Patients with insomnia may experience one or more of the following problems: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning and nonrefreshing sleep. In addition, daytime consequences such as fatigue, lack of energy, difficulty concentrating and irritability are often present. The Center for Disease Control defines insomnia as an inability to fall or stay asleep that can result in functional impairment throughout the day.
Insomnia is classified as primary or secondary insomnia. Secondary insomnia is the most common type of insomnia and is believed to affect more than 80% of people who suffer from insomnia. Secondary insomnia related to another cause such as a medication, medical problem or substance.
Another way to classify insomnia is by its duration. Acute insomnia is defined as insomnia less than 4 weeks. Chronic insomnia is defined as insomnia of greater than 4 weeks. For insomnia to be present it must present greater than 3 nights each week.
Insomnia affects about 60 million Americans each year. Sleep disorders cost about 16 million dollars in direct health care costs each year. Insomnia increases with age and is more common in women than men. A recent analysis showed that slightly less than 50% of people who had insomnia suffered for over three years and about 75% of those with insomnia had symptoms of insomnia for one year.
Age and Sleep
Having an understanding about how much sleep one needs is important in understanding insomnia. Below is a listing of what the average person needs for sleep in a 24-hour period. It must be understood that some people can function fine on less sleep than others (Center for Disease Control, 2008).
- *Adults need between 7-9 hours
- *Adolescents need between 8.5 and 9.5 hours
- *Children ages 5 to 12 years old need between 9 and 11 hours
- *Children ages 3 to 5 years old need between 11 and 13 hours
- *Children ages 1 to 3 years old need between 12 and 14 hours
Different ages have different sleep patterns. At about age 14 there is a shift in the circadian rhythm. Teenager’s internal clock shifts to make them want to stay up late and sleep in. There is a physiological reason that high-school students have trouble sleeping.
Older age is also associated with changes in sleep. Older individuals sleep a similar amount of time, but they often have trouble staying asleep for one long sleep session. Those over 65 wake more frequently at night and have a difficult time falling back asleep. Older adults spend less time in the deeper stages of sleep. Aging comes along with more difficulty adapting to changes in regard to sleep. The older adult is more likely to suffer from sleep disturbances from jet lag or from shift work.
Older adults are more likely to suffer from health problems associated with sleep such as restless leg syndrome, snoring or sleep apnea.
States of Sleep
Sleep is made up of two stages, which include rapid eye movement sleep (REM) and non rapid eye movement (NREM) sleep. When asleep, the majority of time is spent in NREM sleep which is broken down into four stages (one to four). Stage one is the lightest stage and stage 4 is the deepest stage. In stage one, the person is drowsy with the eyes closed, but can be easily woken. The stages get progressively deeper. REM sleep has one stage. This is the stage that dreams occur and it is associated with eye movements, increased brain activity and increased respirations. The body cycles through the stages 5-6 times each night.
Causes of Insomnia
It is often useful to view the insomnia history in terms of predisposing, precipitating, and perpetuating factors. These factors can help identify potential causes of insomnia and treatment targets. Predisposing factors include family/genetic diathesis and chronic mental or medical disorders that increase the likelihood of insomnia symptoms. Precipitating factors are acute events or experiences that may push vulnerable individuals over the threshold into acute insomnia. Perpetuating factors include behavioral patterns (e.g., spending excessive time in bed) and medical or medication factors that maintain insomnia symptoms over time.
Many factors can lead to insomnia. Causative factors include: medical or psychiatric disease, medications and environmental issues. Below is a listing of common causes of insomnia.
- *Medical illness – arthritis, cancer, lung disease, heart failure, stroke, gastroesophageal reflux disease, benign prostatic hypertrophy, acute illness (bronchitis), obstructive sleep apnea and obesity
- *Psychiatric illness – depression and anxiety
- *Psychological stress – money problems, divorce, change in family dynamics, death or new employment
- *Medications – corticosteroids (especially oral), bupropion, decongestants, hormones, alcohol, diuretics, theophylline and albuterol
- *Substances – caffeine, alcohol and nicotine
- *Environmental issues – poor sleep environment, shift work, too much light in the bedroom
Who is at Risk?
Certain factors increase the risk of developing insomnia. Professionals who can identify those at high risk for insomnia are better able to help them. Below is a listing of characteristics to help us predict who may suffer with insomnia.
*Women have insomnia more than men
*Increasing age is associated with insomnia
*Individuals who suffer from illnesses or on medications listed above
* Those who frequently drink alcohol
*Individuals who have high stress levels (stressful job, going through a divorce, bankruptcy or the death of a loved one)
*Individuals who travel long distances
Race is not linked to insomnia
Insomnia and Quality of Life
Insomnia negatively impacts quality of life. Poor sleep affects life in a number of ways. Insomnia affects mental function. Those with insomnia may suffer from reduced concentration and poor memory. It also affects work as insomnia increases work absenteeism, reduces job performance and increases the risk for errors at work.
Poor sleep also affects health as those who suffer from insomnia are more likely to suffer from poor general health, have increased health care costs and are more likely to catch a viral illness.
Insomnia can result from different causes and present in different ways. It is therefore critical for the client complaining of problematic insomnia to be fully evaluated for mental health, as well as physical causes.
In addition to evaluating sleep through questions, feedback and sleep diaries, a complete medical and social work up should be included. The client should be referred to his physician so that they can be evaluated for any of the medical problems that are known to be associated with insomnia.
*Is there any pain? Pain can significantly reduce the quality of sleep. If pain is present the underlying cause should be determined and managed.
*Evaluation of any respiratory conditions should be carried out, as lung diseases are a contributing factor to sleep disturbances.
*Another common cause of sleep disturbance is gastroesophageal reflux disease and specific questions to evaluate for this should be asked.
*The client’s doctor should review the medications the client is on because medications are linked to insomnia.
*Body weight should be evaluated. Those who are obese or have a neck circumference more than 18 inches are at higher risk of obstructive sleep apnea. Enlarged tonsils or an enlarged tongue is also an indication of sleep apnea.
Uncontrolled psychiatric diseases can contribute to insomnia. A major cause of insomnia is stress. Evaluating the patient’s life may give insight into the cause of insomnia. Patients should be asked about any stress in their lives. Some areas to probe include:
*stress at work
* a new job
*stress at home
*a changed personal relationship (divorce, marriage, a child going off to college, etc)
*death of a friend or family member
Some cases of insomnia may require further diagnostic testing. If an underlying chronic disease is suspected than evaluation for that condition should ensue. A popular method to evaluate the patient is through a sleep lab. One test often done is a polysomnogram. This is a recording of the physiological variables of sleep. It usually includes an electroencephalogram (EEG), electromyogram (EMG), electrocardiogram (ECG), respiratory assessment, oxygen saturation and limb movement assessment. Sometimes esophageal pH is monitored to assess for acid in the esophagus.
This assessment can evaluate for the presence of underlying factors that contribute to insomnia. Some conditions that may be picked up include: obstructive sleep apnea, restless leg syndrome gastroesophageal reflux disease and seizures.
The first step in the treatment of insomnia is to manage any underlying medical problems. Most cases of insomnia are secondary insomnia, so the majority of cases will never be properly managed if the underlying cause is not identified and treated.
Counseling Approaches to Treatment
At the same time that underlying conditions are being evaluated and worked up the patient can be taught non-pharmacological interventions to improve sleep. Non-pharmacological interventions are critical to the management of insomnia as pharmacological options are associated with many side effects.
There are many steps patients can take to improve the quality and quantity of their sleep. Those with insomnia need to develop a regular sleep routine. This includes going to bed the same time every day and waking up at the same time.
Maintaining a consistent routine before bed will help set the mood for sleep. Ideally incorporating some sort of relaxation before bed will improve sleep. This may include activities such are meditation, stress management, taking a hot shower or prayer.
Practicing healthy habits will improve sleep. Incorporating an exercise program will improve insomnia. The exercise should be carried out earlier in the day. Vigorous exercise before bed is associated with difficulty falling asleep.
Setting up an adequate sleep environment is helpful to assure adequate sleep. Make sure that the room is dark. Investing in adequate shades and curtains and turning off any lights will help individuals get to sleep. The use of a sleep mask may be needed to get adequate darkness.
The bed should be comfortable. A good mattress and pillows can aid in sleep. Those with back pain can sometimes benefit from a pillow under the knees. A comfortable sleep environment includes a comfortable temperature.
Exercise, eating, using caffeine, drinking large quantities of liquid and alcohol should not occur before bed. Exercise increases the sympathetic nervous system and makes it more difficult to sleep if done to close to bed. Eating before bed, especially a big meal increases the risk of gastroesophageal reflux. Drinking, especially a lot of fluid increases the risk of getting up in the middle of the night to use the bathroom. Caffeine is a stimulant and reduces the ability to sleep. Alcohol, while sedating, actually reduces the quality of sleep and results in early morning awakening.
Encourage clients to be careful what they do when they wake up in the middle of the night. The more one does when they wake up the more work the mind has to do and the more this drives the patient awake.
Placing a nightlight in the bathroom can be used to reduce the need to turn on the bright overhead lights when awakening in the middle of the night. Bright light exposure in the middle of the night drives the patient out of a state of sleep.
Spend a little time outside every day. Bright light during the day is associated with improved nighttime sleep.
Many cases of insomnia can be managed with the above interventions. This may take a lot of work and clients often would rather take a medication then have to take on all the tasks necessary to improve quality of sleep.
Psychological-behavioral treatments have demonstrated efficacy in the treatment of chronic insomnia. A variety of psychological and behavioral techniques have been evaluated in well-designed controlled clinical trials. Specific techniques include:
*sleep restriction therapy
*stimulus control therapy
*multimodal cognitive-behavioral treatment for insomnia
The various psychological and behavioral treatments for insomnia share several common elements that have been combined into briefer forms of treatment. Common elements too many of these treatments include:
1) education regarding sleep, sleep needs, and physiological regulation of sleep
2) the establishing of more regular sleep hours, with particular emphasis on the time of arising in the morning
3) limitation of time in bed to more closely match the individuals actual sleep hours
4) reinforcement of the bed and bedroom as a stimulus for sleep rather than for wakefulness and frustration about sleep.
Cognitive behavioral therapy for insomnia is a structured program that helps the client identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, cognitive behavioral therapy for insomnia helps the client overcome the underlying causes of your sleep problems rather than just treating the symptoms.
Cognitive behavioral therapy for insomnia contains one or more of the following elements:
Sleep education. To make effective changes, it’s important to understand the basics of sleep for example, understanding sleep cycles and learning how beliefs, behaviors and outside factors can affect your sleep.
Cognitive control and psychotherapy. This type of therapy helps you control or eliminate negative thoughts and worries that keep you awake. It may also involve eliminating false or worrisome beliefs about sleep, such as the idea that a single restless night will make you sick.
Sleep restriction. Lying in bed when you’re awake can become a habit that leads to poor sleep. Limiting the amount of time you spend in bed can make you sleepier when you do go to bed. That way you’re more likely to fall asleep and stay asleep.
Remaining passively awake. This involves avoiding any effort to fall asleep. Paradoxically, worrying that you can’t sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
Stimulus control therapy. This method helps remove factors that condition the mind to resist sleep. For example, you might be coached to use the bed only for sleep and sex, and to leave the bedroom if you can’t go to sleep within 15 minutes.
Sleep hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. You may be told to avoid napping and taught to maintain a consistent sleep schedule. It also includes tips that help you sleep better, such as ways to wind down an hour or two before bedtime.
Relaxation training. This method helps you calm your mind and body. Approaches include meditation, hypnosis and muscle relaxation.
Biofeedback. This method allows you to observe biological signs such as heart rate and muscle tension. Your sleep specialist may have you take a biofeedback device home to record your daily patterns. This information can help identify patterns that affect sleep.
Sleep diary. To understand how to best treat your insomnia, your sleep therapist may have you keep a detailed sleep diary for one to two weeks. In the diary, you’ll write down when you go to bed, when you get up, how much time you spend in bed unable to sleep, total sleep time and other details about your sleep patterns.
The most effective treatment approach may combine several of these methods.
Psychologists, therapists, counselors and social workers with adequate training may provide psychological-behavioral treatments for chronic insomnia. In addition, the American Academy of Sleep Medicine provides certification in behavioral sleep medicine. Other health professionals, including nurses as well as physicians, may provide more basic forms of psychological-behavioral treatments.
When all medical co-morbidities have been properly managed and non-pharmacological interventions tried without success, the use of medications to manage insomnia can be implemented by a physician.
Even though medications are often tried as a first-line agent, they should not be considered until all other options have been exhausted. Medications used in the management of insomnia are not without risk and have many side effects. Some of the risks include drowsiness the next day, dependency, impaired memory, hallucinations and sleepwalking. The older adult is at higher risk for side effects and complications.
The majority of agents used in the management of sleep are indicated for short-term use, although many people use them for months to years.
Medications used in the management of insomnia range from over-the-counter medications to prescription medications indicated for sleep to medications not indicated for sleep, but have sedating properties.
Over-the-counter medications used in the management of insomnia typically contain an antihistamine. The two most popular antihistamines in over the counter sleep medications are diphenhydramine (Benadryl) and doxylamine succinate (Unisom).
While these agents are effective in the short-term management of insomnia, tolerance quickly develops to them. In addition they are laced with side effects including constipation, dry mouth, blurred vision, confusion and urinary retention. Side effects are more problematic in the older adult.
A recent analysis showed that sound machines are more effective than over-the counter medicines in the management of insomnia.
Three classes of sleep medications are available for the treatment of insomnia. These include: benzodiazepines, nonbenzodiazepines and melatonin receptors.
When prescription medication is added to the treatment of insomnia, non-pharmacological interventions should still be promoted.
Benzodiazepines are the oldest class of drugs to help with sleep and have some disadvantages over the nonbenzodiazepine class. This class typically has a longer half-life and is more likely to lead to sedation the next day.
Not all benzodiazepines are FDA approved for insomnia. Alprazolam (Xanax) and lorazepam (Ativan) are two popular benzodiazepines, and while often used to induce sleep, are not FDA approved for the treatment of insomnia. A popular benzodiazepine used in the treatment of insomnia is Temazepam (Restoril). This agent is less effective for sleep onset and commonly leads to daytime drowsiness.
Triazolam (Halcion) and estazolam (ProSom) are other agents used for insomnia in the benzodiazepine class. Triazolam has a rapid onset of action and a short half-life making it good for sleep onset insomnia. Like other sleep agents it may be associated with next day drowsiness. Other side effects include: nervousness, nausea, vomiting, headache and coordination problems.
Estazolam has a longer half-life and is more likely to be associated with next day drowsiness. It is also associated with malaise, headache, constipation, dizziness and coordination problems.
Caution should be used in those who have a history of drug or alcohol abuse, those with untreated obstructive sleep apnea and in pregnancy. All medications for insomnia must be used cautiously in those with chronic lung disease as they may suppress the respiratory drive. In addition, they may lead to increased confusion in the older adult.
If the drug has been used for an extended period of time, it must be tapered slowly. Abrupt withdrawal may lead to rebound insomnia, nausea, vomiting, anxiety and memory impairment.
More commonly the nonbenzodiazepine class is used for treatment of insomnia. Medications in this class include: Zaleplon (Sonata), Eszopiclone (Lunesta) and Zolpidem (Ambien).
Melatonin receptor agonists are a newer class of medications used in the management of insomnia. Ramelteon (Rozerem) works through a unique mechanism and is not linked to dependence. Its absorption is decreased after a high fat meal. It is not recommended in those with obstructive sleep apnea or those with severe chronic obstructive lung disease. Common side effects of ramelteon include: fatigue, headache, nausea and dizziness. It is most likely the safest drug to use for long-term use.
Many patients will chose alternative products in place of prescription or over-the counter products in the management of sleep disturbances. Melatonin and valerian root are commonly used for insomnia and may help in its management.
Melatonin is not effective for most cases of insomnia, but it may work in those who suffer from jet lag, shift workers and those with circadian rhythm disturbances.
Valerian root has limited data to show its effectiveness in those with sleep disturbances, but is associated with sedation during the day in those who take it at night.
Insomnia is a widespread problem that can and should be managed by a mental health profession. It is a problem that can be associated with other medical conditions. If not addressed it has the potential to exacerbate other health issues. Your role in the management of insomnia includes: evaluating the condition, refer to a medical professional who can determine possible physical causes of the insomnia, helping the patient implement lifestyle changes to manage insomnia, implementing cognitive behavioral treatment strategies and lastly assist the patient to work with their doctor to use any medications used in the management of insomnia.
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