Insomnia

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30-50% of the general population is affected by insomnia, and 10% have chronic insomnia.

Insomnia is a symptom, not a stand-alone diagnosis. By definition, insomnia is "difficulty initiating or maintaining sleep, or both." Although most of us know what insomnia is and how we feel and perform after one or more sleepless nights, few seek medical advice. Many people remain unaware of the behavioral and medical options available to treat insomnia.

Insomnia affects all age groups. Among older adults, insomnia affects women more often than men. The incidence increases with age.

Stress most commonly triggers short-term or acute insomnia. If you do not address your insomnia, however, it may develop into chronic insomnia.

Insomnia may result from either psychological or physical causes.

• The most common psychological problems include anxiety, stress, and depression. In fact, insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness.



• Physiological causes span from circadian rhythm disorders, sleep-wake imbalance, to a variety of medical conditions. Following are the most common medical conditions that trigger insomnia:
  
  
  • Chronic pain syndromes
  
  
  
  • Congestive heart failure
  
  
  
  • Chronic obstructive pulmonary disease (COPD)
  
  
  
  • Degenerative diseases, such as Alzheimer disease (Often insomnia is the deciding factor for nursing home placement.)


• Certain groups are at higher risk for developing insomnia:
  
  
  • Travelers
  
  
  
  • Shift workers
  
  
  
  • Seniors
  
  
  
  • Adolescent or young adult students
  
  
  
  • People with chronic pain, cardiopulmonary disease
  
  
  
  • Pregnant women
  
  
  
  • Women in menopause


• Certain medications have been associated with insomnia. Among them are certain over-the-counter cold and asthma preparations.
  
  
  • The prescription varieties of these medications also may contain stimulants and thus produce similar effects on sleep.
  
  
  
  • Medications for high blood pressure also have been associated with poor sleep.


• Common stimulants associated with poor sleep include caffeine and nicotine. You should consider not only restricting caffeine use in the hours immediately before bedtime but also limiting your total daily intake.



• People often use alcohol to help induce sleep, as a nightcap. However, it is a poor choice. Alcohol is associated with sleep disruption and creates a sense of nonrefreshed sleep in the morning.



• A disruptive bed partner with loud snoring or periodic leg movements also may impair your ability to get a good night's sleep.

Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms intertwine with those of other medical or mental conditions.

• People with insomnia may complain of difficulty falling asleep. The problem may begin with stress. Then, as you begin to associate the bed with your inability to sleep, the problem may become chronic.
  
  
• Depression and mental illnesses often are associated with insomnia.
  
  
• Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:
  
  
  • Poor concentration and focus
    
    
  • Difficulty with memory
    
    
  • Impaired motor coordination
    
    
  • Irritability and impaired social interaction
    
    
  • Motor vehicle accidents because of fatigued, sleep-deprived drivers
  
  
• People may worsen these daytime symptoms by their own attempts to treat the symptoms.
  
  
  • In 1995, a Gallup poll said 7.9% of respondents used alcohol to help them sleep. Alcohol and antihistamines may compound the problems with sleep deprivation.
    
    
  • Others have tried nonprescription sleep aids.

When to call the doctor

• Your insomnia needs a doctor's attention if it lasts longer than 4 weeks or interferes with your daytime activities and ability to function.

• Insomnia may be a symptom of another medical or psychological problem, which you may need to address first or at the same time.

When to go to the hospital

• Generally, you will not be hospitalized for insomnia. However, accidents may result from poor coordination and attention lapse seen with sleep deprivation.

• Worsening pain or increased difficulty breathing at night also may indicate your need to seek emergency medical care.

Your doctor will begin an evaluation of insomnia with a good medical history.

• The doctor will seek to identify any medical or psychological illness that may be contributing to your insomnia.
  
  
  • For example, you may be asked about chronic snoring and recent weight gain. This may direct an investigation into the possibility of obstructive sleep apnea. In such an instance, your doctor may request an overnight sleep test (polysomnogram). This test is not part of the routine initial workup for insomnia, however.
    
    
  • It is likely that you will be asked to complete a sleep log — a 2-week diary of your sleep-wake periods.
    
    
  • The diary will include your personal assessment of your alertness at various times of the day on 2 consecutive days within the 2-week period.
  
  
• The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness.
  
  
• Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity.
  
  
• Because insomnia may be a symptom of depression, anxiety, or another mental health issue, a mental status examination, mental health history, and basic mental evaluations may be part of your initial assessment.

|Self-Care at Home|

You can do several things to prepare yourself for sleep.

• Exercise regularly.
  
  
  • Aerobic exercise and general fitness are important to maintaining good health.
    
    
  • You should exercise in the early part of the day and avoid strenuous activity before bedtime.
  
  
• Avoid large meals and excessive fluids before bedtime.
  
  
• Control your environment.
  
  
  • Light, noise, and elevated room temperature can disrupt sleep. Shift workers and night workers especially must address these factors.
    
    
  • Your body's circadian rhythm (biological clock) is particularly sensitive to light. Parents who need to sleep during the day may have to make child care arrangements to allow them to sleep.

|Medical Treatment|

Insomnia is a symptom not a diagnosis. As such, your treatment will be personal and will be focused on your underlying condition. Your treatment may include one or more of the following therapies:

• Improving sleep habits



• Correcting sleep misconceptions



• Controlling your sleep environment



• Behavior management



• Light therapy



• Medications

|Medications|

• Nonbenzodiazepine sedatives: These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien).



• Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the center of your brain. At night, melatonin is produced to help your body regulate your sleep-wake cycles. The amount of melatonin produced by your body seems to decrease as you get older.



• Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep.



• For more information on insomnia medications, see Understanding Insomnia Medications.

|Follow-up|

Follow your doctor’s recommendations for your medical and psychological conditions. You will be asked to give your doctor feedback after you have followed a treatment plan.

Often you will have more than 1 option and more than 1 medication available to help you. Do not lose hope if the first medication does not give you the results you want or if you experience side effects or concerns. Report back to your physician for advice.

|Prevention|

The following are suggestions to help anticipate and modify situations likely to be associated with insomnia. They are not foolproof, nor will they safeguard you from the consequences of sleep deprivation once it has occurred.

• Insomnia from jet lag
  
  
  • Behavioral and short-term drug therapy has been employed.
    
    
  • If you can anticipate your trip, begin to shift your bedtime to coincide with the time schedule in your destination.
    
    
  • Short-acting tranquilizers (benzodiazepines) have been shown to be useful. Melatonin, a hormone secreted by the pineal gland that regulates our sleep-wake cycles, is currently being studied.
  
  
• Insomnia from shift changes
  
  
  • Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep deprivation in shift workers.
    
    
  • You should shift your schedules forward in a clockwise direction—from days to evening to night shift—and allow sufficient time to adapt (at least 1 week) between shift changes.
    
    
  • Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a rhythm synchronizer.
    
    
  • Shift workers should stress the importance of good sleep habits with regular bedtime and awakening.
    
    
    • Supplemental naps may be necessary to ensure work time alertness.
      
      
    • Discuss the use of naps with your physician.
      
      
    • Some people promote using short-acting sedatives in the first few days following a shift change, but not everyone agrees.
  
  
• Insomnia from acute stresses
  
  
  • Stress may be positive or negative, and concerns about sleep may vary. Many stressors will go away with support and reassurance.
    
    
  • Education about the importance of good sleep habits also is helpful.
    
    
  • Some people may need short-term medication treatment. Your doctor often will work toward the lowest effective dose with a short-acting sedative to achieve proper sleep.
  
  
• General recommendations include the following:
  
  
  • Work to improve your sleep habits.
    
    
    • Learn to relax. Self-hypnosis, biofeedback, relaxation breathing often are helpful.
      
      
    • Control your environment. Avoid light, noise, and excessive temperatures. Restrict use of bed to sleep and avoid using it for reading, watching TV etc. Sexual activity is an exception.
      
      
    • Establish a bedtime routine. Fix wake time.
    
    
  • Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce use of stimulants including caffeine and nicotine.
    
    
  • If you do not fall asleep within 30 minutes, try a relaxing activity such as listening to soothing music or reading.
    
    
  • Limit naps to less than 15 minutes unless directed by your physician.
    
    
    • It is generally preferable to avoid naps whenever possible to help consolidate your night's sleep.
      
      
    • There are certain sleep disorders, however, that will benefit from naps. Discuss this is with your doctor.

|Outlook|

Recovery from insomnia can vary.

• If you have insomnia caused by jet lag, your symptoms will generally clear up within a few days.
  
  
• If you are depressed and have had insomnia for many months, it is unlikely that your symptoms will go away on their own. You will need further evaluation and treatment.
  
  
• Your outcome will also depend on coexisting medical conditions, which may include congestive heart failure, chronic obstructive pulmonary disease, and chronic pain syndromes.

American Academy of Sleep Medicine
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
(708) 492-0930

American Sleep Association
614 South 8^th St, Suite 282
Philadelphia, PA 19147
(443) 593-2285
sleep@1sleep.com

National Sleep Foundation
1522 K Street, NW, Suite 500,
Washington, DC 20005
(202) 347-3471
nsf@sleepfoundation.org

|Web Links|

American Academy of Sleep Medicine

American Sleep Association

National Heart, Lung, and Blood Institute, Facts About Insomnia

National Sleep Foundation

National Center on Sleep Disorder Research

sleeplessness, stress, anxiety, depression, sleepless, chronic insomnia, acute insomnia, mental illness, sleep habits, insomniac, insomnia, difficulty sleeping, sleep, disorders that disrupt sleep, difficulty falling asleep, primary insomnia, sleep test, polysomnogram, obstructive sleep apnea, insomnia medications, daytime sleepiness, melatonin, nonbenzodiazepine sedatives, pineal gland, jet lag, shift change, parasomnias

Author: Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of New York at Stony Brook.

Coauthor(s): Harbhajan Singh, MD, Chief of Pulmonary Medicine, Director, Department of Respiratory Therapy, South Nassau Communities Hospital.

Editors: Joseph A Salomone III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Richard Harrigan, MD, Associate Professor, Department of Emergency Medicine, Temple University Hospital, Temple University School of Medicine.