The bedroom space should be a sleep sanctuary. Unfortunately, televisions may be present to pass time before the sleep study commences. These should definitely be turned off during the study, and may be best powered down in the hour preceding the anticipated bedtime.

The last hour of the day should be a time of transition to sleep. Work and electronics should be put aside. The time may be spent reading, listening to relaxing music or following a bedtime ritual to prepare for sleep. This will help to ease the transition when the lights are turned out, even in a sleep lab.


Using Relaxation Techniques

All patients should be encouraged to go to bed feeling sleepy or drowsy. This is different than feeling tired or fatigued. Ask: “Are you feeling sleepy and ready to fall asleep?” If the routine bedtime rolls around, but sleepiness is not felt, the study onset should be delayed. This will make it easier for the patient to fall asleep when finally getting settled into bed.

Once the lights are turned out, it is normal for the mind to seek out a focus. With wires in place, in a strange bed and environment, with the pressure of performance anxiety, sleep may not come naturally. If anxiety creeps in, the associated activation may make it even harder to fall asleep. To prevent this chain of events, distraction may be a helpful tool.

Not everyone will need help falling asleep. Many patients have excessive daytime sleepiness as a consequence of sleep apnea. These folks will fall asleep quickly, and any awakenings will be short-lived. Unfortunately, sleep apnea also contributes to chronic insomnia, especially in women and older patients, and this can be a problematic combination.

It is possible to use a few simple relaxation techniques for those who need a little extra help. Consider these options:

  1. Breathing. Focus the mind on a slow, regular pattern of breathing. With eyes closed, breathe in and out through the nose. Feel the cool air drawn in through the tip of the nose. Pay attention to the temperature difference, breathing in and out. Also pay attention to the movement of the air, one side of the nose versus the other. Then shift the mind’s attention to the upper part of the nose, the back of the throat, and the lungs themselves, paying attention to both temperature differences (if apparent) and the air movement.
  2. Progressive muscle relaxation. Tighten and relax the muscles of the body sequentially, starting at the feet and working up to the face (including the toes, hands, biceps, shoulders, and face). Try to follow a 5-3-1 second pattern, tightening for the time specified and then fully relaxing before tightening for the next time suggested in the sequence.
  3. Guided imagery. Recreate a relaxing experience, perhaps a favorite vacation, a trip to the beach, or a hike through the woods. Use the five senses to recall what was felt in that experience. What was seen, smelled, heard or felt? Recall the sense of relaxation and peace.
  4. Creative recall. Try to recall a recent dream, recreating the memory and creatively filling in forgotten details. If dreams are not easily recalled, consider recreating the story of a favorite movie or book, remembering the plot, scenes and dialogue chronologically in as much detail as possible.

Importantly, the key to any of these techniques is distraction. It does not matter what is attempted, as long as it shifts the focus from trying to fall asleep. With relaxation, sleep will more quickly come.

If a patient is feeling particularly agitated, tossing and turning for more than 15 to 20 minutes, it may be important to have him or her get up from bed. Offer some reassurance. Most patients are able to get enough sleep to make the study worthwhile. If a little time is spent reading out of bed, building the desire for sleep, this will make the experience more successful. In some cases, especially with early morning awakenings after enough study data has been collected, it may be best to just end the study early.

Fortunately, with a few simple interventions, it is possible to ease the frustration of insomnia during sleep studies, for both patients and techs alike.

Article originally published in the A2Zzz Magazine  Quarter 1, 2019

Brandon R. Peters-Mathews, MD, is a double board-certified neurologist and sleep medicine physician who practices at Virginia Mason Medical Center in Seattle. He completed his sleep fellowship at Stanford University, where he also serves as an adjunct lecturer. He is the author of “Insomnia Solved,” available now via Amazon, and in the past decade has written more than 1,000 articles on sleep for Verywell.com.