What Is Insomnia?
Insomnia—difficulty in falling or staying asleep, or waking up too early—is the most common sleep disorder. It may affect people of any age, but prevalence increases with advancing years. Sleep requirements vary greatly: Some people need nine hours of sleep a night; others do fine with five. Many who complain of insomnia sleep more than they think they do. Although persistent insomnia may be frustrating and even debilitating, self-treatment is often successful.
Age is a key factor in assessing insomnia. It’s a sign of troubled sleep if a child or young adult has difficulty falling asleep or wakes up repeatedly. But in about 80% of people over the age of 60, sleep becomes more fragmented. People in this age group tend to wake up more often (and for longer periods) during the night, and earlier in the morning, with generally less deep sleep and more light sleep.
Insomnia can interfere with daily functioning, and it significantly increases the risk of having a motor vehicle accident. Some research suggests that chronic insomnia is associated with an increased risk of depression.
Who Gets Insomnia?
The prevalence of insomnia is unknown. Surveys of the general population suggest that 49% of adults report having brief periods of difficulty sleeping and about 10% of adults claim they have had insomnia lasting 2 weeks or longer. About 50% of those who have periods of insomnia also claim it is a significant problem in their lives.
Since insomnia is frequently a symptom of illness, severe stress, or trauma, incidence varies with regard to age, sex, and severity of any predisposing condition(s).
- Difficulty falling asleep or getting back to sleep when awakened.
- Waking often during the night or waking significantly earlier than desired.
- Daytime fatigue, drowsiness, inability to concentrate, or irritability.
- Psychological distress—due to emotional upset, a different or noisy sleeping environment, or worrying about the next day—is the most common cause of insomnia. Anxiety, depression, and mania cause more persistent sleep disturbances.
- Caffeine and other stimulants are common causes. Even a single cup of coffee or tea during the day can lead to insomnia in susceptible people.
- Diuretic medications taken later in the day can cause frequent awakenings to urinate.
- Alcoholic beverages disrupt the sleep cycle and cause frequent awakenings. Chronic alcoholism may cause sleeping problems that persist for years, even after drinking is discontinued.
- Paradoxically, sleeping pills cause insomnia. They tend to lose their effectiveness after a few weeks, and withdrawal may cause rebound insomnia.
- Physical disorders—pain, heart and lung diseases, hyperthyroidism, gastroesophageal reflux, arthritis, and many more—cause insomnia. Prostate disorders, kidney disease, and diabetes may cause frequent awakenings throughout the night to urinate.
- Sleep-related disorders cause insomnia, especially sleep apnea (a breathing malfunction that may interrupt sleep hundreds of times a night) and restless legs syndrome (an ailment marked by burning, prickling, and aching sensations in the legs at night).
- Other causes include a sedentary lifestyle, exercising vigorously late in the day, recent surgery, and pregnancy (especially the last month).
What If You Do Nothing?
Occasional insomnia is nothing to worry about. And remember that there are wide individual differences in how much sleep people need to feel refreshed and alert. Some need nine or ten hours, others only six.
Also, don’t worry that you have to “make up” every hour of lost sleep. One good night will usually repair the fatigue.
- Assessment for insomnia begins with the documentation of a complete sleep history and an evaluation of the patient's sleep hygiene.
- A medical history is obtained and a physical examination is performed to determine if underlying medical or psychiatric conditions are present. Included is whether the patient is taking any medications for which insomnia is a side effect (such as theophylline, albuterol, α-, β- and calcium-channel blockers, fluoxetine, and bupropion).
- In cases with no obvious cause, the doctor may advise an overnight stay at a sleep-study laboratory to monitor brain-wave patterns, breathing, muscle activity, and other body functions.
Insomnia is divided generally into two main categories: sleep onset insomnia and sleep maintenance insomnia. Sleep onset insomnia is the inability to fall asleep naturally. Sleep maintenance insomnia is the inability to stay asleep or to resume sleep after waking in the middle of the sleep cycle. A person may experience both sleep onset insomnia and sleep maintenance insomnia, which leads to both insufficient sleep and poor-quality sleep.
Insomnia can be categorized further as acute or chronic. Acute insomnia is self-limiting, meaning it lasts for a period of time (e.g., a few weeks or months) and ends without treatment. Chronic insomnia lasts longer than 3 months and often needs to be treated.
Insomnia can also be caused by medical problems, such as chronic pain syndromes; psychiatric problems, such as depression; or primary sleep problems, such as periodic limb movement disorder (PLMD) and restless legs syndrome (RLS). This is known as secondary insomnia.
When there is no underlying cause of insomnia, first try the following self-help measures:
- Don’t drink alcohol before bedtime—and don’t smoke. Alcohol can disrupt sleep patterns and make insomnia worse. Nicotine makes you wakeful, too.
- Avoid eating a heavy meal in the evening, particularly at bedtime. Don’t drink large amounts of liquids before retiring.
- Eliminate caffeinated beverages, except in the morning or early afternoon.
- Unless you’re older, try to avoid daytime naps.
- Spend an hour or more relaxing before you retire. Read, listen to music, watch TV, or take a warm bath.
- Go to bed and get up on a regular schedule. Get into bed at the appointed time even if you’re not tired, and arise for the day on schedule no matter how much you haven’t slept.
- If you can’t sleep, get up and do something. Being in bed should be associated with sleep, not wakefulness. If you are unable to fall asleep or if you wake up and cannot get back to sleep, get out of bed and stay up until you feel tired and drowsy.
- Try to correct any stress that’s keeping you awake. If you can’t resolve the stressor on your own, try confiding in a friend, joining a support group, or finding a qualified counselor. When a short-term stressor such as an upcoming event or a recent grief is present, your doctor may prescribe a sedative tranquilizer (such as zolpidem, lorazepam, or alprazolam) to be taken on a short-term basis under his or her supervision.
- If insomnia persists after you have tried self-help measures, you may be helped by a medication prescribed by your doctor. Newer medications, such as Ambien (zolpidem), Lunesta (esoplicone), and Sonata (zolpidem), are central nervous system depressants—they help you fall asleep by slowing brain activity. However, they have a short half life and fewer side effects compared to older benzodiazepines, and they are less likely to produce next-day grogginess. These medications are intended for short-term use, and they should never be combined with alcohol.
Ramelteon (Rozerem) induces sleep differently than the above medications. It acts on the sleep-wake cycle, much like the dietary supplement melatonin does, but with much greater potency. Because it has a much lower potential for dependency and abuse than prescription sleep medications, doctors can prescribe it for long-term use.
Whichever drug you choose to help you combat insomnia, your goal should be to reestablish normal sleeping habits without any drugs.
- For severe intractable insomnia, you may be referred to a sleep disorders clinic. Specialists in a clinic will make a detailed evaluation of your sleeping and waking patterns. Treatment may entail behavioral strategies such as relaxation training and restricting your sleeping time. Medications may also be recommended.
- Avoid or minimize caffeinated beverages.
- Within three hours of going to bed, do not drink alcoholic beverages, smoke, or eat a large meal (although a small bedtime snack may be advised).
- Avoid amphetamines or other stimulants (unless directed otherwise by your doctor).
- Exercise moderately during the day; this should help you feel tired at night.
- If possible, go to bed and get up at set times each day and resist the temptation to take long naps.
- Prior to bedtime, restrict reading and television watching. Try to avoid worrying (it may help to set aside a regular time during the day to think about problems and possible solutions.) Take a warm bath or drink a glass of warm milk to relax.
- Use your bed only for sleeping and intimacy; don’t watch television, talk on the phone, or do paperwork in bed.
When To Call Your
- Make an appointment with a doctor if insomnia persists, is associated with depression, or interferes with normal activities.
- While increasingly fragmented sleep in many older people may be normal, it can also result from a specific sleep disorder such as sleep apnea, a potentially dangerous condition that requires medical diagnosis and treatment.
Robert Hurd, M.D., American Board of Internal Medicine and Professor of Endocrinology and Health Care Ethics, Xavier University, Cincinnati, OH. Review provided by VeriMed Healthcare Network.