What causes normal people to fall asleep?
There are many triggers to help you fall asleep. Light or darkness are the strongest known triggers. Light should be avoided when trying to promote sleep onset, especially blue light. A darkened room prior to bedtime is much more sleep-inducing than a bright television, cell phone or computer screen. Darkness promotes the secretion of melatonin, a natural chemical or hormone in the body which prepares the body for sleep. Your bed should be comfortable, and the room should be cool and free of noise and distractions.
Sleep onset is also triggered by what we call sleep debt. For example, the longer you are awake, the sooner you want to be asleep. This means that the time you wake up each day is more important to helping you fall asleep then the time that you go to bed. In fact, a consistent wake time (including weekends) is one of the strongest triggers for inducing sleep.
Sleep onset can also be affected by the activity which is done prior to sleep. Any activity that tells the body it needs to be awake or alert will delay sleep. For example, exercise close to bedtime can delay sleep as all of the hormones or chemicals in the body are promoting physical performance and turning on systems needed for fight or flight and survival as opposed to turning them off for sleep. Reading books and watching television also prevent sleep, as they turn the brain’s cognitive function on (interpreting, understanding, and keeping track of details), as opposed to clearing and emptying the mind and allowing the brain to dream. People who fall asleep easily usually have a nighttime routine that promotes nightly routines or rituals and relaxation prior to bedtime.
The bed should always be associated with sleep or sex. If you find yourself awake in bed for more than fifteen minutes (estimated), and becoming frustrated that you are not yet asleep, then you are ruining this association. It is better to get up from bed and sit in a comfortable chair in a darkened room until you feel sleepy enough to return to bed. Don’t watch the clock, as this will only increase the pressure and anxiety you feel about being awake.
All these sleep-inducing associations are often combined and used together, often with the temporary addition of medications, to help those with insomnia retrain themselves to have normal sleep.
Can my bedroom be causing insomnia?
Sleep onset is triggered by a decrease in body temperature. Sleeping in a room which is too warm can make it difficult to fall asleep. Usually, a room temperature 65-70 degrees Fahrenheit is felt to be conducive to sleep. A noise-free and comfortable environment is essential, including a comfortable bed. If your bed partner has a sleep disorder which is disruptive to you, this may also ruin your sleep as well.
What toxins can cause insomnia?
There are many substances, some common and some uncommon which cause insomnia. The most common ones include caffeine and alcohol. Drinking caffeine in the late afternoon and early evening can make it difficult to fall asleep and make sleep less restful. Alcohol is more interesting. Initially, alcohol may seem to make it seem easy to fall asleep. However, this is not due to healthy sleep onset, but more to sedation from intoxication. As this wears off, sleep becomes severely disrupted and fragmented and most people awaken feeling unrefreshed and “hung over.”
Similarly, many medications which are used as “stimulants” or wake, or alertness-promoting agents can make it difficult to sleep. These drugs are often used to help focus attention or to relieve fatigue. However, some medications that are not in this class may have increased stimulation as a side effect, such as the antihistamines (i.e., cold and congestion medications). Medications which commonly disrupt sleep and can cause bad dreams also include the antihypertensive medications (i.e., B-blockers, ACE inhibitors, et cetera). However, these medications are often essential to preventing heart attacks and strokes and should not be reduced or stopped without first discussing with a physician.
The least common cause of insomnia is due to poisoning (intention or unintentional) with the heavy metals. The heavy metals include mercury, lead, arsenic and copper. These can be found in contaminated water supplies, fish, natural remedies or medications, fruits or vegetables, or from dust or fumes from pesticides or paints. They may also lead to chronic stomach upset and changes in the hair or nails or skin. Heavy metal poisoning can be tested for and treated for when detected.
When is insomnia a problem?
It is common for anyone to have a week or so of difficulty sleeping. This is usually due to physical illness, emotional stress, or changes in usual daily or nightly schedules or routine. It is only when this continues to recur and persist and leads to decreased functioning in the daytime that this has become a medical problem and requires attention and assistance.
Many people with insomnia are afraid that by not getting enough sleep, they may be “too sleepy” in the daytime to function effectively. In contrast, people with insomnia are often “overstimulated” both during the nighttime and the daytime. This overstimulation leads to a feeling of fatigue and inability to focus which impairs their daytime activities. It is rare that someone with insomnia can easily or unexpectedly fall asleep in the day, and not in the nighttime.
Insomnia can also be associated with depression. When these occur simultaneously, they may make each respective problem worse. Treating insomnia will usually help the depression and vice versa.
One of the most famous cases of reported insomnia was that of the singer Michael Jackson. Sadly, there is no report of him ever seeing a sleep physician. Sleep physicians, in general, have a remarkable success rate at treating insomnia and can successfully help patients to have healthy sleep onset and decrease their time awake in bed when working with patients as a team.
Can sleeping even less make my insomnia better?
It is counterintuitive but restricting one’s time in bed can make the time that you do spend in bed more solid, deeper and eventually better and even longer sleep. This is commonly referred to as “sleep restriction” therapy. This should always be done under the direction of a sleep specialist, as depriving the body of too much sleep can be harmful. Usually it is accomplished in a stepwise fashion, with bedtime and wake time gradually adjusted until adequate and restorative sleep is reached. People with insomnia are often asked to complete sleep logs (or diaries) of their wake and sleep times prior to and during this treatment. It can be successful when used correctly.
What medications are used to treat insomnia?
Insomnia can be treated without medication, by modifying behaviors as previously discussed. However, the temporary addition of medications can accelerate this process. The choice of medication is often influenced by what other contributing circumstances. Sleep aids should never be taken together, or with pain medications or alcohol, as these may lead to over-sedation with decreased breathing and death.
Commonly, people will try over the counter sleeping aids first. These usually consist of two main classes of medications, the antihistamines, and hormones. The most common antihistamine ingredient in over the counter sleep aids is diphenhydramine. It is primarily used in allergy and cough or cold medications but does have a side effect of helping to induce sleep. However, in some people, it can act as a stimulant and make them feel more awake and jittery. It also has many strong cholinergic effects, which make it desirable for allergies and colds, but less desirable for everyday use, such as, dry eyes, dry mouth, mild palpitations, and urinary retention. It is not addictive but should not be used in higher than recommended doses. The second most common over the counter sleep aid is the hormone melatonin. Melatonin tells the body that it is nighttime and drops the body temperature and blood pressure, thereby signaling the onset of sleep. Melatonin supplementation commonly comes from animal sources, as the plant sources usually are not absorbed or effective in people. Because this is not a prescription medication, it is possible for this hormone to become contaminated with animal viruses and the dosing may vary from pill to pill. Melatonin has been known to cause depression and seizures and can cause severe daytime drowsiness as well. Over the counter melatonin is usually not recommended by sleep physicians, who prefer a lower dose safer synthetic melatonin-like medication, Ramelteon.
When people turn to prescription sleep aids, there are three classes of medications which are commonly used, the sedative hypnotics, the anxiolytics and the antidepressants. The most common sedative hypnotics are zolpidem and eszopiclone. Both medications induce sleep by directly signaling the brain. Unlike melatonin, they do not require a certain time of day to work and will induce sleep whenever they are taken (day or night), which makes them useful also to shift workers and travelers. They are not addictive and if used properly, can be used at the same dose for extended periods of time, not requiring any dose escalation. They are, however, associated with daytime grogginess or drowsiness, sleep walking, and falls or hip fractures and should therefore be used under the supervision of a sleep physician. Often, they are used temporarily, to help people adjust to sleep behavior changes and establish new sleeping patterns. However, patients with chronic medical problems and other factors disruptive to sleep may need to use them for an extended time.
Anxiolytics (anxiety lessening agents) are also useful in sleep promotion, especially in patients who have daytime anxiety and find that their “minds race” at night. Unlike the other sedative hypnotics, these medications can be addictive, especially if people take them contrary to how they are prescribed, i.e. at various times of day, with escalation of the doses on their own, and inconsistent use. These medications have the same side effects as other sleeping pills as well, only stronger. These medications should only be used under the supervision of a physician. Similarly, the antidepressant medications can also be used to help promote sleep. These are particularly useful in patients with depression and chronic pain. Many of these drugs are safe for long term use but have significant interactions with other medications and can cause side effects if suddenly discontinued. These drugs, like all prescription medications, should be used exactly as directed by a physician.
Finally, pain medications may also be used to promote sleep, varying from over the counter medications, to nonsteroidal medications, to narcotics. Pain from arthritis, fibromyalgia, chronic back pain and other sources can be extremely disruptive to sleep. In fact, sometimes during sleep testing (polysomnography), the EEG (brain waves) can even reveal a pattern which is indicative of chronic pain. Adequate relief of pain is essential for sleep onset and maintenance. Proper cushioning and positioning, i.e. extra pillows, foam supports, or neck supports may dramatically improve your quality of sleep if you are having chronic pain. Heating lotions and pads as well as cooling creams or ice packs can also be used. However, care should be taken to protect the skin from irritation or burns (i.e., use four hours on and four hours off at time).
What if my elderly parents have dementia and insomnia?
The disruption of sleep leading to confusion and agitation at nighttime, which is disruptive both to the person and their caregiver, is sadly one of the most common reasons for early placement in a nursing home or skilled care facility. Sleep promotion in the elderly is a challenge and can often seem labor-intensive and overwhelming.
As people age, their daytime activity level can drop, either by loss of the ability to be physically active and mobile, loss of companions or spouse, and decreased mental capacity. Because of this, they may begin to nap more often in the daytime, and wake in the early morning hours. Needing to get up to go to the bathroom at night and difficulty in getting out of bed at night or shifting position in bed, can increase their nighttime distress and frustration, and further disrupt sleep.
There is a combination of sleep hygiene and behavioral interventions that can help promote nighttime sleep, as well as medications. Behavioral interventions, however, are greatly preferred, as frequently medications used in the elderly can lead to increased daytime confusion and side effects. The best way to begin to intervene, is to return to the basics of sleep and establish good sleep habits.
First, as previously discussed, maintaining a routine wake time (both during weekdays and weekends) is essential. Once awake, naps should be limited to 15 to 30 minutes and no longer. Allowing too much sleep in the daytime, will make it more difficult to build up enough “sleep debt” for nighttime sleep. If possible, mental stimulation and assistance with mobility should be provided. There are many senior centers which can provide social interaction and daytime stimulation. If possible, seniors should be exposed to daylight in the early morning and late afternoon to also solidify their sleep-wake cycle further.
Limiting nighttime liquid intake and avoiding medications at night may help with the need to get up to the bathroom. If a patient can get themselves out of bed, a simple handrail, nightlight, and having the walker close by may be all that is needed for safe ambulation. It is worth asking a senior to demonstrate getting out of bed to assure their safety. If unavoidable, a bedside commode may be of benefit. If necessary, urinals, bedpans, diapers, and mattress pads can be used to help manage continence issues. Medications that can be used in this age group include doxepin and Remeron.
What is Fatal Familial Insomnia?
Fatal Familial Insomnia is a rare, genetic sleep disorder. This means that this is a disorder that runs in families. The insomnia is extreme to the point that there is absolutely no sleep at all (not even for an hour) for months which then leads to loss of brain function and death. It is linked to early death (around age 40-50) from a progressive insomnia. Genetic testing can identify people with this condition, but there is currently no effective treatment.