Insomnia
Most of us have had problems sleeping at some time but a few of us have chronic or long-term insomnia. This can be quite disabling in some cases and naturally people often come to us for a solution.
It is important first of all, to understand what is causing your insomnia. Common causes include;
Anxiety and depression,
Pain and breathlessness,
Obstructive sleep apnoea, a severe form of snoring, during which the airway is blocked, partially or fully waking the sufferer.
Alcohol and drugs,
A group of problems including restless legs, sleep walking, sleep terrors and teeth grinding. And Shift working.
The commonest request is for sleeping pills as a solution. The difficulty with this, is that sleeping pills such as temazepam and the so called ‘Z drugs’, zopiclone, zolpidem and the rest, are addictive. They become less effective with regular use, until they do not work at all. Higher and higher doses are tried but the body by passes the mechanism by which they originally worked and ultimately intractable sleeplessness, worse than the original problem, ensues.
So, what can be done? Some of the solutions are obvious from the list above. If alcohol and drugs are causing insomnia, then help is needed to withdraw from these. Anxiety and depression (sometimes resulting from drug and alcohol use) can be treated with non-addictive drugs or by Cognitive Behavioural Therapy (CBT).
Pain and breathlessness may have an obvious cause, or a cause needs to be sought so that these can be remedied, or the symptoms controlled.
Obstructive Sleep Apnoea can be a dangerous condition if left untreated, quite apart from its impact on sleep. If you have Apnoea or breaks in your breathing for extended periods at night, report it to your doctor. Those with untreated OSA have a much-increased risk of stroke and heart attack as well as high blood pressure and Atrial Fibrillation (an irregular heart beat associated with increased stroke risk among other things).
Restless legs can result from iron deficiency and should be investigated but can be treated with medication.
Non-drug treatment
It is generally best to manage things without medication where a solution exists.
A package of cognitive behavioral therapy for insomnia, called CBT-I, is the mainstay of non-pharmacological treatment.
In trials CBT-I is consistently better than any drug therapy in chronic insomnia, for both effectiveness and long-term benefits and works in those with chronic pain, depression and cancer as well as in those without such problems. CBT-I can be delivered one-to-one or in groups and computerised CBT-I packages have been shown to be as effective as one-to-one therapy. Importantly, although it can be slow to work, its benefits last over 12m.
CBT-I combines: Sleep hygiene. Stimulus control. Sleep restriction. Relaxation training and Cognitive restructuring. Each element is described below.
Sleep hygiene
For all, sleep hygiene will help, and for some this will be all that is needed. For those with primary insomnia (no underlying cause), 30% will get better with sleep hygiene alone. There is a good leaflet on sleep and sleep hygiene on the patient.co.uk website.
Stimulus control
Sleep hygiene involves the CBT technique of stimulus control – trying to re-associate bed with sleep, rather than a place you lie anxiously waiting for sleep not to come!
Stimulus control involves 5 simple rules:
1. Go to bed only when sleepy.
2. Get out of bed if you are not asleep within 15–20min (repeat as often as necessary).
3. Use the bed and bedroom only for sleeping.
4. Get up at the same time every day.
5. No napping.
Sleep restriction
The idea behind this is that people spend too long in bed, not sleeping. Using a sleep diary, work out how long you actually spend sleeping in bed. For example, let’s say you go to bed at 10pm but don’t get off to sleep until 1am, and then they sleep through to 7.30am. Total sleep = 6.5h, total time in bed = 9.5h. You then need to restrict their time in bed to the total sleep time (6.5h), if their usual getting up time is 7.30am they have to stay out of bed, up and about, until 1.30am, then go to bed. Daytime naps are banned. Over a 2w period people apparently report better sleep (deeper, better quality) and more consolidated sleep. If at the end of a fortnight you are not sleeping better, you can knock a further 30min off your ‘in bed’ time. If you are sleeping better but still feeling sleep deprived, they can add 30min to your ‘in bed’ time. If you drive/operate machinery, you should do this over a holiday period because in the short term you are often sleep deprived before the benefits kick in.
Relaxation training
There is evidence that meditation and Taiichi can be helpful in insomnia
Cognitive re-structuring
Many people who can’t sleep lie in bed worrying about how tired they will be the next day and how terrible they will feel. Cognitive restructuring can help them view their insomnia differently. For example, mindfulness-based approaches to insomnia can help because they aim to reduce excessive rumination and worrying, improve selective attention and efforts to sleep. Using this approach people can develop a new relationship with their insomnia – experiencing it non-judgmentally.
Exercise
Exercise improves sleep. Exercise in the 4h before bed used to be advised against, the thinking being that this might keep people awake. Lately research has shown this not to be true. However, trials have shown that although exercise at any time helps, exercise in the morning tends to produce the best sleep. Aerobic exercise is better than resistance-based exercise.
Drugs for insomnia
Diphenhydramine (sold in the UK over the counter as Nytol) is the most commonly used drug for insomnia. Trials show moderate benefit, but it caused daytime sleepiness and side-effects like dry mouth, constipation, and concern has been expressed about anticholinergics and dementia.
The benzodiazepines and Z-drugs (which are not benzodiazepines but do work on benzodiazepine receptors) have shown benefit for insomnia but are addictive as previously mentioned and may cause daytime sleepiness. DVLA rules on driving and drugs apply to all these agents
A recent link has also been made between long-term use of benzodiazepines and Alzheimer’s.
Sedating antidepressants also have anticholinergic side-effects and may cause daytime sleepiness.
Melatonin. Slow release melatonin is licensed in the UK for use for short-term insomnia in those aged 55y or more, for less than 13w duration. Trials suggest it can help improve sleep onset but not total sleep time. Next day sleepiness was the main side-effect, and this was rarely reported.
So, in summary, search for a cause for your insomnia, try to resolve the cause, if this is not possible, try CBT-I.
Sleep well
Dr Allan Fox
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