Insomnia

Howard Liu, MD, MA, DABMA

Definition

• Insomnia is a sleeping disorder that is characterized by difficulty falling and/or staying asleep. People with insomnia have one or more of the following symptoms:
• Difficulty falling asleep
• Waking up often during the night and having trouble going back to sleep
• Waking up too early in the morning
• Feeling tired upon waking

Types of Insomnia

• Primary insomnia: Primary insomnia means that a person is having sleep problems that are not directly associated with any other health condition or problem.
• Secondary insomnia: Secondary insomnia means that a person is having sleep problems because of something else, such as a health condition (like asthma, depression, arthritis, cancer, or heartburn); pain; medication they are taking; or a substance they are using (like alcohol).

Causes of acute insomnia

• Significant life stress (job loss or change, death of a loved one, divorce, moving).
• Emotional or physical discomfort.
• Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep.
• Some medications (for example those used to treat colds, allergies, depression, high blood pressure, and asthma) may interfere with sleep.
• nterferences in normal sleep schedule (jet lag or switching from a day to night shift, for example).

Causes of chronic insomnia

• Depression and/or anxiety.
• Chronic stress.
• Pain or discomfort at night.

Symptoms of Insomnia

• Sleepiness during the day.
• General tiredness.
• Irritability.
• Problems with concentration or memory.

Treatment for Insomnia

• Acute insomnia may not require treatment. Mild insomnia often can be prevented or cured by practicing good sleep habits.
• If your insomnia makes it hard for you to function during the day because you are sleepy and tired, your health care provider may prescribe sleeping pills for a limited time.

Treatment for Insomnia

• Rapid onset, short-acting drugs can help you avoid effects such as drowsiness the following day.
• Avoid using over-the-counter sleeping pills for insomnia since they may have undesired side effects and tend to lose their effectiveness over time.

Good sleep habits (sleep hygiene)

• Try to go to sleep at the same time each night and get up at the same time each morning. Try not to take naps during the day because naps may make you less sleepy at night.
• Avoid caffeine, nicotine, and alcohol late in the day. Caffeine and nicotine are stimulants and can keep you from falling asleep. Alcohol can cause waking in the night and interferes with sleep quality.

Good sleep habits (sleep hygiene)

• Get regular exercise. Try not to exercise close to bedtime because it may stimulate you and make it hard to fall asleep. Experts suggest not exercising for at least three to four hours before the time you go to sleep.
• Don’t eat a heavy meal late in the day. A light snack before bedtime, however, may help you sleep.

Good sleep habits (sleep hygiene)

• Make your bedroom comfortable. Be sure that it is dark, quiet, and not too warm or too cold. If light is a problem, try a sleeping mask. If noise is a problem, try earplugs, a fan, or a “white noise” machine to cover up the sounds.
• Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath.

Good sleep habits (sleep hygiene)

• Avoid using your bed for anything other than sleep or sex.
• If you can’t fall asleep and don’t feel drowsy, get up and read or do something that is not overly stimulating until you feel sleepy.
• If you find yourself lying awake worrying about things, try making a to-do list before you go to bed. This may help you to not focus on those worries overnight.

Medications to help insomnia?

• Risks of pharmacologic therapy include side effects, as well as physical and psychological addiction with long-term use. These risks may be increased in certain clinical settings:
• Pregnancy – Sedative-hypnotics may increase the risk of fetal malformations if used during the first trimester.

Medications to help insomnia?

• Alcohol consumption – Sedative-hypnotics should not be combined with alcohol because there is a risk of excessive sedation whenever central nervous system suppressants are combined.
• Renal or hepatic disease – Most sedative-hypnotic medications undergo hepatic and renal clearance. Metabolic clearance may be delayed in patients who have renal or hepatic disease, leading to accumulation and excessive sedation.

Medications to help insomnia?

• Pulmonary disease or sleep apnea – Many sedative-hypnotics are respiratory suppressants that can worsen obstructive sleep apnea or hypoventilation.
• Nighttime decision makers – Sedative-hypnotics should not be taken by individuals who may be called upon to make important decisions during the night (eg, clinicians on-call or single parents responsible for the care of young children) because they can cause excess sedation and impair decision-making.

Medications adverse effects

• Patients whose insomnia has been successfully treated with pharmacologic therapy are likely to report improvement of daytime function, better quality of life, and fewer comorbidities (eg, depressed mood).
• Multiple adverse effects: used only for short term and on as needed basis.

Medications adverse effects

• The  most common adverse effects associated with the benzodiazepines and nonbenzodiazepines are residual daytime sedation, drowsiness, dizziness, lightheadedness, cognitive impairment, motor incoordination, and dependence.
• Long-term use may be habit forming and rebound insomnia may occur when some short-acting medications are discontinued.

Medications adverse effects

• Less common adverse effects include complex sleep-related behaviors (eg, sleep walking), anterograde amnesia (particularly Halcion or when used with alcohol), and aggressive behavior.
• Older adults have a particularly high risk of adverse effects, including excessive sedation, cognitive impairment, delirium, night wandering, agitation, balance problems, fall and fractures, and impaired performance of daily activities.

Medications adverse effects

• In March of 2007, the FDA requested that the manufacturers of sedative-hypnotic medications strengthen their labeling to include stronger language about the risks of severe allergic reactions and complex sleep-related behaviors (eg, driving, making telephone calls, eating, having sex while not fully awake). Thirteen drugs were the focus of this request.

Acupuncture to Treat Insomnia

• Fischer MV. Acupuncture therapy in the outpatients-department of the University Clinic Heidelberg [in German]. Anaesthesist. 1982:31:25-32.
• 100% of patients treated for insomnia obtained benefit without recurrences within 18 months of follow-up.

Acupuncture to Treat Insomnia

• Montakab and Lange (Schweiz Med Wochenschr Suppl. 1994;62:49-54 ) diagnosed 40 patients using Chinese traditional diagnosis and performed polysomnographic analyses of true acupuncture vs. control needled patients. Objective change was noted and found statistically significant in the true acupuncture group.