Holistic solutions for patients who can’t sleep

What came first: sleep or the brain? You may be surprised to learn that sleep, or more accurately, periods of rest, seems to pre-date the evolution of the brain and centralized nervous system.

There is research suggesting single-celled organisms have a circadian rhythm. Jellyfish and other living fossil prehistoric animals have regular periods of rest and reduced activity.

Sleep as experienced by humans, with cyclic rapid eye movement (REM) and non-rapid eye movement (NREM), likely emerged around 150 to 200 million years ago.¹ Of course, many people, patients and perhaps even practitioners feel sleep may be a waste of time or simply not necessary in the amount currently recommended — seven to nine hours per day. Here is my rebuke to that idea: Why would sleep be evolutionarily conserved across such diverse species, over hundreds of millions of years, if it wasn’t vital for survival? Many essential processes take place during sleep: consolidation of memories from short-term to longer-term storage, growth hormone release for cellular repair and tissue regeneration, clearance of waste from the brain (including amyloid and tau), immune regulation, restoration of adenosine triphosphate (ATP) energy production and countless more.^2-5 

Even small lapses in sleep can impair the immune system and increase the risk of major diseases.⁶ Research has found any sleep issue can increase the likelihood of stroke, even after adjusting for smoking, physical activity and alcohol consumption. Less than five hours of sleep a night has been equated with having a three times greater likelihood of stroke versus people who get an average of seven hours of sleep.⁷ In a research study, a single night of restricted sleep (about four hours total) reduced natural killer cell activity by about 70%.⁸ 

The right quality and quantity of sleep is something chiropractic practitioners and patients alike should prioritize. Treatments for sleep difficulties generally include lifestyle modifications and supplementation, plus lab testing when indicated. When addressing sleep problems, begin by assessing the issue. 

Assess sleep quality

A few clinically validated questionnaires are available to assess sleep quality: The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale and STOP-BANG, the latter being used to assess for obstructive sleep apnea. These questionnaires are available online and can be useful for monitoring progress. 

Lab tests to consider include an iron panel with ferritin, vitamin D, red blood cell magnesium, complete blood count and comprehensive metabolic panel; you’re looking for anemia or insufficient protein intake, which contribute to sleep dysfunction. 

Suggest lifestyle changes

Here are a few lifestyle recommendations I provide to patients struggling with sleep: 

Achieve complete darkness: Make the sleeping room as dark as possible. Modifications needed may include adding blackout curtains, removing all electronics from the room and using an eye mask. In an interview, Catherine Darley, a naturopathic doctor who is a leader in natural sleep medicine, stated that if you stretch your hands out in your bedroom and can see your fingers wiggling, that’s enough sight to impact melatonin signaling and affect sleep. 

Adopt the 3-2-1 rule: Avoid food intake three hours before bedtime, stop working two hours before bedtime and eliminate screen time at least one hour before bedtime. For caffeine drinkers, try the 10-3-2-1 rule, with no caffeine at least 10 hours before bedtime. 

Get morning sunshine: Receiving bright light as soon as possible after waking (ideally through time outside) helps sync circadian rhythm. If you live in a sunny area, five to 10 minutes of morning sunshine is adequate. On overcast or cloudy days, aim for about 20 minutes outside if possible. I’m originally from Wisconsin, so I understand this can be difficult in the crisp winter months. 

Avoid alcohol: While alcohol can make you feel sleepy, it does not contribute to restful or restorative sleep. It can disrupt sleep architecture, making people spend more time in lighter stages of sleep and less in deep, slow-wave sleep.⁹ 

Supplement to support sleep

A plethora of supplements can help with sleep, so the following is by no means an all-inclusive list. Each patient’s circumstances will be different, requiring a unique protocol. 

Melatonin: More than a hormone

According to the Sleep Foundation, about 27% of adults are currently taking melatonin for sleep.¹⁰ Melatonin is a fascinating compound made by the pineal gland, where it acts like a hormone. Did you know that melatonin is also made in the retina and gastrointestinal (GI) tract, where it acts as a local antioxidant?¹¹ 

Widespread claims about melatonin are that it’s a sleep inducer or acts similarly to some of the sleep medications available. Unfortunately, this view of melatonin can set people up for failure when trying supplemental melatonin. Rather than a sleep inducer, melatonin is more like a sleep coordinator that helps align the physiological processes in the body that shift us from awake mode to rest mode. Educating patients about how melatonin works is a key step in successful supplementation. 

With melatonin, timing is everything. Taking melatonin one or two hours before sleep onset is most effective. There are slow-release melatonin supplements designed to stay in the bloodstream for six to eight hours to keep levels sustained throughout the night; these should be taken two to three hours before bedtime. 

Echinacea: For when you feel tired but wired

One issue common among people with sleep difficulties is the inability to shut off mental chatter. This can be a manifestation of anxiety, stress, suboptimal adrenal function, burnout and more. Many patients may feel tired, yet when they lay their head down they experience an influx of to-do lists for tomorrow, things they didn’t finish today, negative self-talk and excessive worry. 

To calm this chatter, I find a root extract of Echinacea angustifolia to be particularly useful. This extract is standardized for a unique, alkamide profile, which are the key compounds that interact with the endocannabinoid system. When people take 20 to 40 milligrams about an hour before bedtime, echinacea extract can flip the switch to calmness and relaxation. Interestingly, this extract can also be taken in the daytime for anxiety relief without sedation. 

Angelica: Reduce nighttime bathroom trips

A sleep disruptor that tends to affect middle-aged and older adults is nocturia, or waking up several times during the night to use the bathroom. About 50% of adults over 50 report some degree of nocturia, which is commonly seen post-childbirth or during menopause, as well as in people with benign prostatic hyperplasia (BPH), diabetes or hypertension. 

An Icelandic herb, Angelica archangelica, has been used traditionally for more than 1,000 years. An aqueous extract of wild-harvested angelica leaves has been clinically proven to reduce nighttime awakenings from nocturia. One study found that in a subgroup of participants visiting the bathroom more than three times per night, those receiving angelica saw a 48% reduction in bathroom trips at the end of eight weeks. Angelica also helped increase by 180% the time male participants over age 70 slept before their first nighttime bathroom trip.¹² 

Generally, people can start with 100mg of angelica twice per day for the first several days, then reduce the dosage to 100mg per day. It can be taken in the daytime, evening or both. 

Using angelica for nocturia is much preferred to taking anticholinergic drugs, often prescribed to people with overactive bladder (OAB). A 2015 study in JAMA Internal Medicine found cumulative use of anticholinergics for more than three years was associated with a 54% higher dementia risk versus taking them for less than three months.¹³ 

Magnesium: Relax the muscles

Not only does magnesium help increase gamma-aminobutyric acid (GABA) activity, it also facilitates muscle relaxation and even elevates endogenous melatonin.¹⁴ A highly absorbable form of magnesium is magnesium bisglycinate. Starting dosages around 200-400mg can be helpful for supporting sleep. Magnesium can also be combined with zinc bisglycinate and vitamin B6 (as pyridoxal-5-phosphate) for synergistic benefits and increased absorption. 

Red ginseng: The regulator

Many people think of red ginseng as energizing, but in an open-label, pilot trial participants with chronic fatigue syndrome, fibromyalgia or post-viral fatigue were given red ginseng and experienced a 46% average improvement in sleep after a month.¹⁵ Other research has found ginseng can help with sleep architecture, increase GABA levels and regulate key hormones involved in the circadian rhythm.¹⁶ Because ginseng can be energizing, I opt to have patients take it in the morning, which can help provide the energy to get through daily activities. 

Final thoughts

Sleep dysfunction impacts most people at some point in their lives. For many, these issues are temporary and resolve on their own. For patients needing more consistent support, layering in lifestyle modifications and targeted supplementation can be life-changing. 

LEXI LOCH, ND, is an author, educator and integrative medicine practitioner. With a passion for botanical medicine, dietary supplements and collaborative care, she integrates nature, science and intuition to cultivate vitality. For the past nine years, Loch has been a member of the Scientific Affairs and Education team at EuroPharma USA, makers of EuroMedica dietary supplements. 

References

1. Lesku JA and Ly L. Sleep Origins: Restful Jellyfish Are Sleeping Jellyfish. Curr Biol. 2017;27(19):R1060-R1062. PubMed. https://pubmed.ncbi.nlm.nih.gov/29017039/. Accessed March 1, 2024. 
2. Klinzing JG, et al. Mechanisms of systems memory consolidation during sleep. Nat Rev Neurosci. 2019;22(10):1598-1610. PubMed. https://pubmed.ncbi.nlm.nih.gov/31451802/. Accessed March 4, 2024. 
3. Zaffanello M, et al. Complex relationship between growth hormone and sleep in children: insights, discrepancies, and implications. Front Endocrinol (Lausanne). 2024;14:1332114. PubMed. https://pubmed.ncbi.nlm.nih.gov/38327902/. Accessed March 4, 2024. 
4. Chikahisa S and Séi H. The Role of ATP in Sleep Regulation. Front Neurol. 2011;2:87. PubMed. https://pubmed.ncbi.nlm.nih.gov/22207863/. Accessed March 4, 2024. 
5. Mendelsohn AR and Larrick JW. Sleep facilitates clearance of metabolites from the brain: Glymphatic function in aging and neurodegenerative diseases. Rejuvenation Res. 2013;16(6):518-523. PubMed. https://pubmed.ncbi.nlm.nih.gov/24199995/. Accessed March 1, 2024. 
6. Besedovsky L, et al. The Sleep-Immune Crosstalk in Health and Disease. Physiol Rev. 2019;99(3):1325-1380. PubMed. https://pubmed.ncbi.nlm.nih.gov/30920354/. Accessed March 1, 2024. 
7. McCarthy CE, et al. Sleep Patterns and the Risk of Acute Stroke: Results from the INTERSTROKE International Case-Control Study. Neurology. 2023;100(21):e2191-e2203. PubMed. https://pubmed.ncbi.nlm.nih.gov/37019662/. Accessed March 1, 2024. 
8. Irwin MR, et al Partial sleep deprivation reduces natural killer cell activity in humans. Psychosom Med. 1994;56(6):493-498. PubMed. https://pubmed.ncbi.nlm.nih.gov/7871104/. Accessed March 1, 2024. 
9. Roehrs T, Roth T. Sleep, sleepiness, sleep disorders and alcohol use and abuse. Sleep Medicine Reviews. 2001;5(4):287-297. PubMed. https://pubmed.ncbi.nlm.nih.gov/12530993/. Accessed March 1, 2024. 
10. Graham B. How Much Melatonin do We Really Take? [Blog]. Sleep Foundation. https://www.sleepfoundation.org/sleep-news/how-much-melatonin-do-adults-really-take. Accessed March 1, 2024. 
11. Bubenik GA. Gastrointestinal melatonin: localization, function, and clinical relevance. Dig Dis Sci. 2002;47(10):2336-2348. PubMed. https://pubmed.ncbi.nlm.nih.gov/12395907/. Accessed March 1, 2024. 
12. Sigurdsson S, et al. A parallel, randomized, double-blind, placebo-controlled study to investigate the effect of SagaPro on nocturia in men. Scand J Urol. 2013;47(1):26-32.  PubMed. https://pubmed.ncbi.nlm.nih.gov/23323790/. Accessed March 1, 2024. 
13. Gray SL, et al. Cumulative Use of Strong Anticholinergic and Incident Dementia. JAMA Intern Med. 2015;175(3):401-407. PubMed. https://pubmed.ncbi.nlm.nih.gov/25621434/. Accessed March 1, 2024. 
14. Abbasi B, et al. The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled trial. J Res Med Sci. 2012;17(12):1161-1169. PubMed. https://pubmed.ncbi.nlm.nih.gov/23853635/. Accessed March 1, 2024. 
15. Teitelbaum J, Goudie S. An Open-Label, Pilot Trial of HRG80™ Red Ginseng in Chronic Fatigue Syndrome, Fibromyalgia, and Post-Viral Fatigue. Pharmaceuticals. (Basel). 2022;15(1):43. PubMed. https://pubmed.ncbi.nlm.nih.gov/35056100/. Accessed March 1, 2024. 
16. Lee C-I, et al. Repeated Administration of Korea Red Ginseng Extract Increases Non-Rapid Eye Movement Sleep via GABAAergic Systems. J Ginseng Res. 2012;36(4):403-410. PubMed. https://pubmed.ncbi.nlm.nih.gov/23717143/. Accessed March 1, 2024.