Insomnia; Inability to sleep; Dyssomnia; Sleeping difficulty; Wakefulness
Sleeping problems, called insomnia, can take several forms:
- Difficulty falling asleep when you first go to bed at night
- Waking up too early in the morning
- Waking up frequently throughout the night
All types of insomnia can lead to daytime drowsiness, poor concentration, and the inability to feel refreshed and rested in the morning.
Everyone has an occasional sleepless night, and this is not a problem for most people. However, as many as 25% of Americans report occasional sleeping problems, and insomnia is a chronic problem for about 10% of the population. In these cases, the lack of restful sleep impairs the person’s ability to carry out daily responsibilities because they are too tired or they have trouble concentrating.
Most adults do best with about 8 hours of sleep each night until age 60, after which 6 hours may be adequate. Even though the elderly need less sleep, almost one half of people over 60 experience some degree of insomnia.
The best measure of the amount of sleep needed is how you feel. If you awaken feeling refreshed, you are getting enough sleep. For some people, this may take only 4 hours. Others can need up to 10 hours to feel rested.
Using long-acting or high-dose sedatives as a “cure” for insomnia can make the problem worse, not better, over time. Antihistamines (the main ingredient in over-the-counter sleeping pills) can lead to similar difficulties. Using antihistamines over time may also lead to reversible memory impairment.
Strong, prescription sedatives do not produce a natural, restful sleep. In addition, you can develop tolerance or dependence on these drugs. In this case, the same dose of the drug no longer produces sleep, which may lead you to try a higher dose. The circular situation becomes worse. Higher doses worsen the chance of dependence, tolerance, and side effects. Stopping these medications can cause a rebound insomnia and withdrawal.
A life-threatening disease is rarely the cause of problems with sleep. For many people, poor sleep habits are the cause. However, because insomnia is a key symptom of depression, you should be evaluated for depression if you are having sleeping difficulties.
Insomnia may cause a reduced energy level, irritability, disorientation, dark circles under the eyes, posture changes, and fatigue.
It may help to consult a psychiatrist, another physician, or another mental health practitioner for evaluating psychiatric disorders that can lead to insomnia. If you are depressed, antidepressants can help both the sleeping problem and the depression. These medications do not carry the same concerns about tolerance and dependence as sedatives.
Nightmares and dreams that interfere with sleep may also respond to counseling.
- jet lag
- shift work
- wake-sleep pattern disturbances
- depression or major depression
- anxiety or stress
- exhilaration or excitement
- bed or bedroom not conducive to sleep
- nicotine, alcohol, caffeine, food, or stimulants at bedtime
- excessive sleep during the day
- excessive physical or intellectual stimulation at bedtime
- overactive thyroid
- side effect of a new medication
- alcoholism or abruptly stopping alcohol after long-term use
- not getting enough bright-light exposure during waking hours
- abruptly stopping a medication (such as sleeping pills)
- medications or illicit “street drugs” (for example, excessive thyroid replacement hormone, amphetamines, caffeine-containing beverages, cocaine, ephedrine, phenylpropanolamine, theophylline derivatives)
- withdrawal of medications (such as sedatives or hypnotics)
- interference with sleep by various diseases, including an enlarged prostate (men), cystitis (women), COPD, pain of arthritis, heartburn, and heart or lung problems
- restless leg syndrome
Most newborn babies wake several times during the night, but by the age of 6 months they typically sleep through the night. At one year, babies will sleep an average of about 16 hours in every 24. Two to three hours of this sleep will be during the day. Causes of sleeplessness in infants may include:
- desire for parental attention
- infantile colic or other digestive problems
- fever or other illness
Trt modifying your nighttime sleeping habits and other behavior before resorting to drugs to cure insomnia. For example:
- Avoid using alcohol in the evening. Avoid caffeine for at least 8 hours before bedtime. Give up smoking, because nicotine is a stimulant.
- Establish a regular bedtime, but don’t go to bed if you feel wide awake. Use the bedroom for bedroom activities only. Once in bed, use creative imagery and relaxation techniques to keep your mind off unrestful thoughts. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom.
- Take your TV or computer out of your bedroom. Otherwise, your brain becomes used to the stimulation and starts to expect it when you are there. This makes it harder for you to fall asleep.
- Relax by reading, taking a bath, or listening to soothing music before getting to bed.
- A snack before bedtime helps many people. Foods such as warm milk or turkey have a natural sleep inducer called L-tryptophan.
- Exercise regularly, but not in the last two hours before going to bed. Exercise, especially aerobic exercise, has been show to make people fall asleep faster and benefit from deeper and more restful sleep. Sex can be a natural sleep inducer and helps some people.
- Avoid emotional upset or stressful situations prior to bedtime.
IN INFANTS AND CHILDREN
- Avoid being readily available to a child during the night. Otherwise, the child may become dependent on attention and become sleepless if deprived of it.
- For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises.
- Avoid sending a child to bed as punishment which can result in poor sleep caused by fear.
- Never give a child sleeping medicine without consulting the doctor first. Generally, it is unwise to treat the problem with drugs.
- Medication should be a last resort.
- Over-the-counter sleep medicines can have side-effects, including a “hangover” effect the next morning.
- If these fail, you may want to ask you health care provider to recommend other options.
- Avoid all sedatives, including the benzodiazepines, during pregnancy.
Call your health care provider if
Call your health provider if:
- A sleeping problem becomes persistent and unbearable, despite home treatment
- A sleeping problem occurs more than 3 nights per week for more than 1 month
- The insomnia is accompanied by other worrisome symptoms, such as chest pain or shortness of breath
What to expect at your health care provider’s office
Your provider will perfom a physical examination. To help better understand your sleeping problems, he or she may ask the following:
- Do you have difficulty falling asleep or staying asleep (insomnia)?
- Do you awaken from sleep not feeling rested?
- How often do you awaken at night?
- How long have you had the problem?
- Have you taken any over-the-counter sleeping products?
- What medications do you take?
- Do you take any herbal supplements or alternative medicine remedies?
- Do you drink much coffee or alcohol? Have you recently cut down on your coffee or alcohol?
- Do you have any excessive stress or anxiety?
- How much do you normally sleep? What hours?
- What do you do during the few hours before you go to bed?
- Do your sleep schedule change frequently? (shift work)
- Do you fall asleep at inappropriate times or places?
- Does your sleep schedule change drastically on weekends?
- Do you worry excessively about sleep?
- Do you have breath-holding spells or do you snore?
- Do you have any aches or pains that prevent you from sleeping?
In some cases, the following tests may be recommended:
- Sleep log record
- Psychological tests
- Thyroid tests (TSH, T3, T4)
In some rare cases, your health care provider may want you to see a sleep medicine specialist who will perform a sleep study (polysomnography)
In most cases, medication will not be necessary. Your health care provider can explore with you the possibility of using prescribed medications if everything else has failed.
Some antidepressants such as Elavil (amitriptyline) can be used at bedtime because they are sedating. They require a prescription. If insomnia is caused by depression, proper treatment of the depression with other appropriate medications or therapy should solve the problem. Benzodiazepines such as Valium (diazepam) or Ativan (lorazepam) are anti-anxiety medications that can also help induce sleep. They must be used with caution because they can be addictive. They too require a prescription.
Newer medications called hypnotics are now available. They are help reduce the time needed to fall asleep but are less likely to be addictive than benzodiazepines. Ambien (zolpidem) and Sonata (zaleplon) are two examples.
by Simon D. Mitin, M.D.