What is Insomia?
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of one or more of the following:
- difficulty falling asleep
- waking up frequently during the night with difficulty returning to sleep
- waking up too early in the morning
- un-refreshing sleep
Insomnia is not defined by the number of hours of sleep a person gets or how long it takes to fall asleep. Individuals vary normally in their need for, and their satisfaction with, sleep.
Insomnia may cause problems during the day, such as tiredness, a lack of energy, difficulty concentrating, and irritability.
Insomnia can be classified as transient (short term), intermittent (on and off), and chronic (constant). Insomnia lasting from a single night to a few weeks is referred to as transient.
If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more.
What Causes It?
Certain conditions seem to make individuals more likely to experience insomnia. Examples of these conditions include:
- advanced age (insomnia occurs more frequently in those over age 60
- female gender
- a history of depression
If other conditions (such as stress, anxiety, a medical problem, or the use of certain medications) occur along with the above conditions, insomnia is more likely. There are many causes of insomnia.
Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:
- stress
- environmental noise
- extreme temperatures
- change in the surrounding environment
- sleep/wake schedule problems such as those due to jet lag
- medication side effects
Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders.
One of the most common causes of chronic insomnia is depression. Other underlying causes include:
- arthritis
- kidney disease
- heart failure
- asthma
- sleep apnea
- narcolepsy
- restless legs syndrome
- Parkinson’s disease
- hyperthyroidism
Chronic insomnia may also be due to behavioral factors, including:
- the misuse of caffeine, alcohol, or other substances
- disrupted sleep/wake cycles as may occur with shift work or other nighttime activity schedules and chronic stress
- excessive napping in the afternoon or evening
It is fitting for this issues newsletter that focuses on Women’s issues to discuss the gender differences that exist for one of the most common sleep disorders, that being Obstructive Sleep Apnoea.
Population studies show that OSA affects approximately 10% of adult females and 25% of adult males, although most have few or no symptoms. Put another way, it is well recognized that the male sex contributes a particularly strong risk factor and confers a 2 to 3 fold increase of sleep apnoea in the general population at large.
This increased risk may be related to the difference in adipose tissue distribution in men, who exhibit a predominantly central fat deposition pattern around the neck, trunk, and abdominal viscera compared to women. In addition to obesity, hormonal status may impact on sleep apnoea susceptibility, particularly in women. Post-menopausal women demonstrate increases in sleep apnoea prevalence and severity compared with pre-menopausal women.
Importantly, a substantial proportion of obese women are protected from the development and/or progression of sleep apnoea, although the humoral mechanisms conferring the protection remain largely unknown.
Regardless of the gender differences of this condition, it is important to focus on the relevance of identifying its severity, as this has an impact on risk stratification for long term complications. It is well established that severe OSA is strongly associated with increased mortality, stroke and cardiovascular disease in the middle aged population.
The cardiovascular risk from moderate OSA is uncertain, although the data suggest an increased risk for stroke (particularly in men). There is no evidence of increased cardiovascular risk from mild OSA. Despite the high prevalence of this condition, most patients are minimally symptomatic. Furthermore, 15% of patients have moderate to severe sleep apnoea. Hence, the vital issue in clinical practice is to identify those with OSA who have clinically important disease.
The question therefore arises, who should be investigated? clearly, all patients with obvious risk factors and symptoms. However, patients with cardiovascular disease, stroke and diabetes or poorly controlled hypertension are at risk of OSA and should be questioned for symptoms of the like, which if present, may warrant further investigation and treatment.
In summary, the major goals of the management of OSA should be what is currently recommended, that being: to identify and offer treatment to symptomatic patients, regardless of disease severity, whose safety and quality of life is affected; to identify and offer treatment to patients with severe OSA determined by polysomnogram, regardless of symptoms, who may be at risk of adverse health outcomes; to modify adverse lifestyle factors that contribute to OSA pathogenesis and other poor health outcomes. This may include advice on diet and exercise to lose weight, and encouragement to reduce alcohol intake along with smoking cessation.
Who Gets Insomnia?
Insomnia is found in males and females of all age groups, although it seems to be more common in females (especially after menopause) and in the elderly. The ability to sleep, rather than the need for sleep, appears to decrease with advancing age.
How Is It Diagnosed?
Patients with insomnia are evaluated with the help of a medical history and a sleep history. The sleep history may be obtained from a sleep diary filled out by the patient or by an interview with the patient’s bed partner concerning the quantity and quality of the patient’s sleep. Specialized sleep studies may be recommended, but only if there is suspicion that the patient may have a primary sleep disorder such as sleep apnoea or narcolepsy.
How Is It Treated?
Transient and intermittent insomnia may not require treatment since episodes last only a few days at a time. For example, if insomnia is due to a temporary change in the sleep/wake schedule, as with jet lag, the person’s biological clock will often get back to normal on its own. However, for some people who experience daytime sleepiness and impaired performance as a result of transient insomnia, the use of short-acting sleeping pills may improve sleep and next-day alertness.
As with all drugs, there are potential side effects. The use of over-the-counter sleep medicines is not usually recommended for the treatment of insomnia.
Treatment for chronic insomnia consists of:
- First, diagnosing and treating underlying medical or psychological problems.
- Identifying behaviors that may worsen insomnia and stopping (or reducing) them.
- Possibly using sleeping pills, although the long-term use of sleeping pills for chronic insomnia is controversial. A patient taking any sleeping pill should be under the supervision of a physician to closely evaluate effectiveness and minimize side effects. In general, these drugs are prescribed at the lowest dose and for the shortest duration needed to relieve the sleep-related symptoms. For some of these medicines, the dose must be gradually lowered as the medicine is discontinued because, if stopped abruptly, it can cause insomnia to occur again for a night or two.
- Trying behavioral techniques to improve sleep, such as relaxation therapy, sleep restriction therapy, and reconditioning.
- Relaxation Therapy. There are specific and effective techniques that can reduce or eliminate anxiety and body tension. As a result, the person’s mind is able to stop “racing,” the muscles can relax, and restful sleep can occur. It usually takes much practice to learn these techniques and to achieve effective relaxation.
- Sleep Restriction. Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. They may benefit from a sleep restriction program that at first allows only a few hours of sleep during the night. Gradually the time is increased until a more normal night’s sleep is achieved.
- Reconditioning. Another treatment that may help some people with insomnia is to recondition them to associate the bed and bedtime with sleep. For most people, this means not using their beds for any activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy. If unable to fall asleep, the person is told to get up, stay up until sleepy, and then return to bed. Throughout this process, the person should avoid naps and wake up and go to bed at the same time each day. Eventually the person’s body will be conditioned to associate the bed and bedtime with sleep.
- Melatonin Therapy: Benzodiazepines are the most frequently used drug for the treatment of insomnia. Prolonged use of benzodiazepine therapy is not recommended. However, many patients, particularly older patients, have difficulties discontinuing therapy. Melatonin, a hormone that is produced at night by the pineal gland, promotes normal sleep in humans and may be of assistance in maintaining sleep patterns while reducing the benzodiazepine therapy. Melatonin is not used widely in Australia as a treatment for insomnia.
