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Pronunciations amitriptyline barbiturates benzodiazepines chlordiazepoxide dementia diazepam dimenhydrinate diphenhydramine doxylamine encephalitis flurazepam meprobamate narcolepsy opioids parasomnias

Insomnia is difficulty falling asleep or staying asleep or a disturbance in sleep that makes sleep seem inadequate or unrefreshing.

Insomnia is not a disease. It is a symptom that can have many different causes, including an irregular sleep-wake schedule, physical disorders, drug use or withdrawal, drinking large amounts of alcohol in the evening, emotional problems, and stress. Often, the cause is anxiety, nervousness, depression, or fear. Sometimes the cause is simply lack of fatigue. Some people have long-standing (chronic) insomnia that has little or no apparent relationship to a physical disorder, use or withdrawal of drugs, or any stress.

Difficulty falling asleep is common among young and old. About 10% of adults have chronic insomnia, and about 50% have insomnia sometimes.

Because sleep patterns change as people age, older people may think they have insomnia when they do not. As people age, they tend to sleep less at night and to nap during the day. Stage 4 sleep, the period of deep sleep, becomes shorter and eventually disappears. Also, older people awaken more during all stages of sleep. These changes are normal and usually do not indicate a sleep disorder.

There are several types of insomnia. Difficulty falling asleep, called sleep-onset insomnia, often occurs when people cannot let their minds relax and they continue to think and worry. Difficulty staying asleep, called sleep maintenance insomnia, is more common among older people than among younger people. People with this type of insomnia fall asleep normally but wake up several hours later and cannot fall asleep again easily. Sometimes they drift in and out of a restless, unsatisfactory sleep. Early morning awakening, another type of insomnia, may be a sign of depression in people of any age.

Sleep-wake schedule disorder may occur in people whose sleep patterns have been disrupted: They fall asleep at inappropriate times and then cannot sleep when they should. These sleep-wake reversals often result from jet lag (especially when traveling from east to west), working irregular night shifts, frequent changes in work hours, or excessive use of alcohol. Sometimes sleep-wake reversals are a side effect of drugs. Sleep-wake reversals are common among people who are hospitalized because they are often awakened during the night. Damage to the brain's built-in biologic clock (caused by encephalitis, stroke, or Alzheimer's disease, for example) can also disrupt sleep patterns.

Symptoms and Diagnosis

Symptoms include irritability, fatigue during the day, and problems concentrating or performing under stress.

To diagnose insomnia, doctors evaluate a person's sleep pattern, use of drugs (including alcohol and illicit drugs), degree of psychologic stress, medical history, and level of physical activity. Some people need less sleep than others, so the diagnosis of insomnia is based on a person's individual needs.

Treatment

The treatment of insomnia depends on its cause and severity. If insomnia results from another disorder, treatment of that disorder may improve sleep. For most people who have insomnia, some simple changes in lifestyle, such as following a regular sleep schedule, can improve sleep.

Bright light therapy (which exposes a person to bright light at appropriate times) can help reset the biologic clock. This therapy is especially useful for people who have sleep-wake reversal due to jet lag, those who have sleep-onset insomnia, and those who go to sleep and wake too early.

When a sleep disorder interferes with a person's normal activities and sense of wellbeing, the intermittent use of sleep aids (also called hypnotics) for up to a week may be helpful. Most sleep aids require a prescription. Sleep aids available without a prescription (over-the-counter, or OTC—see Over-the-Counter Drugs) contain diphenhydramineSome Trade Names
BENADRYL
NYTOL
SOMINEX
or doxylamineSome Trade Names
NYQUIL
, both antihistamines. These drugs may have side effects, especially in older people.

Older people experiencing age-related sleep changes usually do not need to take sleep aids. Because total nighttime sleeping time tends to decrease with age, older people may sleep better if they go to bed later, get up earlier, or nap less during the day. Even when older people have insomnia, treatment with sleep aids often causes more problems (such as confusion, falls, and incontinence) than the insomnia.

If emotional stress is causing insomnia, treatment to relieve the stress is more useful than taking sleep aids. People who have insomnia and depression should be evaluated by a doctor, and the depression should be treated. Treating depression often relieves the insomnia, but some antidepressants can improve sleep directly because they have sedating effects.

Melatonin (see Medicinal Herbs and Nutraceuticals: Melatonin) is sometimes used to treat insomnia, especially in older people, who may have low levels of melatonin. The drug is also sometimes used to help minimize the effects of jet lag. However, its use is controversial. Melatonin appears to be safe for short-term use (up to a few weeks), but the effects of using it for a long time are unknown.

Ways to Improve Sleep Follow a regular sleep schedule: People should go to bed at the same time each night and, more importantly, get up at the same time each morning, even on weekends. Follow a bedtime routine: A regular pattern of activities—such as walking at a relaxed pace, listening to soft music, brushing the teeth, washing the face, and setting the alarm clock—can set the mood for sleep. This routine should be followed every night, at home or away. Make the environment conducive to sleep: The bedroom should be kept dark and quiet and not too warm or too cold. If noises disturb sleep, wearing ear plugs, using a white-noise machine or a fan, or installing heavy curtains in the bedroom (to block out outside noises) may help. Use the bedroom primarily for sleeping: The bedroom should not be used for eating, reading, watching television, paying bills, or other activities associated with wakefulness. Avoid substances that interfere with sleep: Food and beverages that contain alcohol or caffeine (such as coffee, tea, cola drinks, and chocolate) can interfere with sleep, as can appetite suppressants and diuretics. These substances should not be consumed, especially near bedtime. Quitting smoking may help. Drinking a large amount of alcohol in the evening causes early morning awakenings. Use pillows: Pillows between the knees or under the waist can make people more comfortable. For people with back problems, lying on the side with a large pillow between the knees may be helpful. Get up: When falling asleep is difficult, getting up and doing something else in another room may be more effective than lying in bed and trying harder and harder to fall asleep. Exercise regularly: Exercise can help people fall asleep naturally. However, exercise late in the evening can stimulate the heart and brain and keep people awake. Relax: Stress and worry are major impediments to sleep. People who are not sleepy at bedtime can relax by reading or taking a warm bath. People can aim to leave their problems at the bedroom door. Avoiding too much mental stimulation during the hour or so before bedtime can help. Eat a snack: Hunger can interfere with going to sleep. A light snack, especially if warm, can help.

Sleep Aids: Not to Be Taken Lightly Among the most commonly used sleep aids are sedatives, minor tranquilizers, and antianxiety drugs. Most are quite safe, but all sleep aids can lose their effectiveness once a person becomes accustomed to them. Sleep aids may also produce withdrawal symptoms when they are discontinued. If a sleep aid is taken for more than a few days, discontinuing it can make the original sleep problem suddenly worse (causing rebound insomnia) and can increase anxiety. Doctors recommend reducing the dose slowly. Complete withdrawal can take several weeks. Most sleep aids require a doctor's prescription because they may be habitforming or addictive, and overdose is possible. Sleep aids are particularly risky for older people and for people with breathing problems because they tend to suppress areas of the brain that control breathing. They also reduce daytime alertness, making driving or operating machinery hazardous. Sleep aids are especially dangerous when taken with alcohol, opioids, antihistamines, or antidepressants. All of these drugs also cause drowsiness and can suppress breathing; the combined effects are more dangerous. The most common and safest sleep aids are benzodiazepines. Because they do not decrease the total amount of REM sleep, they do not reduce dreaming. Some benzodiazepines remain in the body longer than others. Older people, who cannot metabolize and excrete drugs as well as younger people, may be more likely to experience daytime drowsiness, slurred speech, and falls. Therefore, doctors try to avoid prescribing long-acting benzodiazepines, such as chlordiazepoxideSome Trade Names LIBRIUM , diazepamSome Trade Names VALIUM DIASTAT , flurazepamSome Trade Names DALMANE , and nitrazepam, for older people. Two useful sleep aids that are not benzodiazepines are zopiclone and zolpidemSome Trade Names AMBIEN . They are short-acting. They help people with insomnia sleep better without changing the natural sleep pattern. Older people appear to tolerate these drugs well. Barbiturates, once the most commonly used sleep aid, and meprobamate are not as safe as benzodiazepines. Chloral hydrate is relatively safe but relatively weak. It is used much less often than benzodiazepines. Some antidepressants, amitriptylineSome Trade Names ELAVIL ENDEP for example, can relieve depressionassociated insomnia and early morning awakening caused by panic attacks, but side effects can be a problem, especially for older people. Diphenhydramine and dimenhydrinate are two inexpensive nonprescription (over-the-counter) drugs that can relieve occasional or mild sleeping problems. However, they are not used primarily as sleep aids, and they may have side effects, especially in older people.

Last full review/revision February 2003