Insomnia

What is insomnia?

Insomnia is when you don’t get the recommended amount of sleep. This could mean insufficient sleep, poor-quality sleep, or difficulty falling or staying asleep. Although this condition is a mild inconvenience for some individuals, it can lead to significant disruption for others. In general, the causes of insomnia can vary widely.

The body requires sleep for various reasons, and scientists are still trying to understand why it is crucial to health. However, experts suggest that insufficient sleep can lead to sleep deprivation, which tends to be unpleasant and prevents optimal functioning.

How do sleep needs and habits differ, and what does it mean for you?

Sleep needs and habits can significantly differ from one person to another. Due to these differences, a range of sleep behaviours is considered ‘normal’ by experts. Common examples include:

• Early birds or early risers: Some individuals prefer going to bed early and waking up early.
• Night owls or late risers: Others prefer staying up late and waking up late.
• Short sleepers: Certain individuals naturally require less sleep than others. According to research, this could be due to genetic factors.
• Learned sleep differences: Some individuals adjust their sleep habits based on specific needs, such as their profession. For example, military personnel with combat experience often learn to become light sleepers due to job demands and associated risks. Conversely, others may learn to sleep heavily to avoid disturbances from surrounding noise.
• Natural alterations in sleep needs: Sleep needs tend to change throughout a person’s life. Infants, for instance, require significantly more sleep, ranging from 14 to 17 hours per day. On the other hand, adults aged 18 and older need at least 7 to 9 hours of sleep per day.

Types of insomnia

Experts typically categorise insomnia in two primary ways:

• Time: Insomnia can be classified as short-term (acute) or long-term (chronic). Chronic insomnia is also referred to as insomnia disorder.
• Cause: Insomnia can be classified as primary or secondary. Primary insomnia occurs independently, while secondary insomnia indicates an underlying condition or situation.

Symptoms

The symptoms of insomnia can include the following:

• Difficulty falling asleep at night.
• Waking up at night.
• Waking up too early.
• Feeling exhausted or sleepy throughout the day.
• Feeling depressed, anxious, or irritable.
• Trouble concentrating, focusing, or remembering things.
• Making more mistakes or being involved in more accidents.
• Constantly worrying about sleep.

Causes

Insomnia can be the primary issue or a symptom of another condition. Long-term insomnia is often caused by stress, major life events, or behaviours that interfere with sleep. Addressing the underlying cause may help resolve insomnia, but in some cases, sleep disorders can persist for years.

Common reasons for long-term insomnia include:

• Stress: Worrying about school, work, health, finances, or family can make it difficult to fall asleep at night as your mind is active. Stressful life events, such as illness, the death of a loved one, job loss, or divorce, can also trigger insomnia.
• Travel or work schedule: Disruptions of the body’s circadian rhythms, which regulate sleep-wake cycles, body temperature, and metabolism, can result in insomnia. Possible causes include jet lag from travelling across time zones, working early or late shifts, or frequently changing shifts.
• Poor sleeping habits: Irregular sleep patterns, such as sleeping and waking at different times each day, napping, too much activity before bed, and an uncomfortable sleep environment can contribute to insomnia. Additional poor habits include eating, working, or watching TV in bed, as well as using smartphones or computers and playing video games before bedtime.
• Excessive eating late in the evening: While a light snack before bed is acceptable, overeating can lead to discomfort when lying down. Many individuals experience heartburn, where stomach acid flows back into the oesophagus (the tube transporting food from the mouth to the stomach), keeping them awake at night.
• Mental health problems: Anxiety disorders, including post-traumatic stress disorder (PTSD), can disrupt sleep. Additionally, waking up too early may signify depression. Generally, insomnia coexists with other mental health problems.
• Medications: Certain prescription medications, like some antidepressants and drugs for asthma or high blood pressure, can disrupt sleep. Over-the-counter medications, including some pain relievers, allergy and cold medicines, and weight-loss remedies, often contain caffeine or other stimulants that may interfere with sleep.
• Health conditions: Chronic pain, cancer, heart disease, diabetes, asthma, overactive thyroid, gastroesophageal reflux disease (GERD), Alzheimer’s disease, and Parkinson’s disease are examples of medical conditions associated with insomnia.
• Sleep-related conditions: Disorders like sleep apnoea, which causes breathing interruptions at night, can disrupt sleep. Restless legs syndrome, which leads to a strong urge to move your legs, can also interfere with the ability to fall asleep or return to sleep.
• Caffeine, nicotine, and alcohol: Beverages like tea, coffee, cola, and others containing caffeine are stimulants and could prevent you from falling asleep if consumed in the late evening or afternoon. Nicotine, found in tobacco products, can also disrupt sleep. While alcohol may initially assist with falling asleep, it hinders deeper sleep stages and usually causes you to wake up in the middle of the night.

Insomnia and ageing

Insomnia generally becomes more common as you age. Possible reasons for this include:

• Alterations in sleeping patterns: Sleep tends to become less restful with age; hence, noises and other disturbances can easily wake you. Your internal clock may also shift, making you feel tired earlier in the evening and waking up earlier in the morning. However, despite these changes, older adults still require the same amount of sleep as younger individuals.
• Changes in activity levels: With age, you may become less physically or socially active, making it more difficult to sleep well at night. Inactivity can lead to more daytime napping, which can interfere with your nighttime sleep.
• Health changes: Persistent pain from conditions like arthritis or back problems, along with feelings of depression or anxiety, can interfere with sleep. Issues with the prostate or bladder that increase the urge to urinate at night can also disturb sleep. Sleep apnoea and restless legs syndrome tend to be more common with age.
• Use of more medications: Older adults generally take more prescription medications than younger individuals, increasing the likelihood of experiencing insomnia related to drugs.

Insomnia in children and teenagers

Sleep disorders can also affect children and teenagers. However, some young people have difficulty falling asleep or resist a routine bedtime due to a delayed internal clock. As a result, they prefer going to bed late and sleeping in later in the morning.

Risk Factors

Most people experience a sleepless night occasionally. Nonetheless, these factors can increase your risk of having insomnia:

• Gender: In women, hormonal changes during the menstrual cycle and menopause can significantly contribute to insomnia. Hot flashes and night sweats during menopause often interfere with sleep. Sleep disorders are also prevalent during pregnancy.
• Age: People over 60 years are more likely to experience insomnia due to alterations in sleep patterns and overall health.
• Mental and physical health problems: Various issues can impact psychological or physical health, thus disrupting sleep.
• Too much stress: Stress can lead to acute insomnia, while long-term or excessive stress can cause chronic insomnia.
• Irregular schedules: Frequent changes, such as shifts at work or travelling, can interfere with your sleep-wake cycle.

Complications

Sleep is essential to overall health, just as much as a nutritious diet and regular exercise. Regardless of its cause, insomnia can have mental and physical effects. Individuals with insomnia often report a reduced quality of life compared to those who sleep well.

Possible complications associated with insomnia include:

• Poor performance at work or school.
• Slower response times while driving, increasing the risk of accidents.
• Mental health issues, including anxiety, depression, or substance abuse.
• A higher likelihood or worsening of chronic conditions or disorders like heart disease and high blood pressure.

Prevention

Practice the following proper sleep hygiene to prevent insomnia:

• Maintain a consistent sleep schedule by going to bed and waking up at the same time each day, even on weekends.
• Stay active, as regular exercise can promote better sleep.
• Limit or avoid daytime naps.
• Reduce or eliminate alcohol, caffeine, and nicotine consumption.
• Avoid large meals and excessive fluid intake before bedtime.
• Ensure your bedroom is comfortable for sleeping and reserved only for sleep or sex.
• Create a relaxing bedtime routine, such as taking a warm bath, listening to soft music, or reading.

Diagnosis

Based on your specific situation, insomnia diagnosis and identifying its cause may involve the following procedures:

• Physical examination: If the reason for your insomnia is unknown, your doctor may perform a physical exam to check for signs of underlying medical issues that could be causing your sleep disorder. Sometimes, blood tests are ordered to assess thyroid problems or other health conditions associated with poor sleep quality.
• Reviewing your sleep habits: Your doctor may inquire about your sleep patterns and ask you to fill in a questionnaire to evaluate your sleep-wake cycle and level of daytime sleepiness. You might also be asked to maintain a sleep diary for a few weeks to track your sleeping habits.
• Sleep study: If the causes of insomnia remain unclear or if there are signs of a different sleep disorder, such as sleep apnoea or restless legs syndrome, you may need to stay overnight at a sleep centre. Various tests, including brain waves, heart rate, breathing patterns, and body and eye movements, will be conducted to monitor and record several body activities while you sleep.

Treatments

Adjusting sleep patterns and addressing any underlying problems associated with insomnia, including stress, health conditions, or medications, can lead to better sleep for most individuals. However, if these measures aren’t effective, your healthcare provider may suggest cognitive behavioural therapy (CBT), medication, or a combination of both to enhance sleep and help you relax.

CBT for insomnia

Cognitive behavioural therapy for sleep disorders can assist in managing or stopping negative actions and thoughts that disrupt your sleep. This is typically recommended as the first line of treatment for those with insomnia. In most cases, CBT is more effective compared to sleep medications.

The cognitive part of CBT helps you understand and change beliefs affecting your sleep. It can also assist in managing or eliminating negative thoughts and concerns that keep you awake. Additionally, CBT may involve breaking the cycle of worrying about falling asleep, which prevents you from sleeping.

The behavioural part of CBT helps you adopt proper sleeping habits and eliminate behaviours that prevent a good night’s sleep.

Strategies of CBT involve:

• Stimulus control therapy: This procedure trains your body and mind to sleep well rather than fighting sleep. For instance, you may be taught to set a regular time to sleep and wake up, avoid napping, and only use your bed for sleeping and sex. You might also be encouraged to leave the bedroom if you can’t fall asleep within 20 minutes and only return when you feel sleepy.
• Relaxation techniques: Techniques such as progressive muscle relaxation, breathing exercises, and biofeedback can reduce anxiety at bedtime. Implementing these approaches helps regulate heart rate, breathing, and muscle tension to promote relaxation.
• Sleep restriction: This method involves reducing the time spent in bed and eliminating daytime napping to encourage deeper sleep. As your sleep improves, you can gradually increase your bedtime.
• Staying passively awake: Known as paradoxical intention, this strategy focuses on reducing anxiety and concerns about falling asleep. Instead of expecting to sleep, you try to remain awake, making it easier to fall asleep by relieving the pressure to do so.
• Light therapy: If you usually sleep and wake up too early, light therapy can help adjust your internal clock. Consider going outside to get exposure to evening light or using a lightbox. Consult your doctor for appropriate advice on this therapy.

Your healthcare provider can suggest additional strategies related to lifestyle and sleep environment to promote habits that contribute to better sleep at night and daytime alertness.

Prescription medicines

Prescription sleeping pills may be recommended to assist with falling asleep, staying asleep, or both. Generally, healthcare providers advise against using these medications for longer than a few weeks. Moreover, drugs shouldn’t be the only solution for insomnia. Several medications have been approved for prolonged use.

The duration of using sleeping pills is unclear. Each prescription is made on a case-by-case basis, and with your provider's help, you will weigh the associated benefits and risks. It’s advisable to take the lowest effective dosage and avoid long-term use.

Medications for individuals struggling to fall asleep include:

• Eszopiclone (Lunesta)
• Ramelteon (Rozerem)
• Triazolam (Halcion)
• Temazepam (Restoril)
• Zaleplon (Sonata)
• Zolpidem tartrate (Ambien, Ambien CR, Edluar)

For those who struggle to remain asleep, wake up too early, or find it difficult to fall back asleep, the following medications may be prescribed:

• Doxepin hydrochloride (Silenor)
• Eszopiclone (Lunesta)
• Suvorexant (Belsomra)
• Temazepam (Restoril)
• Zolpidem tartrate (Ambien, Ambien CR, Edluar)

In most cases, prescription sleeping pills can be associated with side effects like daytime drowsiness and an increased risk of falls. Moreover, they could lead to dependency. It’s important to discuss the side effects and duration of use with your doctor if sleep aids are prescribed.

Non-prescription medicines

Non-prescription or over-the-counter sleeping pills typically contain antihistamines, which can cause drowsiness. However, these should not be taken regularly.

It is important to consult with your physician before taking sleep aids, as antihistamines can result in side effects such as daytime sleepiness, confusion, dizziness, cognitive difficulties, and urination problems. These effects may be more pronounced in older adults.

Lifestyle and Home Remedies

Insomnia is generally a treatable condition, regardless of age. The solution often lies in making adjustments to your daytime and bedtime routine.

The following tips may be helpful:

• Follow a consistent sleep schedule: Go to bed and wake up at the same time each day, even on weekends.
• Stay active: Regular exercise can promote better sleep. Schedule activities for several hours before bedtime and avoid vigorous workouts close to sleep time.
• Check your medications: If you regularly take medications, consult your doctor to see if they might contribute to insomnia. Read labels on over-the-counter products to check for caffeine or stimulants like pseudoephedrine.
• Limit or avoid naps: Napping can make it harder to sleep at night. If you must nap, try to restrict it to 30 minutes or less and avoid napping past 3 p.m.
• Limit or avoid alcohol, caffeine, and nicotine intake: These substances can make it difficult to fall asleep, with effects that may last for several hours.
• Address pain: If pain is affecting your sleep, speak with your doctor about suitable pain relievers to manage discomfort at night.
• Avoid large meals or excessive fluid intake before bedtime: A light snack is acceptable and can help prevent heartburn. However, limit fluid consumption before bed to avoid frequent trips to the bathroom.

During bedtime:

• Create a comfortable sleeping environment: Reserve your bedroom for sleep and sex only. Keep it quiet, dark, and at a comfortable temperature. Remove clocks, such as watches or mobile phones, to avoid worrying about time.
• Relax before bed: Set aside your concerns once you’re in bed. Consider getting a massage or taking a warm bath to prepare for sleep. You can also develop a calming nighttime routine that includes listening to soft music, reading, praying, or doing yoga or breathing exercises.
• Avoid forcing sleep: Trying too hard to fall asleep can be counterproductive. Instead, get out of bed and read until you feel sleepy, and then return to bed. Avoid going to bed too early before you feel drowsy.
• Stay out of bed when not sleeping: Get as much sleep as you need to feel rested, and then get out of bed. Avoid lying in bed when you aren’t sleeping.

Alternative medication

Many individuals with insomnia don’t consult a healthcare provider and instead try to cope with the disorder on their own. Others opt for alternative therapies, such as:

• Melatonin: This non-prescription supplement is often used to address insomnia. Although melatonin is generally safe for short-term use, there isn’t solid evidence supporting its effectiveness for treating insomnia. Moreover, its long-term safety remains unclear. The American Academy of Sleep Medicine advises against its prescription by doctors and mental health specialists.
• Valerian: This dietary supplement is taken as a sleeping aid due to its mild sedative effect. Valerian hasn’t been thoroughly studied; thus, it’s important to consult your healthcare provider before using it, as high dosages and prolonged use have been linked with liver damage. However, it’s unclear if this drug caused the damage.
• Acupuncture: Acupuncture is often used to address insomnia; however, due to a lack of evidence supporting its effectiveness, this therapy is usually not recommended.
• Yoga or Tai Chi: Some studies suggest that regularly practising yoga or tai chi can promote a good night’s sleep. However, this therapy is not typically recommended due to insufficient evidence supporting its benefits.
• Meditation: Some studies indicate that meditation, in combination with conventional treatment, can promote better sleep quality and lower stress.

Preparing for Your Appointment

If you're experiencing trouble sleeping, the first step will likely be to consult your primary caregiver. Inquire about any preparations you need to make, such as keeping a sleep diary, before your visit. If possible, bring your bed partner to provide more information regarding your sleep patterns.

What to do

Get ready for your appointment by creating a list of the following:

• Your symptoms, including those that may seem unrelated to your sleeplessness.
• Personal information, such as any new or persistent health issues, significant stresses, or recent lifestyle changes.
• All medications you take, including over-the-counter drugs, vitamins, and herbal supplements, along with their dosages. Inform your physician of anything you have used to assist you in falling asleep.
• Questions you plan to ask your doctor to ensure you cover everything during your appointment.

Essential questions to consider asking your doctor might include:

• What could be causing my sleeplessness?
• What is the suitable treatment?
• How can I create an ideal sleeping environment?
• How can I manage my insomnia along with my other medical conditions?
• Should I visit a sleep clinic or consult a sleep professional? Will my insurance cover this?
• Do you have brochures or other printed materials I can take with me?
• What websites do you recommend for reliable information?

Feel free to ask any additional questions that arise during your appointment.

What to expect from your doctor

Your healthcare provider is likely to ask you several questions about your insomnia. Common questions may include:

• How often do you experience difficulty sleeping?
• When did your insomnia start?
• How long does it usually take before you fall asleep?
• Do you snore or wake up choking for air?
• How frequently do you wake up during the night, and how long does it take to fall back asleep?
• How do you react when you can't sleep?
• What remedies have you tried to enhance your sleep?

Common questions your doctor may ask regarding your daytime routine include:

• Do you wake up feeling refreshed, or do you feel exhausted during the day?
• Do you doze off or find it hard to stay awake when sitting quietly or driving?
• Do you take naps during the day?
• What do you typically eat and drink in the evening?

Common questions about your bedtime routine may include:

• What is your sleeping routine?
• Are you taking any medications, like sleeping pills, before bedtime?
• What time do you normally sleep and wake up? Is it different on weekends?
• How many hours do you usually sleep each night?

Questions on other issues affecting your sleep may include:

• Have you experienced any recent stressful events?
• Do you consume alcohol or use tobacco?
• Do other members of your family have sleep disorders?
• What medications do you take regularly?
• Do you have an uncomfortable urge to move your legs while trying to fall asleep?