How can disturbed sleep affect my health?

If you have poor or disturbed sleep night after night, you may begin to notice your health getting worse. If you have rheumatoid arthritis (RA), symptoms such as pain may disrupt your sleep.

Several of your body's functions are influenced by sleep:

• Your body clock is controlled by your sleep pattern.
• Many different hormones are affected by sleep. For example, steroid hormones are at their highest level when you wake up and lowest before you go to sleep, so taking corticosteroids  later in the day can affect your body clock and may disrupt your sleep.

If your body clock is altered by a change in your sleep pattern (for example, if you have jet lag), you may feel generally unwell and experience:

• fatigue
• stomach problems
• headaches.

You may also find it difficult to think clearly, concentrate or carry out normal activities such as driving.

What's a normal sleep pattern?

How much sleep do I need?

Most adults need about 7–8 hours' sleep per night, though this varies from person to person. Children tend to sleep more than adults, and older people tend to have lighter sleep.

What are the stages of sleep?

The stages of sleep are commonly referred to as:

• non-rapid eye movement (REM)
• REM or dreaming sleep.

The pattern of your brainwaves differs in each stage.

Non-REM sleep happens in four stages:

• Stages 1 and 2 refer to light sleep.
• Stages 3 and 4 refer to deeper sleep with slow brainwaves.

These phases are repeated several times during the night. Each cycle lasts about 90 minutes, although the proportion of deep sleep and dreaming sleep changes as we get older.

What kind of sleep problems are there?

A severely disturbed sleep pattern can cause all the following problems:

• You may have trouble getting to sleep but then sleep through the night.
• You may wake often during the night or wake up too early.
• You might not remember having disturbed sleep but don’t feel refreshed when you wake up. This is called (non-restorative sleep).

If this continues for a long time, it can cause increased muscle tension and can be linked with muscular pain. Sleep also has a major effect on our mood.

It's normal to wake up once or twice each night, and it's only a problem if you can't get back to sleep again or if you’re not happy with the amount and quality of sleep you’re getting.

Sleep and depression

Depression can result in disturbed sleep but a poor sleep pattern over a period of time often leads to anxiety or depression, or both. It’s sometimes difficult to know whether sleep disturbance is the result of depression or the cause of it.

Sleep and pain

Sleep disturbance may lower the point when you begin to feel pain (your 'pain threshold'). This could lead to:

• increased pain from an already painful condition, your RA
• developing pain from a condition that hadn’t been painful before 
• pain that was felt only in only part of your body (localised pain) becoming more widespread.

How can RA affect my sleep?

RA can affect the way you sleep, especially if your condition causes pain that makes it uncomfortable to lie down.

People with RA are more likely to suffer disturbed sleep than people of a similar age who don’t have RA.

Sleep disturbance is usually worse when your pain is worse, and it’s linked to increased anxiety and depression as well as morning stiffness and fatigue.

How can I improve my sleep?

Keeping a sleep diary

Keeping a diary of your sleep pattern can help you and your doctor spot things that disturb your sleep. It can include:

• what time you go to bed and wake up
• whether you got to sleep easily or not
• any causes of disturbance, such as your mood, pain or fatigue
• any caffeinated drinks 
• your daytime activities.

Sleep hygiene

Healthcare professionals will usually suggest you think about 'sleep hygiene' – things that you can do to improve your sleep pattern:

Do:

• get into a relaxing routine – get up and go to bed (ideally when you’re sleepy) at the same time every day
• make your bedroom dark, quiet and at a comfortable temperature
• exercise regularly, but not within three hours of going to bed
• eat sensibly so you don’t feel hungry during the night, but avoid eating and drinking large amounts just before bedtime
• take a warm bath before you go to bed to help ease stiff or painful joints.

Don't:

• use your bedroom for stimulating activities, like watching TV, playing with devices, working or eating
• sleep during the day because this can make it more difficult to get to sleep at night
• eat/drink caffeinated products (tea, coffee and chocolate) after midday
• drink alcohol if you experience serious sleep disturbance
• smoke before bedtime or during the night.

If you can’t sleep after about 20 minutes, get up and do something that’s not overstimulating (for example, listening to some soothing music). Only go back to bed when you’re sleepy.

Changing your bed

If your mattress is old or uncomfortable, you should probably consider replacing it. Read more about finding a new mattress.

Changing the number or position of your pillows or choosing a soft or moulded pillow may be helpful if you have neck pain or upper back pain.

Some people find it helpful to sleep in a narrow soft foam collar.

Treatments for sleep problems

If your sleep problems continue, speak to your GP, rheumatologist or rheumatology nurse. They'll be able to offer more advice and prescribe medication if you need it.

Medications

There are four main groups of medications that can be helpful. They’re most likely to have an effect when just one factor is causing your sleep disturbance. You may find it useful to take medications from more than one of these groups.

Pain-relievers

Taking paracetamol just before going to bed can ease pain to allow you to get to sleep, but it’s unlikely to last all night.

Non-drowsy pain-relievers that include caffeine are unlikely to help you sleep.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Slow-release NSAIDs such as naproxen reduce pain and stiffness throughout the night. Although these medications have potential side-effects, they can be very useful.

Sedating antidepressant drugs

Some antidepressants, such as amitriptyline, have sedative effects, which means they make you feel sleepy. They may also reduce chronic pain.

These medications aren’t given as sleeping tablets but may improve your sleep as an added benefit. It’s often advisable to take them a few hours before going to bed so that the effect has worn off by the morning.

Sedatives (hypnotics)

Temazepam, zolpidem and zopiclone are given specifically to help you got to sleep, although they may not stop you waking during the night. They’re sometimes called hypnotics.

Doctors often advise against using sedatives because of the risk of dependence, which means you become addicted to them. There's also a risk of side-effects, but they can sometimes be helpful for short-term use.

Cognitive behavioural therapy

Therapists and psychologists may be able to offer relaxation tips or cognitive behavioural therapy (CBT). A number of studies have investigated CBT as a treatment for sleep problems in people with chronic pain.

CBT is a psychological treatment based on the assumption that our thought patterns and reactions are learned and can therefore be changed. It aims to help you change any thoughts, feelings or behaviours that may be having a negative impact on sleep. It can be given either in group sessions or to individuals.

CBT uses a number of different techniques:

• Education teaches about sleep and the factors which help or disturb it (including sleep hygiene).
• Sleep restriction aims to improve sleep efficiency (the proportion of time you spend in bed sleeping). This is based on the principle that lying in bed awake for long periods makes sleep problems worse in the long term. Your bedtimes are changed to better reflect how much sleep you get.
• Stimulus control aims to help you link the bed only with sleep and sex. Common strategies include moving TVs out of your bedroom and not working or reading in bed.
• Cognitive therapy helps you spot and assess any negative thoughts and beliefs about your ability to sleep.
• Relaxation and imagery training can help you distract yourself from stimulating thoughts if you find it difficult to stop thinking about what happened during the day.

Some rheumatology clinics also offer evidence-based self-management groups which deal with fatigue and sleep issues. Ask if your rheumatology team offer this.