Insomnia

Insomnia is the inability to fall or remain asleep when a person wants to be sleeping.

Insomnia can lead to restlessness and anxiety, which make sleep even more difficult. Insomnia can interfere with the ability to function at other times of the day. It is extremely common among older people.

Causes

Insomnia may be due in part to changes in sleep patterns that occur with aging. Certain behaviors can also cause or contribute to insomnia. Examples are drinking a large amount of any fluids during evening hours, drinking even a little alcohol or caffeinated beverages during evening hours, taking drugs that can have a stimulating effect (such as decongestants), and smoking. Exercise has many health benefits for older people and may promote a good night's rest, but exercising vigorously too close to bedtime can also cause insomnia.

Insomnia is sometimes a symptom of a physical disorder (such as heart failure, gastroesophageal reflux disease, or hyperthyroidism), a mental health disorder (such as depression or anxiety), or a sleep disorder (such as sleep apnea or restless legs syndrome). Insomnia sometimes occurs as a normal response to stress or to a change in surroundings. It can also occur for no apparent reason.

Diagnosis

Determining that a person has insomnia is simple: The doctor relies on the person's report of a problem falling or remaining asleep. Determining the causes or the severity of insomnia is less straightforward.

Causes of insomnia are identified by looking closely at a person's sleep patterns, habits around bedtime, use of drugs, use of cigarettes and alcohol, physical activity, and medical history. This evaluation along with a few common blood tests usually provides all the information the doctor needs. However, if the insomnia continues for more than 6 months and does not improve with treatment, a person may be referred to a sleep laboratory. The person's brain waves, heart rate, and breathing may be monitored while they sleep. This test, called polysomnography, can help a doctor determine whether a specific sleep disorder (such as periodic limb movements or sleep apnea) is causing the insomnia.

Treatment

Adopting proper sleep habits is the most important thing a person can do to relieve insomnia. For people with insomnia, trying to refrain from napping during the day is essential. They should also eat dinner at least 2 to 3 hours before going to bed and avoid beverages containing caffeine (such as cola, coffee, and tea) during the late afternoon or evening.

Relaxation techniques, such as controlled breathing to relieve tension and meditation to relieve worry, are useful and safe for inducing sleep. Limiting the amount of time a person spends lying awake in bed when he is having trouble falling asleep may help. Instead, the person should get out of bed and engage in relaxing activities (for example, reading or listening to soothing music). Time spent in bed can be gradually increased as sleep improves. Learning about sleep from a therapist or another source can also be helpful.

When these measures are ineffective, drugs used appropriately can help a person sleep. Drugs that cause sleepiness (sleep aids, sometimes also referred to as hypnotics, sedatives, or tranquilizers) are generally safe and effective when used in low doses and for very short periods. However, most require a doctor's prescription because they can become habit-forming when used for longer periods or in higher doses. Also, some sleep aids can produce dangerous effects when taken with alcohol and opioid analgesics, such as morphine.

Sleep aids can cause daytime sleepiness and confusion in older people. Insomnia can recur as sleep aids wear off (an effect called rebound insomnia). When used for a long time on a nightly basis, sleep aids become less effective or not effective at all. Prolonged use of sleep aids can cause a person to depend on them for sleep.

Benzodiazepines are the most commonly used sleep aids. Short-acting preparations (such as temazepam, estazolam, and lorazepam) are safer than long-acting preparations. The longer-acting benzodiazepines (such as diazepam and flurazepam) stay in the body past nighttime, causing daytime sleepiness, forgetfulness, and confusion. Older people who use longer-acting benzodiazepines can become unsteady on their feet, increasing the risk of falls (which can lead to hip fractures and other broken bones). Paradoxically, benzodiazepines can directly stimulate the brain, causing agitation and worsening insomnia in some older people. This effect is often worse when the drug is first started or when the dose is increased.

Zolpidem and zaleplon are also effective sleep aids for older people. However, these drugs can cause confusion and disorientation. Their long-term effects in older people are not known, and their effectiveness may lessen if used for long periods.

Certain antidepressant drugs (such as trazodone, nefazodone, and mirtazapine) cause sleepiness and may be effective for depressed people who cannot sleep. Antidepressants that cause sleepiness may also be effective for people without depression if insomnia has not responded to other treatment. However, each of these drugs can cause side effects. Trazodone can lower blood pressure when a person stands up, leading to falls when getting up at night or in the morning. Nefazodone has less effect on blood pressure, but it has caused life-threatening liver failure. Thus, it should be avoided by people with liver disease. Mirtazapine can cause weight gain.

Several sleep aids are available without a prescription. Many antihistamines (such as diphenhydramine) contained in cold and allergy remedies cause sleepiness. But they also cause impaired thinking and balance, dry eyes and mouth, and urinary problems and should be avoided. They are far less safe for older people than sleep aids available with a prescription.

Melatonin is a hormone in the brain that naturally sets the body's sleep cycles. It is sold as a supplement in some drug stores and alternative health stores. It may help some people, and it causes few side effects. However, the manufacture and marketing of melatonin supplements is unregulated, so the amount and quality of melatonin in supplements made by different manufacturers may not be the same. Consequently, most doctors do not prescribe or recommend melatonin. Little is known about its effects in older people.

Outlook

The outlook for people with insomnia is good if they receive treatment for any disorders causing or contributing to insomnia and they adopt healthy sleep behaviors.