Insomnia
What is insomnia?
Insomnia means difficulty getting into sleep, or, once asleep, difficulty to continue sleeping for appropriate amount, or both. It is a malfunction of normal sleep mechanisms, from a variety of causes.It may be useful to know basics of normal sleep before addressing its malfunction.
What is sleep? And why do we need it?
Sleep is critical to our living. Without sleep, we may easily get sick, both psychologically and physically, and not be able to sustain. Every cell in our body goes through some type of reparative process on daily basis, including the cells and the circuitry of the brain. One of the main functions of sleep is to clean and repair brain cells, and de-clutter and rearrange its operations. It is not just a passive process of shutting a switch off, it is rather a sophisticated interplay of chemical and electrochemical signaling, turning some circuits off and others on, to achieve full benefit of every stage and cycle of sleep. Cellular waste material is collected and cleared during sleep. Every type of experience our body goes through, consciously or subconsciously, is a potential part of our memory bank. All that is reviewed; most of it discarded while some kept. What is kept is cataloged and stored, either in temporary folders or permanent, depending upon its value for our survival and wellbeing.
What are different stages and cycles of sleep?
Sleep stages: Sleep is divided into four stages: N1, N2, N3, and REM. The letter N stands for non-REM sleep. It typically starts with getting drowsy followed by light sleep when we are still somewhat aware of our surroundings. This is the N1 stage of sleep. As we go deeper into sleep, we completely lose awareness of our surroundings by entering N2 sleep. After that is N3 sleep, which is deep sleep and, if someone tries to wake us up, it is little difficult to come out of it. The next stage of sleep is REM sleep, which sometimes is also called paradoxical sleep. This is because our brain, if we check its electrical activity during this stage, seems to be awake but we are not. In this stage, our eyes flicker or move rapidly, so is the name of REM (rapid eye movement) sleep. REM also is lighter part of sleep.
I described stages of sleep in these simple descriptive terms, though in practice, stages are determined based upon changes in brain’s electrical activity, or EEG. Sleep stages are in a continuum, meaning that N1 is followed by N2, to N3, and then REM sleep, but there may not be much or any N3 sleep during later parts of the sleep, while the duration of REM sleep increases with every passing cycle of sleep.
Sleep cycles: As we go into sleep, we start with N1 sleep that may last for a few minutes. It leads to N2 sleep, which may continue for 30-60 minutes. After that we may enter N3 sleep, which may last for 10-30 minutes. Finally, we enter REM sleep that may last for 10-20 minutes. The whole set of N1, N2, N3 and REM sleep stages lasts for about 90-120 minutes, and is called a sleep cycle. As one cycle ends, we go into another similar cycle, and before we wake up, we may have gone into one or two more cycles of sleep. Most of the deep sleep occurs in the first or early cycles, later replaced by N2 sleep. Also, the amount of REM sleep increases in later parts of sleep.
What is appropriate sleep?
Sleep is not just lying down in bed for certain number of hours; appropriate sleep fulfills some other criteria.
Sleep quality: Quality of sleep is a measure of different stages of sleep. In a good quality sleep, we go through normal amount of different stages of sleep. An example of a poor-quality sleep is to have minimal or no N3 (deep) sleep. Each stage of sleep has its particular significance and function, a lot of which is unknown. Sleep quality may be disturbed in patients with depression, and by the medicines taken to treat it.
Sleep efficiency: Efficiency of sleep is a measure of the amount of time we are asleep compared to the total amount in the bed. Sleep efficiency is considered good when a person is asleep more than 90% of sleep time. Efficiency of sleep declines if, while in the bed for sleeping, one spends less time sleeping and more staying awake. This is one of the main issues in insomnia.
Sleep continuity: One may believe to have totaled many hours of sleep but when looked closely, there may be frequent arousals, sometimes almost every minute. This is the issue in obstructive sleep apnea.
Sleep related risks: In some patients, sleeping put them under risk of a medical condition. A good example is a patient with lung disease whose blood oxygen level may drop during sleep to the extent that supplemental oxygen may be needed.
What normally happens during REM sleep?
REM sleep is a relatively lighter and somewhat dramatic stage of sleep. It comes at the tail end of each sleep cycle, and more so in morning hours. It is understood that memories are handled and cataloged in this stage, especially the ones with emotional connotations. It is also the stage when dreaming can occur, especially dreams with emotional undertones. Some of these dream situations can be emotional enough to wake the person up, like a fearful or a sexual encounter. Even in normal situations, these arousals can be so vivid that we may never forget them. REM sleep is actively turned on and off in the brain. When on, another circuitry that controls voluntary motor activity of our body is disabled. So, in normal circumstances we do not fully act out our dreams. This is with some exceptions, such as nocturnal sexual emission, which is considered a normal experience. On the other hand, in REM sleep behavior disorder, the patient may act out dream activity by shouting, kicking, or getting out of bed.
What are different types of insomnia?
For better understanding, one may divide insomnia in types in a few different ways:
Based upon duration: Insomnia can be acute, or chronic, if it lasts more than 3 months
Based upon severity: Insomnia can be mild, moderate, or severe
Based upon time: Sleep onset insomnia (difficulty falling asleep), sleep maintenance insomnia (difficulty staying asleep), and terminal insomnia (early am awakening.
Based upon the cause: Primary insomnia (no obvious cause), secondary insomnia from a known condition or a definable reason
How does finding the type of insomnia help with diagnosis and treatment?
Most patients with insomnia have difficulty going into sleep, which is sleep onset insomnia. This is also the classic problem with restless leg syndrome. On the other hand, some patients have no problem going into sleep, and in fact they may start sleeping moments after putting their head on the pillow, but they have difficulty maintaining their sleep. For many reasons, they may keep on waking up. Patients may remember awakening, if it is more than a few minutes, or not, if only for a few seconds. A patient with sleep apnea may wake up hundreds of times without remembering any arousals. In a different category are patients with stress and depression, where the main issue is being wide awake in early morning hours, much earlier than expected time of awakening, and without completing appropriate amount of sleep. They have difficulty going back to sleep. All this information is useful to figure out the cause of insomnia, and its treatment.
What is jetlag?
Humans have an internal clock that rotates, in biochemical terms, based upon the days and nights of where we live. Based upon this clock certain changes in our body occur at different times of the day. For example, a small gland in the brain called pineal gland secretes a hormone called melatonin. It is secreted in darkness and stops with exposure to daylight. Its secretion helps to maintain our schedule of nighttime sleep and awakening in AM.
Airline travel can quickly take us in a different time zone, where, in comparison to our home time zone, the night may start earlier (eastward travel) or later (westward travel). The impact of travel on sleep differs based upon the direction of travel. Taking a flight westward may cause earlier than normal wakefulness and traveling eastward may cause difficulty sleeping at usual time of the night. With traveling too far and quickly, the fine balance maintained by our internal clock gets perturbed. This is because, at least for a few days, the pineal gland continues to secrete melatonin based upon its home time zone. After a few days, the pineal gland adjusts itself to its new location, but during those days the traveler may have significant insomnia. This insomnia, the jetlag, can be minimized by taking supplemental melatonin for a few days.
What is the best time to sleep at night?
The answer, “one should sleep when feeling sleepy,” seems logical, but may not be the best response. The time of sleep is dictated by a combination of biochemical factors we all have, certain peculiar sleep syndromes some of us have, and many environmental factors. In fact, in modern way of living, environmental factors outplay others. With work schedule starting around 7-8 AM, we may schedule our sleep time accordingly and may sleep around midnight. This may fulfill the time duration of sleep, but the sleep may not be fully rejuvenating. For most adults, going to sleep couple of hours before midnight, and waking up couple of hours before starting the work schedule in AM may be a better option. Unfortunately, impact of modern living with artificial lights and multiple other activities is widespread, resulting in the common issue of insomnia. In addition, not everyone can follow this schedule.
What is delayed sleep phase syndrome?
It means falling asleep later than what a typical standard or tradition is. Typically, teenager and young adults have this issue. It may just be due to peer pressure or psychosocial reasons. On the other hand, there are some people who simply cannot fall asleep, even if they do everything right, until late night or early morning hours. Their waking time in AM is also delayed. They may have a condition called delayed sleep phase syndrome. But most cases are due to behavioral reasons due to poor sleep- hygiene. This is also the reason that at least in USA, schooling times for children are reversed from what they used to be. It used to be that high school started earlier, and the school buses picked them first, and younger or elementary graders later. Now this routine is reversed to give teen-agers some extra time to sleep.
Both, teen-agers and people with biologically delayed sleep phase syndrome do not need to take any medicine. Teen-agers should follow sleep hygiene rules. Adults are better off adjusting their life according to their sleep schedule. It is better to avoid professions where they are required to be at work in early morning hours. Some of them, with significant delay, may be the best candidates to work the 3rd shift.
What is advanced sleep phase syndrome?
Unlike the group above who has difficulty sleeping in evening hours, people with advanced sleep phase syndrome have difficulty keeping themselves awake in evening hours. This is much more rare condition. People with this condition typically fall asleep in early evening hours and, after appropriate sleep, wake up in early AM hours when most of us are asleep. Again, there is no reason to treat this with a medicine, or any intervention. A better strategy is to adjust life’s schedule accordingly. They should avoid working any other but morning shift, and they may opt to start early and leave early.
What is shift-work sleep disorder?
It is when a person’s sleep is affected because of the work schedule, or the work shift. Imagine asking people with advanced sleep phase syndrome to work evening shift, which is their peak sleep time. They may never perform well. But someone with delayed sleep phase syndrome may prefer that shift. Similarly, asking someone with delayed sleep phase syndrome to come to work in early morning hours is not going to work. I do not recommend any medicines for these conditions; the treatment or appropriate management is to change work schedules.
What may cause chronic insomnia?
Insomnia is a complicated symptom, as it may come from a variety of reasons. Following are the main causes of chronic insomnia:
- Primary insomnia: These patients do not seem to have any medical, social or environmental cause for insomnia; the cause probably is the defective neuronal and/or hormonal circuitry in the brain.
- Medical disorders: For example, cancer, lung disease, heart disease, pain, skin conditions, etc.
- Neurological disorders: For example, dementia, stroke, Parkinson disease, etc.
- Psychiatric disorders: For example, anxiety, depression, psychosis, etc.
- Sleep disorders: When the cause is a different sleep disorder, such as obstructive sleep apnea, restless leg syndrome, and many others.
- Menstruation and pregnancy
- Substance abuse, including alcohol
- Poor sleep hygiene
How is insomnia diagnosed?
Diagnosis of insomnia is made by taking detailed history about sleep, other medical conditions, and any psychosocial factors. A sleep study is not required, unless a different type of sleep disorder is suspected. Asking the patient to maintain a sleep diary for couple of weeks can be very useful. If available, Actigraphy (an electronic instrument to monitor sleep) can also help.
How is insomnia treated?
Poor sleep hygiene is an artifact of modern-day living. Ideally, our sleep time starts with darkness, when we shall finish all activities and try to sleep. But, for many people, the time after dark is full of activities that are not conducive to sleep. This dramatic behavioral shift started after advent of electricity and our exposure to bright artificial lights. Going back to ancient ways may not be a practical option anymore, but there are many commonsense measures listed below that may help to improve our sleep quality and efficiency:
- Treat sleep as an important part of life and not just waste of time. Sleep is critical to our physical and mental wellbeing.
- Try to follow a set schedule of sleep, even on weekends.
- An average adult requires at least 6-8 hours of sleep, some little more. The ideal number is close to 8 hours not 6. Have appropriate amount of sleep.
- During few hours before sleeping, avoid activities that may affect going to sleep, such as drinking caffeine, an overtly exciting discussion or activity (other than sex).
- Avoid activities that may cause anxiety or stress before sleep, such as watching news, or whatever makes you anxious or nervous.
- Use bedroom only for sleep and sex and avoid bringing TV or similar gadgets in it.
- Avoid drinking alcohol before sleep.
- Minimize fluid intake starting 3-4 hours before sleep.
- In case of a noisy dwelling, consider a noisemaker, like a small fan.
- Make a habit of waking up before sunrise and getting exposure to early morning light. You may feel more refreshed and energetic following this regimen. This may not be practical for people living in extreme north, where a strict schedule of darkness and light can be followed. One may have to create artificial darkness in summer and light in winter.
- If you take a water pill or a diuretic, avoid taking it at night.
- Review medicines with your doctor, including herbs and over the counter, to make sure something is not interfering with sleep, which you may be able to take earlier in the day.
- Exercise regularly, though not too close to sleep time. Enjoy aerobic exercise (like walking or slow jogging) in morning hours or earlier in the day. Later in the day, choose an activity that may quickly tire your muscles, heart, and lungs (like fast bicycling or sprinting). Sexual activity does not count, but it has its own benefits.
- Have dinner at least 4-5 hours before sleep, and avoid eating anything before sleep, especially if you have acid reflex disease. Make a habit of sleeping with empty stomach.
- Acid-reflex disease is a common problem. One way to avoid this condition is to follow a habit of never eating to the stomach’s full capacity; always leave some room open and stop eating before completely full. If you have acid-reflex disease, avoid late supper and take appropriate medicine.
- After about 50 years of age, it is not unusual to have an urge to urinate in the middle of night. There are many reasons, both in men and women, and not all are fixable. If possible, keep the bedroom and toilet light at minimum. Exposure to bright light in wee hours may create difficulty going back to sleep.
- If your partner or you snore, or move in the bed too much, consider sleeping in separate beds or in separate bedrooms.
- Avoid bringing pets in the bedroom.
What about natural remedies for sleep?
Insomnia being the most common sleep disorder, people have explored wide variety of products for its treatment. Some listed products in this category are melatonin, valerian root, lavender, magnesium, passion fruit, gingko biloba, chamomile tea, and glycine. In this group, melatonin is more effective than others, but it also is mildly effective. Other products lack proper clinical trial evidence.
What medicines are available for insomnia?
Before we investigate the list of medicines, it is important to make sure that any other factors that may have affected the sleep are resolved, and sleep hygiene issues are addressed. Medicine for sleep is another option but may not be an ideal one. Ideally, a sleep medicine may let us have proper sleep with natural sleep stages and cycles. Unfortunately, we do not have any such medicine. All sleep medicine helps to improve in some manner but also impact the nature of sleep. Following is some of the medicines used for insomnia (not all are FDA approved for this condition):
- Antihistamines
Doxylamine (Unisom) – half-life 10-15 hours
Diphenhydramine (many brands) – half-life 4-9 hours
Hydroxyzine (many brands) – half-life 20-25 hours
Antihistamines are considered relatively safe class of medicines, and many are available over the counter. They may sometimes create serious side effects.
- Benzodiazepines:
Triazolam (Halcion) – half-life 2-5 hours
Temazepam (Restoril) – half-life 6-8 hours
Lorazepam (Ativan) – half-life 14 hours
Estazolam – half-life 10-24 hours
Clonazepam (Klonopin) – half-life 20-50 hours
Diazepam (Valium) – half-life 30-100 hours
Flurazepam (Dalmane) – half-life 36-120 hours
If one pays close attention, many of them with long half-life are not useful to treat insomnia, such as clonazepam, diazepam, or flurazepam. Other common problems with this group are too much sedation causing cognitive problems, unsteadiness, falls, addiction, tolerance, overdose, and respiratory depression. The risk is higher in elderly, where insomnia is more common.
- Benzodiazepine agonists:
Zolpidem (Ambien) – half-life 2.5-3 hours
Zaleplon (Sonata) – half-life 1 hour
Eszopiclone (Lunesta) – half-life 6 hours
These agents are somewhat different and are designed to make safer benzodiazepine like drugs. But they may have some peculiar and dangerous side effects. They may cause waking up confusion, sleepwalking, or even driving while not fully awake. This is called complex sleep behavior, which is a contraindication to use these medicines. Benzodiazepines and benzodiazepine agonists increase non-REM sleep and decrease REM sleep.
- Sedating antidepressants:
Amitryptiline (Elavil) – half-life 10-26 hours
Nortryptiline (Pamelor) – half-life 18-44 hours
Imipramine (Tofranil) – half-life 11-25 hours
Mirtazapine (Remeron) – half-life 20-40 hours
Trazodone (Oleptro)– half-life 3-9 hours
Doxepin (Selinor) – half-life 15 -30 hours
Nefazodone – half-life 2-4 hours
Most of these agents are not suitable for treatment of insomnia due to their long half-life and, because of that, daytime drowsiness. In younger patients, there is risk of worsening of underlying depression, and suicide. In elderly, this phenomenon is not noted. Nefazodone may cause liver failure. Small dose of Mirtazapine (7.5-15mg) is a better choice for elderly. Trazodone an also be tried, especially for people with anxiety disorder.
- Anti-psychotics
Quetiapine (Seroquel) – half-life 6-7 hours
- Unknown mechanism
Meprobamate – half-life 10 hours
Gabapentin (Neurontin) – half-life 5-7 hours
Meprobamate may be useful if insomnia is triggered by anxiety. Besides many other side effects, its risks include abuse and dependency. Gabapentin is reasonably safe and can also help with restless leg syndrome.
- Melatonin agonists:
Ramelteon (Rozerem) – half-life 1-5 hours
Some risks include worsening of depression, suicide ideation, and complex sleep-related behavior.
- Orexin antagonists:
Suvorexant (Belsomra) – half-life 12 hours
Lemborexant (Dayvigo) – half-life 17-19 hours
Some risks include worsening of depression, suicide ideation, and complex sleep-related behavior, and abuse.
Which one is the best medicine for insomnia?
Like a cliché, an answer to this question is not straightforward. An ideal medicine for insomnia is the one that works in minutes to an hour, works every time it is taken, keeps the person asleep at least for 6 hours, does not drastically change the sleep architecture (stages and cycles), is not addictive, does not have any residual effect upon waking up, and does not have any serious problem with long term use. No such medicine is available. There is always a process of give and take when trying to figure out a medicine for insomnia.
One way to address this issue is to look at what other conditions patient has and pick a medicine that may help with more than one problem. Anxiety is a common ingredient effecting patients with insomnia, so using a medicine that that can help with both sleep and anxiety, like a benzodiazepine or trazodone, may be a better choice. If anxiety is not an issue, taking these medicines may create uncomfortable daytime side effects. If depression is an issue, one may instead try a sedative antidepressant, like amitryptiline. In old age, or patients with dementia, one may try small dose of mirtazapine or trazodone. In patients where benzodiazepine or a tricylic agent is not a choice, one may try benzodiazepine agonist like zolpidem. Melatonin agonist or an orexin antagonist can be tried in any adult.
Are sleep medicines addictive?
They can be, some more and some less. Benzodiazepines (e.g., diazepam, lorazepam, clonazepam) and benzodiazepine agonists (e.g., zolpidem), more than others. At the same time, taken as prescribed, these medicines may be very useful for a properly selected patient.
How much sleep an average person needs every day?
An adult person requires 7-8 hours of sleep. One may function with less sleep in young age but chronic sleep deprivation, even of an hour a day, ultimately creates problems. Children require few more hours of sleep.
Where may I get more information about sleep and insomnia?
American Academy of Neurology
American Academy of Sleep Medicine
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