The Best Brain Health Boost in 2024: Fix Your Sleep

10 proven strategies for a better night's sleep

A cold walk in Kelly, Wyoming yesterday.

Hello, brain health ambassadors, and happy New Year! Today we are diving back into the topic of sleep. As we went into last month, good quality sleep is crucial for a healthy brain. While you sleep, your brain clears out toxins (like amyloid protein) via the glymphatic system. We all know sleep is foundational and yet, the quest for a good night’s sleep gets progressively more challenging with age. 

This year, why not make fixing your sleep a top priority? Tapping into proven sleep strategies will not only help you think and remember better, it will help protect your brain from Alzheimer’s later. 

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I heard from many of you about your sleep challenges. You are not alone! Most of us struggle with sleep at times. I hear that you often wake up in the middle of the night and can’t get back to sleep. (That’s called sleep maintenance insomnia, more below.) Or, you are concerned about having slept poorly for many years and are wondering if the damage can be reversed. (The answer is yes, sometimes.) Some of you are struggling with sleep apnea or wonder if you have it. And, as always, the question of taking a pill (or a gummy) to help with sleep is top of mind.

I don’t claim to have all the answers—sleep science is still in its infancy. But you may be surprised to learn that the most evidence-based sleep strategies have nothing to do with taking a pill. 

Think about sleep strategies as falling into one of these 3 categories:

Sleep Strategies Backed by Excellent Data

• Diagnosing and treating sleep apnea

• Cognitive Behavioral Training for Insomnia (CBT or CBTi)

• Treating menopausal vasomotor symptoms with HRT

• Treating chronic pain or restless leg syndrome

• Abstaining or limiting alcohol intake

• Paying attention to sleep hygiene

Sleep Strategies with Promising Data

• Magnesium supplementation

• Ashwagandha supplementation

• Gratitude journaling

• Sleep tracking with wearables (like Oura, an Apple watch, and Whoop)

Sleep Strategies with Disappointing or Mixed Data

• Cannabinoids (CBD)

• Sleeping pills

• Melatonin

Who needs to see a sleep doctor

When most people talk about trouble sleeping, they are referring to insomnia—difficulty falling asleep, staying asleep, or both. When symptoms last a month or longer, it’s called chronic insomnia. Not all sleep problems are insomnia, though; some are actually medical conditions. If you think you may have one of these disorders, it’s time to see a sleep specialist. This could be a physician, nurse practitioner, psychologist or other medical professional trained in the diagnosis and treatment of sleep disorders.

• Restless leg syndrome (RLS): a neurological condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation. It typically happens in the evening or nighttime hours when you're sitting or lying down. Also called Willis-Ekbom disease, RLS is a sleep disruptor that generally worsens with age. Getting an accurate diagnosis is key; not only are treatments available, RLS could be a sign of another health disorder—such as kidney disease or iron deficiency—that should be corrected as well. 

• Narcolepsy: If you suffer from excessive daytime drowsiness, or even sudden sleep attacks, see a sleep specialist to rule out narcolepsy, a treatable sleep disorder that can impact memory and cognitive function.

• Sleep apnea: a potentially serious sleep disorder in which breathing repeatedly stops and starts. If you snore loudly and feel tired even after a full night's sleep, you might have sleep apnea. Obstructive sleep apnea (OSA) is the most common type that occurs when throat muscles relax and block the flow of air into the lungs.

Sleep Apnea

What sleep apnea does to the brain
Simply put, episodes of sleep apnea starve the brain of oxygen. This is especially harmful to the highly oxygen-sensitive hippocampus (the memory center of the brain). Although it is unlikely that sleep apnea causes dementia, it may worsen cognitive function. People with sleep apnea tend to have more memory problems and have more biomarkers for Alzheimer’s (such as amyloid and tau protein on brain scans). In this meta-analysis of 11 studies and over 1 million patients, those with sleep apnea were more likely to develop any neurodegenerative disease, especially Alzheimer’s, Lewy Body, and Parkinson’s. 

Treating sleep apnea improves cognitive health, reduces Alzheimer’s risk
The good news is this: cognitive impairment from sleep apnea (especially OSA) is mostly reversible with appropriate treatment. One of the most effective treatments entails using a device that delivers pressurized air to keep airways open while you sleep: a continuous positive airway pressure (CPAP) machine. 

There is a compelling case for using a CPAP machine to reduce the heightened risk for Alzheimer’s that comes with OSA. This prospective study of people with mild cognitive impairment showed that using a CPAP for one year slowed the trajectory of their cognitive decline. This comprehensive review supports treating OSA to reverse cognitive impairment, a strategy that works even in those who already have Alzheimer’s disease. Other strategies to tackle OSA include avoiding alcohol, losing excess weight, using an oral device designed to reduce snoring, sleeping on your side not your back, and oral surgery to correct breathing  problems.

Insomnia

Behavioral therapy is first-line for insomnia
If you’ve ruled out a sleep disorder, chances are your sleeping problems fall under the category of insomnia. Difficult falling asleep is one type of insomnia. Waking and staying up in the middle of the night—sleep maintenance insomnia—is another. While it’s not always clear what triggers insomnia, these common factors are the low-hanging fruit that must be addressed: stress and anxiety, a poor sleeping environment, drinking alcohol or caffeinated beverages too close to bedtime, or lifestyle factors like jet lag or shift work. 

Insomnia is the most common sleep problem;
stress and anxiety are the most common insomnia triggers.

It’s not surprising, then, that behavioral therapies are proven most effective when combating insomnia. This includes addressing sleep hygiene factors: like the ones I listed here including having a regular sleep schedule, a caffeine curfew, keeping a gratitude journal, avoiding alcohol and heavy meals before bed, and winding down before bed. If your partner is keeping you up, there may be advantages to sleeping apart. (Sometimes called a “sleep divorce,” this article goes into the pros and cons.) 

When good sleep hygiene doesn’t solve your sleep problems: consider CBTi

Cognitive behavioral training for insomnia (CBTi) is a program developed by sleep professionals to retrain your brain to sleep better. This approach goes beyond sleep hygiene. CBTi therapists may ask you to spend less time in bed (sleep restriction) and take into account your chronotype (whether you are an early bird or a late owl). A series of in-person or online sessions slowly retrains your brain to deal with intrusive thoughts that make it difficult to fall asleep or keep you up at 3 am. (Remember: stress is the number one causative factor in chronic insomnia.)

CBTi is extensively studied and posts remarkable success rates for treating chronic insomnia: 70%–80% have significant improvement and a full 40%–50% achieve resolution. It’s approved by the Food and Drug Administration as treatment for chronic insomnia. And, some studies have shown that doing an online course is just as beneficial as doing it in person. These findings have led several professional organizations to recommend CBTi as the first-line treatment for chronic insomnia. Learn more about how CBTI works here.

Sleep Trackers

Sleep trackers raise sleep awareness but also sleep anxiety
According to the American Academy of Sleep Medicine, 1 in 3 Americans track their sleep with a wearable biosensor device. This could be an Apple watch, an Oura ring, or a WHOOP worn as a bracelet. While you sleep, these devices record your heart rate and breathing to estimate how long you cycle through the various stages of sleep: light, deep, rapid eye movement. They use this data to calculate heart rate variability (HRV), which is considered a measure of overall fitness. 

Are sleep tracking devices worth the time, cost, and effort? This study (albeit sponsored by WHOOP) suggests that sleep tracking leads to pro-sleep behavior. A survey by the American Academy of Sleep Medicine agrees: 77% who have tried a sleep tracker have found them helpful and 68% have changed behavior because of what they learned. For example, are you wondering if that afternoon latte or 7 pm glass of wine is clobbering your sleep cycle? A sleep tracker will help you figure it out.

Sleep trackers are great for building awareness about your sleep habits. But they may also overestimate the time spent in light sleep which fuels orthosomnia—an unhealthy preoccupation with achieving optimal sleep. When your sleep experience doesn’t match what your device says, that may lead to anxiety and worry over sleep. Most experts recommend manual sleep logs over tracking devices to reduce sleep anxiety.

Sleeping Pills and Supplements

Are sleeping pills ever a good idea?
A class of drugs referred to as the Z-drugs (zopiclone, eszopiclone, zaleplon, and zolpidem) are FDA-approved for insomnia, but experts don’t generally recommend taking them for longer than 2 weeks. The reason is twofold: adverse reactions are high (sleep-walking, sleep-driving, daytime brain fog) and effectiveness for chronic insomnia is low. Plus, sleeping pills are notoriously addictive, meaning taking something like Ambien for more than 2 weeks can make it extremely difficult to sleep without it. A medical professional may prescribe a sleep medicine for a few situations, however, like extreme stress (as in grieving the death of a loved one) or resetting the sleep cycle in a new time zone. 

Hormones that help with sleep
Estrogen isn’t a sleeping pill, of course, but hormone replacement therapy (HRT) deserves mention here as a proven sleep strategy. Estrogen is the most effective treatment for sleep-disrupting night sweats, which as I wrote in October, aren’t just bothersome but could also be an indicator of early brain disease. Natural progesterone (often taken with estrogen) can also be sleep-inducing. Taken before bed, progesterone may reduce anxiety that leads to insomnia. In addition, progesterone increases respiratory drive (how frequently one breathes) which may help with mild cases of obstructive sleep apnea. 

OTC sleep aids
Many antihistamines used for treating allergies also have a sedative effect. Diphenhydramine (Benadryl) is one of the most common “PM” medications marketed for sleep in combination with an anti inflammatory such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol). Antihistamines can certainly get the job done if one needs to fall asleep quickly, but most sleep experts won’t recommend them because they suppress a normal sleep cycle. The result: you may sleep for several hours uninterrupted but wake up feeling groggy and tired.

Sleep supplements that may help
The most common sleep supplement—melatonin—actually has very little scientific data to say that it’s effective. Neither the American Academy of Sleep Medicine nor the American College of Physicians recommend taking melatonin for chronic insomnia. It may be useful, however, when traveling to a new time zone. 

Ditto for cannabinoids (CBD). These supplements induce sleep by tapping into the body’s own endocannabinoid system, and small studies have shown them to be helpful inducing sleep, especially in those with anxiety. One large review did not find an overall benefit. The problem: withdrawal. A common trend seen in studies is difficulty sleeping after taking CBD. 

Ashwagandha is an herbal extract of the plant Withania somnifera (related to nightshades) with a long history of being used to treat anxiety in India. Current studies (like this case series and this randomized controlled trial) are promising: taking ashwagandha during the day may help improve sleep quality at night. Those over 60 should know that there is very little data about the safety of ashwagandha in this age group. Typical doses range from 1 to 2 grams of ashwagandha root powder, two 225 to 300 milligrams capsules, or 1 to 2 cups of ashwagandha tea per day.

Magnesium is a key brain health nutrient and many people are deficient. If you are following a brain-healthy dietary pattern rich in nuts, seeds, whole grains, and leafy greens, chances are your magnesium levels are just fine. There are a handful of studies, however, that indicate taking a magnesium supplement can help improve sleep quality. This may be because it reduces muscle cramps, lends a bit of muscle relaxation (which can help restless people fall asleep), or some other mechanism not yet understood. 

Some formulas like magnesium oxide can increase intestinal motility (which may not be very restful at night!), but for most there is very little downside to taking up to 500 milligrams of magnesium threonate or magnesium glycinate for sleep. NeuroReserve recently published an excellent review article of the types and dose ranges for magnesium.

Focus on sleep progress over perfection

As with all brain health lifestyle pillars, focus on progress over perfection. Striving to prioritize sleep most of the time is a lofty goal. Now I’d love to hear from you: Which sleep strategies have you tried? What seems to work the best? Are you excited to make good quality sleep a priority this year?

I’ll be back this weekend with a non-traditional look at New Year’s resolutions. Plus, I am excited to announce two new Brain Health Retreats in Italy in fall of 2024. As always, paying subscribers get first dibs on spots. Until then, thank you for reading, sharing, and taking the best care of your brains.

Love,

Annie