Definition
Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep. You may still feel tired when you wake up. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life.
Epidemiology of Insomnia in the Elderly
Epidemiologic data have demonstrated a higher prevalence of insomnia in older persons when compared with younger individuals. As many as 40% of patients over the age of 60 may experience insomnia, frequent awakening, and disrupted sleep. In a recent study from Thailand, nearly half of patients over the age of 60 years had insomnia. Poor perceived health and depression were factors strongly associated with insomnia in this cohort.
In a survey completed a decade ago by the National Institute on Aging (NIA) with over 9000 patients age 65 years or older, 28% reported difficulties initiating sleep and 42% reported symptoms of both difficulties in sleep initiation and maintenance. Sleep complaints in this cohort were associated with an increasing number of respiratory symptoms, physical disabilities, nonprescription medications, depressive symptoms, and poorer self-perceived health.
Types
Insomnia is commonly separated into three types:
Transient insomnia – occurs when symptoms last up to three nights.
Acute insomnia – also called short-term insomnia. Symptoms persist for several weeks.
Chronic insomnia – this type lasts for months, and sometimes years. According to the National Institutes of Health, the majority of chronic insomnia cases are side effects resulting from another primary problem.
Risk factors
Insomnia can occur at any age, and is more likely to affect women than men. According to the National Heart, Lung, and Blood Institute, people with certain risk factors are more likely to have insomnia. These risk factors include:
- High levels of stress
- Emotional disorders, such as depression or distress, related to a traumatic life event
- Lower income
- Traveling to different time zones
- Certain medical conditions
- Sedentary lifestyle
- Changes in work hours or night shifts
Causes of insomnia
Insomnia can be caused by physical and psychological factors. There is sometimes an underlying medical condition that causes chronic insomnia, while transient insomnia may be due to a recent event or occurrence. Insomnia is commonly caused by:
Disruptions in circadian rhythm – Jet lag, job shift changes, high altitudes, environmental noise, extreme heat or cold.
Psychological issues – Bipolar disorder, depression, anxiety disorders, or psychotic disorders.
Medical conditions – Chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease (GERD), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson’s and Alzheimer’s diseases, hyperthyroidism, arthritis, brain lesions, tumors, stroke.
Hormones – Estrogen, hormone shifts during menstruation.
Other factors – Sleeping next to a snoring partner, parasites, genetic conditions, overactive mind, pregnancy.
Symptoms of Insomnia
According to guidelines from a physician group, people with insomnia have one or more of the following symptoms:
- Difficulty falling asleep
- Difficulty staying asleep (waking up during the night and having trouble returning to sleep)
- Waking up too early in the morning
- Unrefreshing sleep (also called “non-restorative sleep”)
- Fatigue or low energy
- Cognitive impairment, such as difficulty concentrating
- Mood disturbance, such as irritability
- Behaviour problems, such as feeling impulsive or aggression
- Difficulty at work or school
- Difficulty in personal relationships, including family, friends and caregivers
Diagnosing Insomnia
There is no definitive test for insomnia. Doctors use many different tools to diagnose and measure insomnia symptoms, some of which involve asking you questions in the office, having you fill out logs and questionnaires, performing certain blood tests, or doing an overnight sleep study. All of these tests help your doctor understand your personal experience with insomnia and create the right treatment plan.
Sleep log: A sleep log is a simple diary that keeps track of details about your sleep. In a sleep log, you’ll record details like your bedtime, wake up time, how sleepy you feel at various times during the day, and more. A sleep log can also help your doctor figure out what might be causing insomnia. Here is a sample sleep log.
Sleep inventory: A sleep inventory is an extensive questionnaire that gathers information about your personal health, medical history, and sleep patterns.
Blood tests: Your doctor may perform certain blood tests to rule out medical conditions such as thyroid problems, which can disrupt sleep in some people.
Sleep study: Your doctor may suggest that you do an overnight sleep study, or polysomnography, to gather information about your nighttime sleep. In this exam, you sleep overnight in a lab set up with a comfortable bed. During the exam you will be connected to an EEG, which monitors the stages of your sleep. A sleep study also measures things like oxygen levels, body movements, and heart and breathing patterns. A sleep study is a non-invasive test.
Treatment and medications
As a continuing theme of this review, there is no evidence that any type or subtype of insomnia is differentially responsive to one or more treatment types. This said, a general overview of treatment approaches is provided below.
Pharmacologic approaches
In general, there are four approaches to the medical treatment of insomnia.
The first approach is via the use of sedative hypnotics (barbiturates (e.g., amobarbital), benzodiazepines (e.g., temazepam), and benzodiazepines receptor agonists (e.g., zolpidem)). Of these classes, barbiturates are no longer considered to have a primary indication for the treatment of insomnia, owing to its low therapeutic index.
Currently, there are no data to suggest that benzodiazepine receptor agonists have superior efficacy or safety profiles as compared to benzodiazepines, although it is generally believed that benzodiazepine receptor agonists have a higher therapeutic index.
The second approach is via the use of melatonin agonists. Currently, there is only one compound with a Food and Drug Administration (FDA) indication for the treatment of insomnia (ramelteon). While there are no data regarding this medication’s relative efficacy, it has been shown to have larger effects on polysomnographic (PSG) measures as compared to prospective self-report measures (sleep diaries).
The third approach is via the use of low-dose doxepin (Silenoir). This compound, originally developed and marketed as an antidepressant, is thought to provide good efficacy while providing a reduced risk for side effects and tolerance, especially in elderly patients.
The fourth approach includes a variety of off-label approaches using antidepressant (e.g., trazodone) and/or antipsychotic (quetiapine) medications. At present, the limited data that exist do not suggest that either approach has superior efficacy and/or better safety profiles than the benzodiazepines or benzodiazepine receptor agonists.
Cognitive behavioural approaches
The primary cognitive behavioural treatment of insomnia (CBT-I) is a multicomponent behavioural therapy that usually comprises three core treatments: stimulus control, sleep restriction, and sleep hygiene therapies. Interestingly, and despite the ‘C’ in CBT-I, it is often the case that formal cognitive therapy is not part of the CBT-I intervention.
Stimulus control therapy
Stimulus control instructions
- Restrict the behaviour’s that occur in the bedroom to sleep and sex,
- Limit the amount of time patients spend awake in bed or the bedroom, and
- Promote counterconditioning by insuring that the bed and bedroom environment are tightly coupled with sleepiness and sleep.
Sleep restriction
Sleep restriction therapy (SRT) requires patients to limit the amount of time they spend in bed to an amount equal to their average total sleep time (TST). When sleep proves to be efficient, TST is incrementally increased.
Sleep hygiene
This intervention requires that the clinician and patient review a set of instructions which are geared toward helping the patient maintain good sleep habits. Sleep hygiene instructions, it should be noted, are not helpful when provided as a monotherapy
Alternative medicine
Many people never visit their doctor for insomnia and try to cope with sleeplessness on their own. Although in many cases safety and effectiveness have not been proved, some people try therapies such as:
Melatonin. This over-the-counter (OTC) supplement is marketed as a way to help overcome insomnia. It’s generally considered safe to use melatonin for a few weeks, but no convincing evidence exists to prove that melatonin is an effective treatment for insomnia, and the long-term safety is unknown.
Valerian. This dietary supplement is sold as a sleep aid because it has a mildly sedating effect, although it hasn’t been well-studied. Discuss valerian with your doctor before trying it. Some people who have used high doses or used it long term may have had liver damage, although it’s not clear if valerian caused the damage.
Acupuncture. There’s some evidence that acupuncture may be beneficial for people with insomnia, but more research is needed. If you choose to try acupuncture along with your conventional treatment, ask your doctor how to find a qualified practitioner.
Yoga or tai chi. Some studies suggest that the regular practice of yoga or tai chi can help improve sleep quality.
Meditation. Several small studies suggest that meditation, along with conventional treatment, may help improve sleep and reduce stress.
Prevention
General recommendations for prevention of insomnia include the following:
- Work to improve your sleep habits.
Learn to relax: Self-hypnosis, biofeedback and relaxation breathing are often helpful.
Control your environment: Avoid light, noise, and excessive temperatures. Use the bed only to sleep and avoid using it for reading and watching TV. Sexual activity is an exception.
Establish a bedtime routine: Have a fixed wake time.
- Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce the use of stimulants including caffeine and nicotine.
- If you do not fall asleep within 20 to 30 minutes, try a relaxing activity such as listening to soothing music or reading.
- Limit daytime naps to less than 15 minutes unless directed by your doctor.
- It is generally preferable to avoid naps whenever possible to help consolidate your night’s sleep.
- There are certain sleep disorders, however, that will benefit from naps. Discuss this issue with your doctor.
