3.
Insomnia: Assessment and
Management  in Primary Care




  1. Introduction
  2. Definition and Prevalence
  3. Types of Insomnia
    bulletAcute Insomnia
    bulletChronic Insomnia
    bulletInsomnia Associated with Psychiatric, Medical, and Neurological Disorders
    bulletInsomnia Associated with Medication and Substance Use
    bulletInsomnia Associated with Specific Sleep Disorders
    bulletPrimary Insomnia
  4. Consequences
  5. Sleep/Wake Profile
  6. Recognition and Assessment
  7. Management
    bulletIntroduction
    bulletBehavioral Treatment
    bulletRelaxation Therapy
    bulletSleep Restriction Therapy
    bulletStimulus Control Therapy
    bulletCognitive Therapy
    bulletPharmacological Treatment
    bulletHypnotic Medications
    bulletAntidepressants
    bulletAntihistamines
    bulletMelatonin
    bulletOther Drugs
  8. Conclusion
  9. References
  10. How do I Cure Insomnia?
  11. Trouble Sleeping? Chill Out
    bulletA Drop in Temperature May Help You Fall Asleep
  12. Using Light Therapy to Treat Insomnia
  13. Natural Treatments For Insomnia
    bulletBedroom Inventory
    bulletCreating a Peaceful Place
    bulletWhat's Worrying You?
  14. Melatonin
    bulletWhat is Melatonin?
    bulletWhy Isn't Melatonin Considered a Drug?
    bulletWhat Does This Mean to You?
    bulletWhy Do People Take Melatonin?
    bulletUnderstanding Insomnia
  15. Stanford Group Therapy Program Aims to Put Insomniacs to Sleep




  Introduction

As many as one-third of patients seen in the primary care setting may experience occasional difficulties in sleeping, and 10 percent of those may have chronic sleep problems. Although insomnia is rarely the chief reason for an office visit, its detection can be enhanced by incorporating sleep-related questions into the general review of patient systems.

This document offers up-to-date information on insomnia and highlights the key role of the primary care physician in its recognition and management. Behavioral treatments, such as relaxation therapy, sleep restriction therapy, and stimulus control therapy, are described in addition to pharmacological treatments, such as hypnotics, antidepressants, and other medications.




  Definition and Prevalence

Insomnia is an experience of inadequate or poor quality sleep characterized by one or more of the following:

  1. difficulty falling asleep,
  2. difficulty maintaining sleep,
  3. waking up too early in the morning,
  4. nonrefreshing sleep.

Insomnia also involves daytime consequences such as

 

  1. tiredness,
  2. lack of energy,
  3. difficulty concentrating,
  4. irritability.

Periods of sleep difficulty lasting between one night and a few weeks are referred to as acute insomnia. Chronic insomnia refers to sleep difficulty at least three nights per week for one month or more.

About 30 to 40 percent of adults indicate some level of insomnia within any given year, and about 10 percent to 15 percent indicate that the insomnia is chronic and/or severe.1

The prevalence of insomnia increases with age and is more common in women.1,2




  Types of Insomnia



Acute Insomnia

Acute insomnia is often caused by emotional or physical discomfort. Some common examples include significant life stress; acute illness; and environmental disturbances such as noise, light, and temperature.3 Sleeping at a time inconsistent with the daily biological rhythm, such as occurs with jetlag, also can cause acute insomnia.4



Chronic Insomnia

Chronic insomnia can be caused by many different factors acting singly or in combination, and often occurs in conjunction with other health problems. In other cases sleep disturbance is the major or sole complaint, and involves abnormal sleep-wake regulation or physiology during sleep.

Insomnia associated with psychiatric, medical, and neurological disorders. Although psychiatric disorders are a common source of chronic insomnia, they account for less than 50 percent of cases.


Selected Circadian Rhythm Sleep Disorders

 
bulletdelayed sleep phase syndrome
bullet- difficulty falling asleep at the desired time
bullet- difficulty waking at the desired time

bulletadvanced sleep phase syndrome
bullet- difficulty staying awake in the evening
bullet- waking too early

bulletshift worker
bullet- difficulty getting enough sleep during available sleep times


Mood and anxiety disorders are the most common psychiatric diagnoses associated with insomnia. 5,6 Insomnia can also be associated with a wide variety of medical and neurological disorders. 7,8 Factors that cause problems throughout the day such as pain, immobility, difficulty breathing, dementia, and hormonal changes associated with pregnancy, perimenopause, and menopause can also cause insomnia. Many medical disorders worsen at night, either from sleep per se, circadian influence (e.g., asthma), or recumbency (e.g., gastroesophageal reflux).

Insomnia associated with medication and substance use. A variety of prescription drugs, nonprescription drugs, and drugs of abuse can lead to increased wakefulness and poor-quality sleep.9,10 The likelihood of any given drug contributing to insomnia is unpredictable and may be related to dose, lipophilicity, individual differences, and other factors. Some drugs commonly related to insomnia are stimulating antidepressants, steroids, decongestants, beta blockers, caffeine, alcohol, nicotine, and recreational drugs.

Insomnia associated with specific sleep disorders. Insomnia can be associated with specific sleep disorders, including restless legs syndrome (RLS), periodic limb movement disorder (PLMD), sleep apnea, and circadian rhythm sleep disorders.

Restless legs syndrome is characterized by unpleasant sensations in the legs or feet temporarily relieved by moving the limbs. Symptoms increase in the evening hours, especially when a person is lying down and remaining still. The dysesthesias cause difficulty falling asleep and are often accompanied by periodic limb movements.

Periodic limb movement disorder is characterized by bilateral repeated, rhythmic, small-amplitude jerking or twitching movements in the lower extremities, and less frequently in the arms. These movements occur every 20 to 90 seconds and can lead to arousals, which are usually not perceived by the patient. Rather, there is a report of nonrefreshing sleep.

Obstructive sleep apnea is most commonly associated with snoring, daytime sleepiness, and obesity, but occasionally can cause insomnia.11

Circadian rhythm sleep disorders are characterized by an inability to sleep because of a mismatch between the circadian sleep rhythm and the desired or required sleep schedule. Examples are given in the box above.

Primary insomnia. When other causes of insomnia are ruled out or treated, remaining difficulty with sleep may be classified as primary insomnia. Factors such as chronic stress, hyperarousal, poor sleep hygiene, and behavioral conditioning may contribute to primary insomnia.12




  Consequences

The primary consequences of acute insomnia are sleepiness, negative mood, and impairment of performance. The severity of these consequences is related to the amount of sleep lost on one or more nights.

Patients with chronic insomnia frequently complain of fatigue, mood changes (e.g., depression, irritability), difficulty concentrating, and impaired daytime functioning. Because insomnia has a variety of causes, the consequences may not be uniform. For example, when objectively assessed, the level of daytime sleepiness may be elevated with periodic limb movement disorder13 and rheumatoid arthritis,14 but not in primary insomnia.15 Insomnia appears to contribute to increased rates of absenteeism,16 health care utilization,17 and social disability.17,18




  Recognition and Assessment

A brief sleep history incorporated into the routine review of systems can be helpful in detecting insomnia. Direct inquiry is important because more than half of the people who believe that they have chronic insomnia have never discussed their problems with a physician. Examples of appropriate questions are shown in the box below. It is helpful for the patient to keep a 1- to 2-week sleep diary. Sleep diaries usually record bedtime, total sleep time, time to sleep onset, number of awakenings, use of sleep medications, time out of bed in the morning, and a rating of subjective quality of sleep and daytime symptoms. The sleep diary provides a night-to-night account of the patient's sleep schedule and perception of his or her sleep. Moreover, it may serve as a baseline for assessment of treatment effects. Completing the diary each morning, and using estimates rather than exact times, should minimize the likelihood that the process itself will be disruptive to sleep. See Table 1 for a sample sleep diary.

Assessment should include questions that address both sleep and daytime functioning, mainly because sleep needs vary markedly from person to person. One patient sleeping 6 hours may feel totally nrefreshed, while another one may be sleeping 6 hours but have no complaints during the day. Although the ability to maintain sleep decreases with age, the need for sleep does not change significantly. A complaint of simply not sleeping "a full 8 hours" but otherwise having restorative sleep is within the bounds of normal behavior, and reassurance may be all that is needed. However, a complaint of severe insomnia or excessive daytime sleepiness should prompt an evaluation, regardless of the patient's age.19




  Sleep/Wake Profile

 
bulletHow has the patient been sleeping recently?

Suggested Questions Following a Complaint of Insomnia
bulletWhen did the problem begin? (to determine acute vs. chronic.)
bulletDoes the patient have a psychiatric or medical condition that may cause insomnia?
bulletIs the sleep environment conducive to sleep (relative to noise, interruptions, temperature, light)?
bulletDoes the patient report "creeping, crawling, or uncomfortable feelings" in the legs relieved by moving them? (Relates to restless legs syndrome.)
bulletDoes the bed partner report that the patient's legs or arms jerk during sleep? (Relates to periodic limb movements in sleep.)
bulletDoes the patient snore loudly, gasp, choke, or stop breathing during sleep? (Relates to obstructive sleep apnea.)
bulletIs the patient a shift worker? What are the work hours? Is the patient an adolescent? (Relates to circadian sleep disorders/sleep deprivation.)
bulletWhat are the bedtimes and rise times on weekdays and weekends? (Relates to poor sleep hygiene.)
bulletDoes the patient use caffeine, tobacco or alcohol? Does the patient take over-the-counter or prescription medications (such as stimulating antidepressants, steroids, decongestants, beta blockers)? (Relates to substance-induced insomnia.)

Signs of Sleepiness
bulletWhat daytime consequences does the patient report?
bulletDoes the patient report dozing off or difficulty staying awake during routine tasks, especially while driving?




  Management



Introduction

Often the cause of acute insomnia (no one episode lasts longer than several weeks) is related to a single specific event. The need for treatment is usually determined by the severity of the daytime sequelae, the duration of the episode, and the degree to which episodes become predictable. Even brief episodes of acute insomnia may warrant treatment because individuals who are typically good sleepers can and do become significantly sleepy after loss of just a few hours of sleep on one or more nights.20 Also, there is a possibility that untreated acute insomnia may develop into a chronic, learned insomnia.

General Sleep Hygiene Measures
Sleep hygiene measures may help promote sleep in all people. Sleep hygiene measures involve health practices and environmental influences relating to sleep.
bulletWake up at the same time of day.
bulletDiscontinue caffeine 4 to 6 hours before bedtime, and minimize total daily use. Caffeine is a stimulant and may disrupt sleep.
bulletAvoid nicotine, especially near bedtime and upon night awakenings; it is also a stimulant.
bulletAvoid the use of alcohol in the late evening to facilitate sleep onset; alcohol can cause awakenings later in the night.
bulletAvoid heavy meals too close to bedtime, as this may interfere with sleep. A light snack may be sleep-inducing.
bulletRegular exercise in the late afternoon may deepen sleep; vigorous exercise within 3 to 4 hours of bedtime may interfere with sleep.
bulletMinimize noise, light, and excessive temperature during the sleep period.
bulletMove the alarm clock away from the bed if it is a source of distraction.

Sample Sleep Diary

Name:________________________________________________________________________

Example
Date Monday, 4/10    
Bed Time (of previous night) 10:45 p.m.    
Rise Time 7: 00 a.m.    
Estimated time to fall asleep (previous night) minutes 30    
Estimated # of awakenings & total time awake (previous night) 5 times
2 hours		    
Estimated amount of sleep obtained (during previous night) 4 hours    
Naps(Time & Duration) 3:30 p.m.
45 minutes		    
Alcoholic Drinks
(Number & Time)		 1 drink @ 8:00 p.m.
2 drinks @ 9:00 p.m.		    
List stresses experienced today Flat tire
Argued w/son		    
Rate how you felt today
  1. Very tired/sleepy
  2. Somewhat tired/sleepy
  3. Fairly alert
  4. Wide awake
2    
Irritability
1=Not at all
5=Very 		5=Very    
Medications      


When the insomnia persists beyond a night or two, or becomes predictable, treatment should be considered. Pharmacological treatment usually predominates—especially the use of short-acting hypnotics. Adjunctive sleep hygiene measures may also be useful. See box in this chapter. The goal of treatment is to improve the patient's sleep, but it may not be possible to achieve normal sleep every night.

Chronic insomnia is often a significant therapeutic challenge. Since chronic insomnia is often multifactorial in etiology, multiple treatment modalities may be needed for any one patient. If an underlying medical or psychiatric condition is identified, this condition should be treated first. In some patients, the mechanisms that maintain the insomnia are more important than precipitating factors.

If the complaint of chronic insomnia appears to be primary or persists after treatment of an underlying condition, two general treatment approaches are available—behavioral and pharmacological. Usually pharmacological treatment provides rapid symptom relief, but long-term treatment is unstudied. Behavioral approaches take a few weeks to improve sleep but continue to provide relief after training sessions have been completed.21




Behavioral Treatment

Behavioral interventions seek to change maladaptive sleep habits, reduce autonomic arousal, and alter dysfunctional beliefs and attitudes, which are presumed to maintain insomnia. These therapies have been shown to produce reliable and durable improvements for patients with chronic primary insomnia.22 At times, the various behavioral treatments are compatible with each other and can be combined, although it is not clear whether increased therapeutic benefit results.

Relaxation Therapy. Relaxation therapy is based on observations that insomnia patients often display high levels of physiologic, cognitive, and/or emotional arousal, both at night and during the day-time. There are several relaxation methods although none has been shown to be more efficacious than the others. Progressive muscle relaxation, autogenic training, and EMG biofeedback seek to reduce somatic arousal (e.g., muscle tension), whereas attention-focusing procedures such as imagery training or meditation are intended at lowering presleep cognitive arousal (e.g., intrusive thoughts, racing mind). Abdominal breathing is often a component of various relaxation techniques, or it may be used alone. Relaxation therapy is useful for both sleep onset and maintenance insomnia. All these techniques require regular practice with a trained professional over a period of several weeks.

Sleep Restriction Therapy. Poor sleepers often increase their time in bed in a misguided effort to provide more opportunity for sleep, a strategy that is more likely to result in fragmented and poor-quality sleep. Sleep restriction therapy 23 consists of curtailing the amount of time spent in bed to increase the percentage of time asleep. This improves the patient's sleep efficiency (time asleep/time in bed). For example, a person who reports staying in bed for 8 hours but sleeping an average of 5 hours per night would initially be told to decrease the time in bed to 5 hours. The allowable time in bed per night is increased 15 to 30 minutes as sleep efficiency improves. Adjustments are made over the weeks until an optimal sleep duration is achieved. Typically, it is best to alter bedtime and keep the rise time constant in order to maintain a regular sleep-wake rhythm. By creating a mild state of sleep deprivation, this therapy promotes more rapid sleep onset and more efficient sleep. To minimize daytime sleepiness, time in bed should not be reduced to less than 5 hours per night. Sleep restriction therapy is modified in older adults by allowing a short afternoon nap.21

Stimulus Control Therapy. Stimulus control therapy 24 is based on the premise that insomnia is a conditioned response to temporal (bedtime) and environmental (bed/bedroom) cues usually associated with sleep. The main objective of stimulus control therapy is to reassociate the bed and bedroom with rapid sleep onset. Stimulus control instructions involve (a) going to bed only when sleepy; (b) using the bed and bedroom only for sleep; (c) getting out of bed and going into another room when unable to fall asleep or return to sleep easily, and returning to bed only when sleepy again; (d) maintaining a regular rise time in the morning regardless of sleep duration the previous night, and (e) avoiding daytime napping. Clinical trials have documented the efficacy of stimulus control therapy for both sleep onset and sleep-maintenance insomnia.25,26

Cognitive Therapy. Cognitive therapy involves identifying dysfunctional beliefs and attitudes about sleep and replacing them with more adaptive substitutes. For example, patients who believe that sleeping 8 hours per night is an absolute necessity to function during the day are asked to question the evidence and their own experience to see if this is true for them. Those who are convinced that insomnia is destroying their ability to enjoy life are encouraged to develop more adaptive coping skills and to cease viewing themselves as victims. These attitudinal changes often help to minimize anticipatory anxiety and arousal that interfere with sleep.




Pharmacological Treatment

Hypnotic Medications. The primary indication for hypnotic medication is the short-term management of insomnia—either as the sole treatment modality or as adjunctive therapy until the underlying problem is controlled. The most common type of medications used to promote sleep are the benzodiazepine receptor agonists. These compounds have all been shown to be effective in inducing, maintaining, and consolidating sleep as compared with a placebo.27 Patients report significant relief of both nighttime and daytime symptoms. 28 There are small differences between compounds in their ability to induce and maintain sleep based on rate of absorption and elimination. The most common side effect of these drugs is anterograde amnesia and, for long-acting drugs, residual daytime drowsiness. Currently an estimated 10 to 15 percent of hypnotic users take them regularly for more than 1 year, 29 although there are little safety or efficacy data to guide their use beyond 2 to 3 months. While selected patients may benefit from chronic use, there are no clear indications of which patients might benefit from chronic therapy.

Dose, pharmacokinetic properties (absorption rate, distribution, elimination half-life), and risk-benefit ratio are the key factors in selecting the most appropriate medication. Dose is the single best predictor of the frequency of side effects reported with these medications. It impacts both the peak amount of a drug in the body as well as the duration of action of the medication. Once an effective dose is established, increasing the dose rarely leads to increased efficacy but does reliably predict an increase in the frequency of side effects.

Elimination half-life varies considerably among hypnotics and is the best predictor of next-day residual effects. For patients who need to be alert because of occupational or societal demands, short-acting medications are preferred. However, patients with insomnia and high levels of daytime anxiety may benefit more from long-acting medications. It is important to remember that the volume of distribution and rate of metabolism for most of these medications slow with age. This leads to higher drug concentrations and a longer duration of action. Hypnotic medications are ontraindicated in pregnant women, patients with untreated obstructive sleep apnea, patients with a history of substance abuse, and patients who might need to awaken and function during their normal sleep period. Finally, patients with hepatic, renal, or pulmonary disease need to be monitored more carefully than otherwise healthy insomniacs.

Antidepressants. It is very common for sedating antidepressants to be prescribed for insomnia, often in low dose, but there is little scientific evidence to support the efficacy or safety of this approach in most types of insomnia. When prescribed to patients with major depression, sedating antidepressant improve subjective and objective measures of insomnia, and sleep symptoms often improve more quickly than other symptoms of depression. When administered concurrently with "alerting" antidepressants, low doses of sedating antidepressants such as trazodone again improve insomnia.31

However, in nondepressed individuals there are minimal data upon which to recommend use of antidepressants. 32 Antidepressants have a range of adverse effects including anticholinergic effects, cardiac toxicity, orthostatic hypotension, and sexual dysfunction (selective serotonin reuptake inhibitors [SSRIs]). Tricyclic antidepressants and SSRIs can exacerbate RLS and PLMD in some individuals. The lethal dose/effective dose ratio for tricyclics is worse than for benzodiazepines.

With little scientific evidence supporting the efficacy and safety of antidepressants in insomnia, the clearest indications are for patients with insomnia associated with psychiatric disorders or a previous history of substance abuse.

Antihistamines. Drugs that antagonize central histamine-1 receptors have sedative effects. The most common antihistamines used for insomnia are diphenhydramine and hydroxyzine; most over-the-counter sleep aids include an antihistamine. Few recent studies assess the efficacy of antihistamines for treating insomnia, but older studies demonstrate subjective and objective improvements during short-term treatment.33
The long-term efficacy of antihistamines for insomnia has not been demonstrated. Adverse effects associated with antihistamines include daytime sedation, cognitive impairments, and anticholinergic effects. Tolerance and discontinuation effects have been noted.29

Melatonin. Melatonin has several physiological actions, including a phase-shifting effect on circadian rhythms, increased sleepiness when administered during daytime hours, and asoconstriction. Its mechanisms of action are unknown but may involve interaction with melatonin receptors in the suprachiasmatic nucleus. The role of melatonin in treating any sleep-related disorder remains to be defined.34 Clinical studies in patients with insomnia have provided inconsistent results.

Other Drugs. Barbiturates and a number of older non-benzodiazepine, nonbarbiturate drugs such as chloral hydrate, methyprylon, and meprobamate are still available. These drugs are not ecommended for treatment of insomnia because of their narrow therapeutic ratio, rapid development of tolerance, systemic toxicity, potential for abuse, and possibility of severe clinical complications on withdrawal.

Finally, a variety of herbal preparations (e.g., valerian root, herbal teas), nutritional substances (e.g., L-tryptophan), and over-the-counter drugs are also promoted for the treatment of insomnia. In general, there is little scientific evidence for the efficacy or safety of these products.




  Conclusion

Sleep disturbance is a reliable predictor of psychological and/or physical ill health. Thus a report of disturbed sleep signals the need for further evaluation. Physicians should inquire about sleep during periodic patient assessments. Insomnia is often associated with psychiatric or medical illness, sometimes as the primary or first symptom of a problem. Effective treatments for insomnia are available. For some patients, improvement in sleep leads to an improved quality of life.15

Source:
  		National Center on Sleep Disorders Research and Office of Prevention, Education, and Control
National Institutes of Health


References

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  8. Klink ME, Quan SF, Kaltenborn WT, Lebowitz MD. Risk factors associated with complaints of insomnia in a general adult population. Arch Intern Med 1992; 152:1634-1637.

     

  9. Buysse DJ. Drugs affecting sleep, sleepiness and performance. In: Monk TH, ed. Sleep, Sleepiness and Performance. Chicester: John Wiley & Sons, Ltd., 1991:249-306.

     

  10. Obermeyer WH, Benca RM. Effects of drugs on sleep. Neurologic Clinics 1996; 14(4):827-840.

     

  11. Buysse DJ, Reynolds CF, Hauri PJ, et al. Diagnostic concordance for sleep disorders using proposed DSM-IV categories: A report from the APA/NIMH DSM-IV field trial. Am J Psychiatry 1994;151(9):1351-1360.

     

  12. Bonnet MH, Arand DL. Hyperarousal and insomnia. Sleep Medicine Reviews 1997;1(2):97-108.

     

  13. Doghramji K, Browman CP, Gaddy JR, Walsh JK. Triazolam diminishes daytime sleepiness and sleep fragmentation in patients with periodic leg movements in sleep. J Clin Psychopharmacol 1991;11:284-290.

     

  14. Walsh JK, Muehlbach MJ, Lauter SA, Hilliker NA, Schweitzer PK. Effects of triazolam on sleep, day time sleepiness, and morning stiffness in patients with rheumatoid arthritis. J Rheumatol 1996;23:245-252.

     

  15. Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep 1995;18(7):581-588.

     

  16. Kuppermann M, Lubeck DP, Mazonson PD, Patrick DL, Stewart AL, Buesching DP, Fifer SK. Sleep problems and their correlates in a working population. J Gen Intern Med 1995;10:25-32.

     

  17. Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997;154(10):1417-1423.

     

  18. Üstün TB, Privett M, Lecrubier Y, et al. Form, frequency and burden of sleep problems in general health care: A report from the WHO collaborative study on psychological problems in general health care. Eur Psychiatry 1996;11(suppl l):5S-10S.

     

  19. National Institutes of Health Consensus Development Statement: The treatment of sleep disorders of older people. March 26-28, 1990. Sleep 1991;14(2):169-177.

     

  20. Carskadon MA, Dement WC. Nocturnal determinants of daytime sleepiness. Sleep 1982; 5:S73-S81.

     

  21. Morin CM. Insomnia: Psychological Assessment and Management. New York: Guilford Press, 1993.

     

  22. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta- analysis f treatment efficacy. Am J Psychiatry 1994;151(8):1172-1180.

     

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  32. Walsh JK, Erman M, Erwin CW, et al. Subjective hypnotic efficacy of trazodone and zolpidem in DSM-III-R primary insomnia. Hum Psychopharmacol 1998;13:191-198.

     

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Members of the National Heart, Lung, and Blood Institute Working Group on Insomnia

James K. Walsh, Ph.D. (Chair)
Director
Sleep Medicine and Research Center
St. Luke's Hospital
Chesterfield, MO

Ruth M. Benca, M.D., Ph.D.
Associate Professor of Psychiatry
Associate Chair, Department of Psychiatry
University of Wisconsin/Madison
Madison, WI

Michael Bonnet, Ph.D.
Director, Sleep Disorders Laboratory
VA Hospital
Dayton, OH

Daniel J. Buysse, M.D.
Associate Professor of Psychiatry
Medical Director, Sleep and
Chronobiology Center
Western Psychiatric Institute & Clinic
Pittsburgh, PA

Jim Ricca, M.D., M.P.H.
Department of Family Medicine
Georgetown University Medical Center
Washington, DC

Peter J. Hauri, Ph.D.
Administrative Director
Mayo Sleep Disorders Center
Mayo Clinic
Rochester, MN

Charles Morin, Ph.D.
Professor of Psychology
Director, Sleep Disorders Research Center
Universite Laval
Ecole de Psychologie
Ste-Foy, Quebec

Thomas Roth, Ph.D.
Division Head
Sleep Disorders Center
Henry Ford Hospital
Detroit, MI

Richard D. Simon, Jr., M.D.
Medical Director
Katherine Severyns Dement Sleep
Disorder Center
St. Mary Medical Center
Walla Walla, WA

National Institutes of Health Staff

James Kiley, Ph.D.
Director
National Center on Sleep Disorders Research
National Heart, Lung, and Blood Institute
Bethesda, MD

Andrew Monjan, Ph.D., M.P.H.
Chief of Neurobiology and
Neuropsychology
National Institute on Aging
Bethesda, MD

Susan Rogus, R.N., M.S.
Coordinator, Sleep Education Activities
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
Bethesda, MD

Support Staff

Pamela Christian, R.N., M.P.A.
R.O.W. Sciences, Inc.
Rockville, MD

Susan Shero, R.N., M.S.
R.O.W. Sciences, Inc.
Rockville, MD




  How Do I Cure Insomnia?

The average adult needs eight hours of sound sleep each night. However, most adults get between six and seven hours. This falls short of the recommended amount by one to two hours. Unbeknownst to many, this one to two hours of sleep that is lost each night can have a profound affect on one's health.

Insomnia is described as having trouble falling asleep, staying asleep or waking up too early and can be caused by any number of things. Some of the more common reasons insomnia occurs are stress, depression, anxiety, pain and even some medications can be the culprit. Medical conditions such as sleep apnea can also cause insomnia. Sleep apnea is more commonly known as the stoppage of breathing while sleeping.

People who don't get enough sleep can suffer greatly if not treated. Depression, heart disease and other illness can occur because of the lack of sleep. You may also have a hard time recovering from illnesses or injury if you do not get enough sleep.

Your mind and body need time to recoup after a day of living. No matter what you do, working, playing or just sitting around, your mind and body can only withstand so much. Without sleep, your mind doesn't work as clearly, you feel physically drained, and you will be less able to cope with every day stresses.

For most, rearranging one's sleep habits will more than likely solve the insomnia problem. As a child, you were more than likely trained by your parents or caregiver how to sleep. As strange as this sounds, you were put to bed in your bed when it was time to sleep. This routine trained your body and mind, hence your sleep habits were formed. However, sleep habits change. A change in sleep habit can occur for any reason and should be treated promptly to avoid problems with insomnia.

There are many things one who suffers from insomnia can do. A simple lifestyle change is more than likely all that is needed. Some examples would be to make time to just relax, not necessarily sleep, but some wind down time. Take a warm bath, or read a book, boring ones seem to work best at getting you to sleep. Listening to calming music or drinking a cup of chamomile tea also helps. Avoid working out four hours before bedtime and avoid cigarettes and caffeine.

If for some reason a lifestyle change is not the answer for you, seeing a doctor or physician may be the order of the day. He or she will be better able to diagnose your symptoms and come to a conclusion for treatment. Some of the treatments your physician may suggest would include:
bulletover-the-counter medications
bulletdietary supplements
bulletprescription sleep aids

For people that require an over the counter medication to induce sleep there is a wide variety to choose from. Sominex and Unisom are two of the most common. They contain antihistamines that cause drowsiness. Tylenol PM can help with pain and also induce sleep if the cause of your insomnia is pain. If you happen to have a cold that is keeping you awake, some cold medications will help with sleep.

Also available without a prescription are dietary supplements. Supplements that contain the herb melatonin or valerian are particularly helpful. Melatonin is thought to play a key role in the brain's ability to know when it is time to sleep. Valerian is thought to have a calming affect. Understand that the FDA (Food and Drug Administration) does not regulate these types of products and you should consult with a physician on the proper method of treatment.

As a last resort, your physician may prescribe a sleep aid. These drugs are know to many as hypnotics. They slow the central nervous system. Drugs such as Valium and Klonopin are benzodiazepines. Then there are nonbenzodiazepines such as Ambien and Sonata. If you suffer from anxiety, your doctor will be more likely prescribe a benzodiazepines type medication. This type of medication will cut the time it takes to fall asleep and reduce anxiety symptoms.

No matter what the cause of your sleep problems, it is always advisable to consult with a physician that knows how to treat the problem properly. It may take some experimenting, but once you get treatment, you will be on your way to a better night's sleep every night.




  Trouble Sleeping? Chill Out


A Drop in Temperature May Help You Fall Asleep

A drop in body temperature near bedtime triggers the subjective sense that is's time to go to sleep. Responding promptly to this internal signal may help you fall asleep faster and sleep more estfully, according to a report in the current issue of the journal Sleep.

Making a special effort to cool down before bedtime may be of particular benefit to insomniacs, say researchers Patricia Murphy, Ph.D., and Scott Campbell, Ph.D., of the Laboratory of Human Chronobiology at the New York Hospital/Cornell Medical Center in White Plains, New York.

Body temperature, contrary to the common belief, is not uniformly 98.6°F. That is merely an average. Temperature cycles from about 1 degree below to 1 degree above this average over the course of the day. For healthy young adults who sleep at night, body temperature usually is lowest around 4 to 5 a.m. Most sleep episodes occur in a window from about 6 hours before the daily low to about 2 hours after it.

Sleep specialist have long debated whether the nighttime drop in temperature induces sleep or follows it. One theory is that is simply the result of lying down and curtailing physical activity.

To investigate this question, Drs. Murphy and Campbell recruited 21 men and 23 women, aged 19 to 82. All of the subjects were healthy and ordinarily slept between 6 and 9 hours at night. For the study, the participants had their sleep monitored for 2 nights, the first to facilitate adaptation and the second to serve as a baseline. Then they spent 3 consecutive days and nights in special studio apartments isolated from all time cues. During the study, they wore rectal thermometers continously to provide a minute-by-minute record of their body temperature.

They were encouraged to eat and sleep whenever they wanted and told specifically not to try to overcome bouts of sleepiness. To boost compliance, the researchers gave them only a deck of cards, a jigsaw puzzle and limited reading material. They could stretch but not engage in any other exercise, and they were discouraged from doing any physical activity that might keep them awake. They were not allowed to take showers and wore comfortable, pajama-like clothing throughout the 72-hour study period. The lights were kept low. As a result, the participants spent most of the time lounging on the couch or in bed.

At the end of the study, the researchers examined each subject's 72-hour stint in the laboratory, looking for sleep bouts that began between 10 p.m. and 6 a.m. and lasted at least 4 hours. Some 65 sleep episodes met this criteria. The researchers then identified the time at which the subjects' body temperature fell most precipitously. This point almost always occurred in the 2 hours before sleep began.

In everyday life, Drs. Murphy and Campbell point out, it is easy to disregard the body's readiness for sleep: watching the last innings of a baseball game or reading a good book can serve as a potent distraction. On the night before the subjects began their stay in the time isolation laboratory, the interval between the fall in body temperature and the onset of sleep was about 60 minutes. In the laboratory, where subjects were encouraged to go to sleep as soon as they felt sleepy, the interval was only 44 minutes.

On the pre-study baseline night, older subjects slept worse than younger subjects, waking more often after sleep began. In the time isolation part of the study, this difference nearly disappeared. That suggests, the researchers say, that older people might sleep better if they responded promptly to sensations of sleepiness, which may mean going to sleep a little earlier than they customarily do. "There's a trade-off, however," Dr. Campbell points out. "While they may sleep more soundly, they also may awaken earlier than desired in the morning. They need to decide in advance what to do if they get up before the rest of the household."

People with trouble falling asleep might benefit from taking hot baths about 90 minutes before bedtime, the researchers speculate. When they get out of the bath, body temperature will drop rapidly, and that might help them to fall asleep faster.

 

Source: Patricia Murphy and Scott Campbell. Nightime drop in body temerature: a
                physiological trigger for sleep onset? Sleep, 1997; 20 (6):505-511.

Sleep is the journal of the American Sleep Disorders Association and the Sleep Research Society. These independent organizations represent more than 3,500 physicians and other clinical specialists, laboratory scientists, and technicians in pulmonary medicine, neurology, psychiatry, sychology, otolaryngology, internal medicine, pediactrics and other disciplines.




  Using Light Therapy to Treat Insomnia

Waking up in the wee hours of the morning.Nodding off during the day. Struggling to fall asleep at night. These are signs of sleep disorders that are all too common among seniors.

Dr. Daniel Kripke, a professor of psychiatry and faculty member of The Sam and Rose Stein Institute for Research on Aging at UCSD, says such sleep disorders are sometimes linked to too little light exposure and desynchronized body clocks.

"Our bodies need bright light—the kind you get outside on a sunny day— to keep our internal clocks ticking on the right schedule. The light seems to set the schedule for when our bodies sleep and wake," Kripke said.

This theory may explain why some seniors have trouble sleeping or tend to wake up too early. Kripke and his colleague, Dr. Sonia Ancoli-Israel, surveyed nursing home residents at several different facilities and found that many people were exposed to very little natural light. In some facilities, residents on average spent only one minute a day outdoors. In another study, Kripke found that older men are outside about three times as much as women. These elderly women tended to get up one hour earlier than men and reported more cases of insomnia.

Kripke explains that as the retina in the eye is exposed to light, nerve impulses are transmitted to the suprachiasmatic nucleus in the brain. This structure sends signals to brain's pineal gland in the brain, telling it when to release a hormone called melatonin. Melatonin seems to signal the body when to fall to sleep and wake up.

Kripke says the brightness level of light a person sees affects this timing system.
"If we spent most of the day outside like our ancestors, our body clocks would be set normally. However, most people are indoors much of the day. Even though we don't consciously realize it, we are being exposed to very low levels of light," Kripke said.

Light brightness is measured in lux. Outside on a bright, sunny day, the brightness level is about 10,000 lux. In the shade, the brightness goes down to 3,000 lux. Indoors, the level drops to 200 lux, and in front of the TV with the lights dimmed, the brightness is only 10 lux.

Kripke says that purposeful exposure to bright light can help eliminate some sleeping problems. For example, if someone tends to wake up too early in the morning, his body clock may be running too early. Exposure to a bright light in the evening, perhaps near the television, helps reset the body clock back to normal. For those who are able, a relaxing walk outside in the sunshine can also help cut back on sleeping problems.

Kripke is also curious about another observation showing that melatonin levels—the hormone that helps control body clocks—are much lower in older people than in younger people. "We're not sure if this is part of normal aging or if the fact that younger people generally spend more time outdoors affects the melatonin levels," Kripke said.

Kripke hopes to study this question using the new Human Circadian Pacemaker Research Laboratory, located in the The Sam and Rose Stein Institute for Research on Aging, Clinical Sciences Building on the UCSD School of Medicine campus. This laboratory includes sleep isolation labs that look like studio apartments—complete with a bed, bathroom, kitchen, computer workstation and television. The laboratory also has computerized ceiling lights that can be adjusted to several different levels of brightness. In this controlled environment, technicians can carefully alter the amount of lux a person is exposed to and observe how this affects sleep patterns and melatonin levels. Melatonin can be measured through blood samples.

Whatever insights such future experiments may bring, the message for today is clear_try to get outside and get plenty of bright sunshine. But don't forget the suntan lotion.


This column is contributed by physicians and researchers associated with The Sam and Rose Stein Institute for Research on Aging, a program of UCSD School of Medicine. The Institute is dedicated to developing better treatments and cures to diseases related to aging in order to advance lifelong health and independence.

For more information about the Institute, call (619) 534-6299.




  Natural Treatments For Insomnia

If you're having trouble sleeping more that three times per week you may be suffering from insomnia. Even though this is a very common condition, Insomnia can be difficult to deal with. You're getting up early in the morning to get the kids ready for school and then head to work, but you barely slept four hours last night! How can you possibly function at your peak? You can't, and therefore, your work suffers, your family suffers, and your health suffers. Many people go for weeks maintaining a regular schedule while their bodies are lacking the necessary rest. This type of behavior can lead to serious complications.

Statistics show that insufficient sleep is the cause of many car accidents. It can also interfere with work performance leading to job loss, and if gone untreated serious medical conditions can occur. If you find yourself in this situation, you need to evaluate the situation to find the underlying cause and solution. The following ideas will help you to evaluate the possible causes and assist you in taking control of the situation.



Bedroom Inventory

Your bedroom's atmosphere plays an important part in the amount of time that it takes you to fall asleep. Is your bedroom a relaxing place to be in? Or is it a room that provokes work and stimulation of the mind? Start by taking an inventory of your room looking for everything that can act as a stimulant. Look for such things as a television, stereo, exercise equipment, desk, computer, paperwork, and reading material that excites rather than relaxes the mind. Check the amount of lighting coming through the windows, the room temperature and moisture level. Is there a lot of street noise coming into your room? Is the size of your bed large enough and is the mattress comfortable?



Creating a Peaceful Place

Once you've done the inventory it's time to remove all the items that incite work and turn your bedroom into a peaceful and restful room. For instance, if the temperature in your room is too hot or too cold, adjust the thermostat to 65°-70°; according to sleep clinics this is the ideal temperature for sleeping. If the air is too dry you may need to use a humidifier, especially in the wintertime. If you have a stereo or CD player, instead of removing it from the room use it to play soft music meditations only. If there's too much street noise, purchase a nature sounds CD to drown out the noise. Use light blocking window shades or thick curtains if there is light coming through the windows.
Now that you've removed all the possible causes and replaced them to produce a soothing atmosphere it's time to start a diary.



What's Worrying You?

For the next couple of nights write down everything that you're feeling, sensing, and any thoughts that keep popping up when you're trying to fall asleep. Does your mind start chattering? Do you begin making mental to-do lists? Are you feeling anxious, worried, or preoccupied?

If you find yourself solving problems when you should be sleeping then the following will help you to break this habit. Set a scheduled time during the evening, at least two or three hours before bedtime for problem solving. During this time you can make your to-do lists and engage in any matters that are lingering on your mind. Do this on a daily basis; this is your time to deal with problems. Once this becomes a habit your mind will stop using your sleep time for problem solving.

Other causes and possible solutions:
bulletDon't eat dinner less than three hours before bedtime.

 

bulletDon't exercise less than four hours before bedtime.

 

bulletDon't nap during the day.

 

bulletStop all caffeine intake no later than 4:00 p.m.; these include coffee, soda, chocolate, tea containing caffeine, etc.

 

bulletHave you been taking any migraine medication? These contain plenty of caffeine that'll keep you awake if taken in the evening.

 

bulletLavender is a natural sleep-inducing plant that works through the sense of smell. Soak in a warm bath with a few drops of lavender oil, and place a lavender sachet under your pillow. The subtle scent will help to ease you into a restful sleep.

 

bulletDrinking chamomile tea 30 minutes before bedtime will help to relax your body.

 

bulletRelaxation exercises, yoga, and meditation are very good ways to help your body and mind relax before going to bed. Fifteen minutes of any one of these exercises dramatically improves sleep.

 

bulletIf you choose to read in bed, don't read mind-stimulating books. Does this mean that you should read boring books? Well, not necessarily boring, but don't read any action adventures or mind boggling books. If after using all these tips you're still not getting any sleep, it's time to visit your doctor.

Soure: PageWise, Inc.
http://txtx.essortment.com




  Melatonin


What is Melatonin?

Melatonin is a natural hormone made by your body's pineal (pih-knee-uhl) gland. The pineal gland lies at the base of the brain. And when the sun goes down, and darkness comes, the pineal gland "goes to work." As melatonin production rises, you begin to feel less alert. Body temperature starts to fall as well. Sleep seems more inviting. Then melatonin levels drop quickly with the dawning of a new day. Levels are so low during the day that scientists often have difficulty detecting melatonin then.

Melatonin levels go hand in hand with the light-dark cycle, not just for people, but for plants and animals that keep alert during the day. Melatonin production is also related to age. Children manufacture more melatonin than the elderly do. But melatonin production begins to drop at puberty.

If you're curious about melatonin, it's not surprising. There has been a lot of attention paid to the hormone in popular magazines and books, scholarly journals, and advertisements. You may have heard claims that melatonin cures everything from jet lag to insomnia to aging.

And chances are good that you've seen melatonin in healthfood stores, heard it being discussed, or seen an advertisement or article about it. But what is sold in stores is not the same substance as that produced in your body.

Healthfood stores sell synthetic (artificial) or, on occasion, animal melatonin. Synthetic melatonin is made in factories where the manufacturing process is not controlled by the U.S. Food and Drug Administration (FDA). Melatonin is one of only two hormones not regulated by the FDA and sold over-the-counter without a prescription. (DHEA, or dehydroepiandrosterone, is the other.)



Why Isn't Melatonin Considered a Drug?

Because melatonin does appear naturally in some foods, the U.S. Dietary Supplement Health and Education Act of 1994 allows it to be sold as a dietary supplement. And dietary supplements (like vitamins and minerals), do not need to be approved by the FDA or controlled in the same way drugs are. Melatonin makers are only limited in what they can say. They can't say melatonin can cure, treat or lower the risk of a disease. But they can say something more general, like that it can help promote sleep.


What Does This Mean to You?

 
bulletFew studies have been done on melatonin's safety, side effects, interactions with drugs, and long-term effects. (Unlike products recognized as "drugs, melatonin does not require extensive testing in animals and people before being sold in the U.S.)
bulletHow much to take, when to take it, and melatonin's effectiveness for many groups of people are also unknown.
bulletInformation about reported side effects do not have to be listed on the product's packaging. Yet worsened fatigue and depression, constriction of the arteries to the heart (which could increase the risk of heart attack), and possible effects on fertility have been reported.
bulletThe manufacturers of melatonin do not have to follow the rigorous procedures and safety checks that the manufacturers of "drugs" do. Problems with disease-causing impurities are more likely than with FDA-recognized drugs.
bulletListed doses may not be accurate. (In fact, one batch tested contained far more than the amount listed on the label.) And no one knows which dosage level might be the most effective.



Why Do People Take Melatonin?

Given the fact that so many questions remain unanswered about melatonin, why have so many people tried it?

Mostly to promote sleep or fight jet lag. Older people may think of mela-tonin as "replacement therapy." But one study found that the same dose of melatonin caused very different blood levels of the substance in those over 50. High levels may lower body temperature or increase levels of other chemicals. How this affects health is not known.



Understanding Insomnia

About half of American adults have trouble sleeping at one time or another or all of the time, according to the 1995 National Sleep Foundation Gallup Poll: Sleep in America. The trouble experienced may be difficulty falling asleep or staying asleep. Emotional stress is a major cause of why people can't sleep. Feelings of sadness or worries can make it hard to fall asleep or stay asleep. Certain behaviors can affect sleep too. For example, drinking caffeinated beverages or having alcohol too late in the day can make it harder to sleep. So can exercising too close to bedtime, waking and going to sleep at different times each time, or concentrating on work right before trying to fall asleep. And shift work, a fact of life for about 25 percent of American workers, can lead to difficulty falling asleep when desired.

If you have trouble sleeping, try to put your finger on the cause.



For More Information

 
bulletWrite to the National Sleep Foundation (NSF) or visit the NSF Web site:

www.sleepfoundation.org.

 

bulletFor a list of accredited centers, send a stamped, self-addressed envelope to:


National Sleep Foundation
1522 K St., NW, Suite 510
Washington, DC 20005




  Stanford Group Therapy Program Aims to Put                      Insomniacs to Sleep
by Mitch Leslie

For the 30 percent of the population who have trouble falling or remaining asleep, nightfall has come to signify the enemy. As the culprit descends, anxiety mounts, making the nightly struggle to sleep even harder.

Though insomnia is the most common sleep disorder, general medical practices and even sleep clinics rarely provide appropriate treatment, according to Derek Loewy, PhD, co-director of the Insomnia Program at the Stanford Sleep Disorders Clinic.

Answering the need for better diagnosis and treatment, Loewy and his colleague Rachel Manber, PhD, have launched the first group therapy program for insomnia in the United States. The eight-week, outpatient program combines education to instill healthy sleep habits with counseling sessions that help patients exorcise negative attitudes about sleep.

Though more common among the elderly, insomnia strikes people of all ages. Its symptoms include difficulty falling asleep, frequent awakening during the night, or awakening too early in the morning. The typical insomniac has sought help repeatedly and unsuccessfully, Loewy said. "Our insomniacs tend to be those with the thickest medical charts," he said.

Loewy said the first step in the treatment involves a thorough examination to rule out other possible causes for the patient's sleeplessness, such as depression or other sleep disorders.

Meeting once a week in groups of 5 to 7, patients then begin what is called cognitive-behavioral therapy (CBT), which involves adjusting behaviors to promote sleep and to alter the patients' misconceptions about their sleep problem, Lowey said. This can be difficult, because behaviors that disrupt sleep are surprisingly common and often seem sensible. For instance, to compensate for sleep loss or to remain awake after a restless night, many bleary-eyed insomniacs try napping, sleeping late and using caffeine or other stimulants during the day. At night, some people attempt to sedate themselves with alcohol.

All of these measures are counterproductive because they distort the body's sleep-wake cycle, Lowey said.

One of the most common misconceptions is that insomnia can be beaten through sheer determination, by stubbornly remaining in bed until you doze off. Lying awake is one of the worst things you can do, Loewy said. Failure to sleep breeds frustration and actually promotes further sleeplessness.

Instead, Lowey counsels, if you don't fall asleep quickly, get out of bed and do something relaxing and enjoyable. Reading, knitting and other quiet activities fit the bill. During these times, avoid exercise or exposure to bright light, since both can trigger arousal, he said.

Loewy and Manber also stress positive actions that can improve sleep, such as having set times for waking up and going to bed, something that helps the body's sleep-wake cycle settle into a regular rhythm.

During the trickier part of the treatment, Loewy and Manber try to get patients to talk through some of the worries that often trouble insomniacs. For some, their inability to sleep becomes so frustrating that they unconsciously develop negative associations with their own bed _ this explains why insomniacs typically sleep better away from home. For most people, "the sight of your bed should not be a source of anxiety," Loewy said.

Loewy and Manber encourage patients not to worry around bedtime, but to carve out a "worry time" during the day for fretting. They also teach breathing exercises that promote relaxation, and help patients deal with the sleep deficit that results when they begin adhering to a set wake-up time.

Unlike some past insomnia treatments, the program shuns drugs. Though sedatives can induce sleep, they lose their effectiveness as the body develops tolerance, and addiction remains a possibility, Loewy said.

The approach used at Stanford draws on Scottish research and work published in the March 17 issue of the Journal of the American Medical Association. That study, conducted by scientists in Virginia and Canada, found that drug therapy, cognitive-behavioral therapy and a combination of the two alleviated insomnia in the short term. But two years after treatment ended, only the CBT patients reported that the improvement in their sleep had persisted.

Source: www.stanford.edu