The Medical Minute: Trouble sleeping is a significant problem

April 06, 2005

By John Messmer
Penn State Family and Community Medicine
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine

"To sleep, perchance to dream -- aye, there's the rub." Hamlet wasn't discussing his trouble sleeping, but his anxiety might have kept him awake. If so, he would have been like 15 percent of Americans with short-term insomnia. With the 10 percent of us with chronic insomnia, one quarter of us at any time has trouble sleeping. Of those, less than one-third ever seek medical treatment.

Insomnia does not refer simply to a lack of sleep but to one of several possible problems including difficulty falling asleep, frequent awakenings with trouble returning to sleep, awakening too early in the morning and failing to awaken refreshed. People vary in the amount of sleep they need to feel rested so insomnia is not defined by a certain number of hours of sleep. Older people and women tend to have complaints of insomnia more often.

Insomnia can be short term, long term or intermittent. Many things can contribute to developing insomnia. Stress, environmental noise and temperature extremes or a change in surroundings may interfere with relaxation. Changes in sleep and wake cycles as in shift workers and travelers across time zones affect the internal mechanisms that allow sleep. Medications and foods also can contribute as can smoking.

Chronic insomnia is more complex and may stem from medical problems and treatments, psychiatric disorders, caffeine and alcohol and the use of over-the-counter and prescription medications, and varying schedules whether from shift work or other nighttime activities. Aging affects the stages of sleep. Older people have about the same sleep needs as younger people, but may divide it between night and daytime. As people experience insomnia, they may try to treat it in ways that make the problem worse.

Sometimes people have sleep state misperception, a condition in which they think they are not sleeping adequately but actually do get enough sleep. Normal sleep has cycles of light and deep sleep and every 90 minutes or so, brief awakenings. As we age, the duration of awakening increases from a few seconds to about a minute and a half. Sometimes people remember being awake and conclude they have not slept.

If a person experiences acute insomnia, he or she may worry it will become a long-term problem. This interferes with relaxation and perpetuates the problem. Due to reduced sleep, a person may turn to caffeine to promote daytime wakefulness. As we age, we become more sensitive to caffeine's side effects, resulting in even more trouble sleeping. Long daytime naps due to sleepiness can make it harder to get to sleep in the evening. Over-the-counter sleep aids may improve sleep in the short term, but we rapidly develop tolerance to these and they can sometimes affect sleep quality so we do not awaken rested.

There are things you can do to prevent insomnia or treat it should it occur. Regular exercise promotes healthy sleep patterns as long as it is not close to bedtime. Tobacco is not only harmful to your health; it can interfere with sleep, so avoid it. People vary in their sensitivity to caffeine, but if you are having trouble sleeping, avoid it after noon. Be wary of decongestants, which can be stimulating. While alcohol can make you sleepy, it is not a sleep aid and can make the problem worse. Limit alcohol in the evening.

Avoid stimulating activities, such as, exciting books, movies or games before bedtime. Try to keep the same routine each evening. Our bodies recognize the pattern after a while and begin to get our brains ready for sleep. Don't try to make up for lack of sleep by staying in bed longer. Try to go to bed and arise at roughly the same time every day, even on weekends, so that internal cycles settle into a pattern. Use the bedroom only for sleeping and sex, not for TV and other activities to help maintain the pattern. Keep the bedroom as dark as possible and slightly cooler than the other rooms.

If someone finds himself unable to get to sleep, he should get up and do something quiet for 10 to 20 minutes until he is sleepy, then return to bed. It's easy to tell someone to avoid stressful thoughts and worries, but it takes practice to accomplish it. If an individual is a worrier, try to set aside time just after the evening meal to put your worries on paper and deal with them then.

Relaxation techniques are a good way to learn to fall asleep, but the skill must be developed. There are many books, tapes and CDs on the market to teach the process. Mastery of relaxation can help us deal with daytime stress as well.

Some individuals' sleep phases are out of alignment with normal. Adolescents are typical of this, but adults may find themselves unable to get to sleep until the middle of the night and unable to get out of bed until noon. Sleep phase shifting by gradual adjustment of sleep and waking times and use of bright light at appropriate times can help this, but it requires some experience to set the parameters of treatment.

If an individual continues to have difficulty with sleep, a medical evaluation may help. Pain can interfere with sleep. Arthritis, neurologic conditions, fibromyalgia, heart and lung problems, and various medications can affect sleep. Physicians may look for certain sleep-associated medical problems, such as, sleep apnea, restless leg syndrome or periodic leg movement disorder. Some basic testing may be done and occasionally an evaluation in a sleep laboratory is needed. Physicians need to sort out whether the insomnia is due to environmental, psychological or medical problems.

Sometimes a medication is useful in the management of insomnia. When sleep stages are disrupted, a low dose of one of several antidepressants can restore normal sleep architecture. Short-term insomnia can be managed with one of the newer prescription sleeping medications. Older medications were in the benzodiazepine class, the same as tranquilizers such as Valium. Over time, people developed tolerance to the effects and could become addicted. Newer benzodiazepines were safer but still had potential long-term problems.

For several years, a new class of medications is available. They work like benzodiazepines but are not in that class. While no medication is totally safe, these appear to be safer than previous medications. Some people have long-term insomnia that does not respond well to other treatment methods. Medical research has suggested that long-term use of these non-benzodiazepines might be appropriate in selected circumstances.

If individuals find themselves unable to get the kind of sleep needed to meet the day's demands, they should consider their daily habits. Avoid over-the-counter sleeping aids, except for rare use and consider seeing their doctors to get their 40 winks and pleasant dreams.

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Last Updated March 19, 2009