I want to introduce insomnia and review some of the causes, the evaluation, and some ideas about managing. The vast majority of people with insomnia have difficulties with falling asleep or maintaining sleep. They often don’t recognize that there are simple and quick fixes to help improve insomnia without medications.
What is insomnia?
Either difficulty with falling asleep. These are difficulties with sleep initiation. Difficulties maintaining sleep that is awakening that is undesirable in the middle of the night with difficulties falling back asleep or early morning awakening. Those are the type of symptoms that patients present with how they can have a combination of sleep initiation and sleep maintenance or sleep maintenance; only any of those would be sufficient to diagnose insomnia.
Early morning awakening is often suggesting depression.
The next day consequences are really what defines insomnia as a disorder.
- Difficulties with memory and cognitive issues.
- Difficulties with fatigue the next day
- feeling depressed.
Those are the type of symptoms that can indicate a sleep disorder that we need to treat. Having difficulties with sleep initiation or maintenance without daytime consequences may not be a disorder; however, if the patient has problems with daytime symptoms, that’s a red flag where we need to intervene with management.
Also, there is a frequency. That is at least three times per week for chronic insomnia. We need three months of insomnia to occur at any given time.
How frequent is insomnia in the general population?
It’s pretty common and frequent. One in ten people has chronic insomnia. More like 30% of the population having it at any given time.
As we grow older, the rates of sleep disturbances tend to go higher. And it’s not typical for women right around the time of menopause. Insomnia mostly has to do with depression and anxiety. Also, frequent urination at night because of prostate enlargement, medications for other medical issues, and psychiatric complaints tend to increase with aging around late life.
Older adults need as much sleep as younger adults. They need eight hours of sleep as let’s say 20 years old. However, their ability to sleep is disrupted.
What causes insomnia and also how to treat insomnia
Insomnia can be transient or acute. That has to do with an exam or pain or hospitalization versus chronic insomnia, which tends to occur with depression and other medical and psychiatric conditions.
There are predisposing factors, and there are precipitating factors, and there are perpetuating factors.
You have to have predisposing factors and precipitating factors. These include individuals who have an anxiety disorder or depression, or they’re just having the symptoms of anxiety just before they’re about to fall asleep.
Precipitating factors can include issues related to pain, hospitalization, loss of a loved one, and jetlag issues as if you travel to Europe tomorrow. That’s the precipitating factor for insomnia. They’re going to precipitate a sleep issue.
Perpetuation issues are related to bad habits and poor sleep hygiene.
Here’s a breakdown of some causes of insomnia:
- About two-thirds of patients probably have some underlying behavioral or psychotic issues like depression or anxiety.
- Imperfect environment. Such as living by the airport or having too much or excessive light exposition just around at time going to bed.
- Poor sleep hygiene.
When should you see a sleep physician or when should you have a sleep study?
If they complain of insomnia and have daytime consequences, that’s a clinical diagnosis. You don’t really need to do an expensive sleep study to diagnose it.
However, if the patient snores if they stop breathing at night or kick their legs at night and the leg movements are disruptive, that’s a critical issue. Those are important symptoms to evaluate further by doing a sleep study. Specifically, we’re looking for sleep apnea.
Sleep apnea can also cause insomnia, especially sleep maintenance insomnia. If you snore, you stop breathing that tends to fragment your sleep architecture. That’s a good reason to see your doctor and get further evaluation. A sleep study can ensure that the patient doesn’t have sleep apnea or other motor disorders. Other movement disorders that keep people awake at night are periodic leg moments during sleep. It’s essential to be able to rule out those conditions using a sleep study.
We treat sleep apnea with continuous positive pressure therapy. That’s the CPAP. It improves sleep quality. And likewise, when we treat the leg movements with specific medications, they’re less disruptive, and the patient can actually have improved sleep duration.
What is sleep hygiene?
It would help if you didn’t want to be sleep deprived one day and then make it up the next day. You want to get about 8 hours of sleep every single night. And, more importantly, at the same time during the night consistently.
Here is a list of some dos and don ts. Most of you are probably familiar with this.
Enhance your sleep environment:
- dark bedroom
- cold temperature
By cold temperature, I mean something around 65 – 68 degrees Fahrenheit, but cooler is actually better because it promotes melatonin’s secretion.
- Increased light exposure during the day, not during the night, so we want to maximize light in the morning and afternoon.
- Relaxation routine, such as deep breathing.
- Regular exercise, but in the morning or early afternoon. Never too close to bedtime.
Some people do yoga before bedtime. Reduce the time bed in which you are awake. So if you find that it takes you 15 minutes to fall asleep and you haven’t fallen a thick, you need to get up, you need to move to a different room. You need to pick up a boring book, and when you feel that you are sleepy, you should go back to bed.
Here are some things that you shouldn’t do
- Do not watch the clock. You’re going to look at the clock, and you’re going to feel more and more frustrated. Why it is now 2:00 or 3:00 in the morning, and you haven’t been able to fall asleep. So get rid of the clock.
- Don’t use stimulants. Particularly caffeine and tobacco, especially too close to bedtime.
- Don’t go to bed on a full stomach.
- At the same time, don’t go to bed on an empty stomach. When you’re feeling hungry, you can have a piece of banana, granola, or some crackers with cheese, which can improve your tryptophan levels.
- Limit your beverage consumption close to bedtime. So you can prevent those episodes of say awakening because your bladder is full.
- Should be not doing work in the in bed. The bed is really supposed to be used for sleep, sex, and sickness.
- Don’t watch television or work on the computer or your phone just before bedtime because the light from the screen is very disruptive.
- If you have a mattress that’s not very comfortable, you might want to invest in a new mattress or a more beneficial pillow for sleeping.
Never use alcohol as a hypnotic
Even though alcohol is notorious for worsening the sleep quality causing multiple awakenings, up to 28 percent of people use alcohol before bedtime. Because alcohol relaxes them, people don’t recognize that having a glass or two of wine before going to bed can disrupt their sleep patterns.
When you fall asleep, you stop drinking, and when you wake up, you perpetuate insomnia. Alcohol can make you snore and fragment your sleep, make you have sleep apnea.
If you are snoring, it can disrupt your good quality sleep, and it has some issues with dependence tolerance.
If you are not able to sleep, do something relaxing or boring. Get out of the bedroom and use a dim light, and when they feel sleepy again, they can go back to bed.
When all of those factors are removed, it can reverse insomnia and improve the symptoms without using any medications.
Medications that can help you fall asleep
Those are called hypnotics are medications that we use to help improve your ability to fall asleep.
Some of the medications that we use specifically to improve sleep enhance the brain’s inhibitory neurotransmitter that allows for improved quality sleep. For example, benzodiazepines. Drugs that make you sleepy include histamine antagonists like Benadryl, but you will wake up very dizzy.
For insomnia, there is a relatively new medication on the market that’s approved for sleep initiation. The medication is Rozerem (Ramelteon) is indicated for folks who have difficulties falling asleep, and they take it before bedtime. It’s actually very effective in helping improve sleep duration. It’s available on prescription.
Avoid drugs that last too long because then you can wake up and be dizzy all day. Also, don’t take drugs that don’t really have sufficient duration, so it only lasts for an hour where you have an issue very early in the morning. That’s not going to be sufficiently long enough to improve sleep quality. You want the medication to be effective sufficiently long enough to cover the night.
Using over-the-counter medications for insomnia
You can buy over the counter dietary supplements that include melatonin and valerian. Your body produces melatonin. The only problem with melatonin for insomnia is the timing, and the dose is not really well established. However, melatonin helps with jet lag, for example.
Tylenol contains acetaminophen, and it can damage your liver. Advil is a non-steroid anti-inflammatory drug. In the case of an Advil PM, the PM formulation contains diphenhydramine, an antihistamine. It can make you dizzy and can, in older adults, have a paradoxical reaction. Therefore, insomnia can become more severe. If you’re using those substances, probably you may have improved sleep, but over a long period of time, they can damage your stomach and kidneys.
You should never take those substances regularly. If you have insomnia once a week or once a month and associated with pain, using those substances maybe once a week or a month is okay.
Antidepressants for insomnia
Those drugs actually never have been studied specifically for insomnia, and I wouldn’t really recommend them for older adults because they tend to cause your blood pressure to drop and your heart rhythm change. There is also the issue of fatigue and sleepiness the next day.
Alon Avidan MD, MPH, professor of neurology, UCLA Sleep Disorders Center, Department of Neurology https://www.uclahealth.org/neurology/sleep-disorders