To sleep…perchance to dream

            Insomnia, dissatisfaction with sleep quality or duration, is a common problem. Some 10% of Americans have chronic insomnia and another 15-20% have occasional insomnia.

            While scientists do not fully understand why we (and virtually all living animals) need to sleep, lack of sleep contributes to many problems, including interpersonal, school and work functioning, depression and hypertension.

            There are specific medical problems that may underlie insomnia. Restless legs and obstructive sleep apnea lead this list and will respond to specific therapies. Your bed partner is more likely to pick up on these than are you, and a session in the sleep lab will usually confirm the diagnosis.

            Shift workers are particularly at risk for insomnia and the problem may not go away until you get a regular work schedule.

            Most have insomnia as its own problem. Insomnia may have started at the time of a life stress or due to jet lag and then persists.

            What can you do? There are many ‘common sense’ hints that may be all you need. Try to go to bed and get up at the same time every day, including weekends. Be sure your bedroom is dark and cool. Exercise early in the day, not in the evening. Do not work right up until bedtime; allow yourself time to decompress by relaxing reading or music. Do not eat within 2 hours of bedtime.

            If these do not work, what next?

            Sleeping pills, whether over-the-counter or prescription, are fine for short-term use but are not that effective when used chronically, and the more effective prescription drugs can have side effects.

            Older individuals are at particular risk of falls, morning confusion and even dementia with chronic use of benzodiazepines (Valium, Ativan etc.). The so-called “Z drugs,” (Zolpidem, zaleplon and eszopiclone) have black-box warnings because of sleepwalking and other potentially risky sleep behaviors.

            Sedating antihistamines like Benadryl have limited efficacy and cause dry mouth and daytime sedation. They are also potentially causes of dementia if used chronically.

            Most experts strongly recommend cognitive behavioral therapy (CBTI) before medication. The success rate is high and there are no side effects. The problem is the lack of trained therapists and the cost.

            An alternative is a web-based or phone app. These have been found to be almost as effective as in-person coaching. Two web-based programs that have good studies behind them are no longer available. I was able to download Shuteye, which promises a full year of coaching for $30 which appears good, but I have not fully tested it. Similar, and free, is Insomnia Coach, developed by the VA.

            Also recommended, for technophobes, is the book Quiet Your Mind and Get to Sleep.

            Should CBTI not work, young adults whose problem is falling asleep can try melatonin or a short-acting benzo. If sleep maintenance is the problem, low-dose doxepin or similar drugs are useful. Also approved for this use are three orexin receptor antagonists (ask your doctor!), which have fewer side-effects than benzos but are quite expensive. If you are going to use medication, be sure to also practice good “sleep hygiene” as noted above.

            Sweet dreams.

            Edward Hoffer MD is Associate Professor of Medicine, part-time, at Harvard.

What Does The Doctor Say?

By Dr. Edward Hoffer

            If you read this column regularly you know that from time to time I rant on unelected bureaucrats at the state and federal level dictating what we can and cannot do in our own town. What I am about to tell you falls under “you ain’t seen nothing yet.”.

            Let me introduce you to Marty the Magician. For many years Marty Hahne has performed his magic at elementary schools and children’s birthday parties around the little town of Ozark, Missouri. He is a master at vanishing little bunny rabbits. But I am getting ahead of myself.

            Some years ago, Congress passed a law designed to protect animals like lions, tigers, and bears, from neglect and abuse which required “exhibitors” like circuses, zoos, and animal acts to have a license for each of their animals. Enter Marty the Magician who had a bunny rabbit named Casey.

            Discovering this regulation Marty duly applied and received a license for Casey. The license required Marty to submit to periodic, surprise inspections of his home. Also, if he performed away from Ozark, he had to submit a detailed itinerary to the U.S. Department of Agriculture. I’m guessing, but I’ll bet by the time the U.S.D.A approved the itinerary the little birthday kids were sixteen years old. But I digress.

            After hurricane Katrina the Feds “improved” the law by requiring a contingency plan for animals’ safety during a disaster. Marty duly complied submitting a 29-page plan to protect Casey from floods, tornados, heat, chemical leaks, etc. Casey also had to be caged when not performing. The inspector declared that Marty’s plan was “pretty short” saying, since Casey was licensed, the bunny was the “most important” concern during a disaster. However, the U.S.D.A inspector mentioned that if the rabbit were raised for food, it would not need a license. Upon hearing that, Marty asked “Are you’re telling me I can kill the rabbit to eat… but I can’t take it across the street to (entertain) a birthday party without a license?” Yup. You can’t make this stuff up.

            But wait there’s more.

            Have you heard of Heminway’s cats? Ernest Hemingway the writer had a cat named Snow White who had six toes. Six toed cats are claimed to bring good luck. Not to the Hemingway Museum, a National Historic Site, which his home became after he died (the writer, not the cat). Apparently, Snow White had many offspring, all with six toes. Over the years the museum has accumulated over 60 cats that are well cared for and roam freely around the property to the enjoyment of visitors who often return just to visit the cats. They also attracted U.S. Department of Agriculture officials.

            These agents were concerned about the cats’ “containment.” They ordered the museum to hire a night watchman to ensure the felines would not escape into the neighborhood at night. Or, as an alternative, they could increase the height of the surrounding wall. (Which would be against National Historic Site regulations.) And they would need a license to keep each cat confining them in cages (like Casey the bunny). The museum refused so the Feds returned with another “suggestion” …electrify the wall and provide raised “resting” platforms for the cats. The museum complied. Well, you know what happened. While no cat vanished, like Casey the magic bunny, one got burned and another escaped jumping over the wall from its raised platform.

            Despite reluctantly complying to that rule the museum had to apply four times for the licenses, each time being rejected on a technicality. In the meantime, fines of $200 a day for each cat accumulated. The Feds persisted, sending in undercover agents dressed as tourists and even renting a house next door to secretly photograph the cats.

            After five years, a lawsuit, and spending $200,000 the museum complied with modified regulations which recognized their unique historical situation. To this day Hemingway’s cats continue to roam the museum grounds. 

            Marty the Magician continues to amaze little kids. Casey the bunny is now enjoying a happy retirement.

            Mattapoisett resident Dick Morgado is an artist and happily retired writer. His newspaper columns appeared for many years in daily newspapers around Boston.

Thoughts on…

By Dick Morgado