By Dr. John Messmer, M.D.
Penn State Milton S. Hershey Medical Center
"To sleep, perchance to dream..." Do you find yourself quoting Hamlet as you lie awake in bed wondering how you'll get through the next day if you don't get some sleep? It's not that uncommon. If you have trouble sleeping, you are among one third of the general population and as many as nine out of 10 older Americans who have trouble getting enough sleep. Insomnia is not one entity -- there can be many reasons why a person can not sleep properly, so just taking a sleeping pill is often not the correct treatment.
Insomnia can be divided into trouble falling asleep or difficulty staying asleep and can be short term or chronic. We establish cycles of awakening in daytime and sleeping at night early in life. Later, school or social activities can disrupt this -- a common occurrence in adolescents who also have a physiologic requirement for more sleep. Shift workers can have difficulty resetting their sleep cycles with frequent shift changes, but even those who consistently sleep during daylight may chronically be deprived of enough sleep.
It may be difficult to relax and fall asleep due to psychological problems such as worrying, or physical symptoms such as pain, coughing or heartburn. Medication side effects also can disturb sleep.
Sleep apnea causes frequent awakenings because of the need to gasp for air. Other people have involuntary muscular activity such as leg movements during sleep or awaken with an urge to get up and move around or use the bathroom.
Medical problems that cause sleep disturbance should be evaluated by a physician. Sometimes a sleep lab evaluation is needed to sort out the cause and prescribe the appropriate treatment. However, most common sleep dysfunction can be prevented or managed with some basic understanding of how to get a good night's sleep.
Don't "confuse" your brain by using the bedroom for anything other than sleep or sex. Watching TV, conducting business and so on can interfere with our ability to clear our minds so we can relax. Try to go to sleep and get up at approximately the same time every day, even on days when you do not have to go to work or school. This helps maintain your wake and sleep cycles.
The hours before sleep should be reserved for relaxing activity. Sleep only when you are sleepy and don't fall asleep somewhere else -- like the couch --then get up and go to bed. Avoid daytime naps if possible. If a short rest is really needed, do it before mid-afternoon and limit the nap to less than an hour.
Caffeine, nicotine and large meals within four to six hours of bedtime can interfere with sleep. Alcohol may seem a reasonable sleep aid since it causes drowsiness, but it also disturbs sleep stages. Strenuous or stimulating activity before bed can delay sleep onset but regular exercise earlier in the day improves sleep. Try to eliminate background noise and light and if you awaken and can not get back to sleep, get out of bed and engage in quiet activity such as reading until you feel sleepy again.
Sleep medications may be useful in some circumstances. Over the counter sleep aids all have a sedating antihistamine as the main ingredient. However, these medications are not appropriate for children or the elderly. If unfamiliar surroundings or unusual circumstances interfere with sleep, the average healthy adult could try these for a night or two although some people feel residual sedation in the morning.
Effective sleep aids are found in a class known as benzodiazepines, most of which are used as antianxiety drugs. One problem -- users can build a tolerance to the drugs requiring greater doses to get the same effect. For short term use, such as, in a hospital or for stressful times, they are acceptable. A newer class of medication works in the same part of the brain as benzodiazepines but leave the system faster and tend not to cause tolerance or addiction.
Various herbal or "natural" aids to sleep are available. Some have been shown to be dangerous -- kava kava has been associated with liver toxicity and contaminated tryptophan caused several deaths. These products are not subjected to the testing done for FDA approved medications so other dangers may yet be discovered. Melatonin has not been found effective for insomnia although it may have usefulness in preventing jet lag or in shifting sleep cycles.
Relaxation therapy has been used for decades to help in a variety of problems including sleep dysfunction. This technique is a skill which requires practice but once mastered can be a lifelong aid in achieving rest and stress reduction. Methods vary but usually involve a series of exercises. Typical programs include the use of relaxing imagery or progressive muscle relaxation. Starting at the feet, letting muscles intentionally relax one group at a time until the entire body is relaxed slows one's physiology and allows the brain to move into sleep mode.
If you are able to get through the day without being sleepy and find no difficulty concentrating you are probably getting enough sleep even though you may remember being awake often during the night. However, if you need a nap or find yourself falling asleep commonly during the day, you may not be getting enough sleep. If you have eliminated the distractions and problems noted above, and still have trouble, check with your doctor.
The National Heart Lung and Blood Institute website offers more information about sleep and sleep disorders: http://www.nhlbi.nih.gov/about/ncsdr/