By H. Andrew (Drew) Wilson, Jr. MD, FCCP
Diplomate, American Board of Sleep Medicine Pulmonary & Sleep Associates of Alabama
The first week of March 2015 has been designated as National Sleep Awareness Week, designed to help increase understanding of the importance of sleep in overall health and functioning. We will celebrate the occasion by highlighting one of the most common medical complaints experienced in society: Insomnia.
Insomnia is a sleep symptom that virtually everyone has at one time or another. It may take the form of difficulty falling asleep, staying asleep, or waking up earlier than desired, with some associated deficit in daytime functioning. Sometimes the sleep difficulty may last for days or even weeks, but often it will resolve without the need for a great deal of intervention by a physician.
There are a multitude of known causes of insomnia. We’ve all had those nights when stress, excitement or a change in schedule rob us of a good night’s sleep. Poor sleep habits such as daytime napping, heavy caffeine use, smoking, drinking alcohol at bedtime and use of electronic devices in the bed can dramatically affect sleep quality. Circadian rhythm shifts (i.e., jet lag or shift work) can realign the brain’s clock, moving the “sleep on” switch to a later hour. If such shifts occur on a recurrent basis, the brain is left in a constant state of playing catchup. Medications are notorious causes of insomnia - typical culprits include antidepressants, steroids, and beta blockers. Mood disorders such as depression and anxiety are common causes of insomnia. Medical conditions such as COPD, heart failure, and arthritis are frequently associated with sleep disruption. Obstructive Sleep Apnea can lead to insomnia by repeatedly fragmenting the sleep cycle. Restless Legs Syndrome and nighttime repetitive leg jerks, known as Periodic Limb Movement Disorder, can also result in trouble falling and staying asleep. And then, there are those folk who suffer from chronic insomnia that describe virtually lifelong difficulty sleeping.
Bottom line - sleep is a complex physiologic state, and the interplay of multiple influences can disrupt the harmonious functioning of the brain’s sleep centers.
So what’s a physician to do when confronted with the poor sleeper? First of all, realize insomnia is usually temporary. If insomnia lasts less than 3 months it can be considered short term, and there is often an identifiable stressor. These folk may benefit from a review of good sleep habits, perhaps a hypnotic such as zolpidem or eszopiclone, and a bit of reassurance. There are a number of basic sleep hygiene recommendations that can be recommended to all patients, whether they have insomnia or not. A list can be accessed at the National Sleep Foundation website: http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips .
Patients with chronic insomnia are often more of a challenge. Chronic insomnia is typically the result of years of learned behaviors that may have medical, psychological and even genetic influences. There are many insomniacs that live in a state of hyperarousal such that they often do not feel especially sleepy during the day regardless of how little sleep they get at night. They’ve often tried all the OTC aids, melatonin, herbal remedies, and prescription hypnotics with usually limited benefit.
Some of the most helpful techniques in treating chronic insomnia include stimulus control, sleep restriction and Cognitive Behavioral Therapy. Stimulus control is geared to break the association that a patient has with being in bed and the inability to sleep. It works like this: if a patient is lying in bed more than 20” and is unable to sleep, he should get out of bed, go to another room, and do something rather non-stimulating, (i.e., reading) until he feels so sleepy he is ready to fall asleep. Only then should he go back to bed. If he again has trouble sleeping later that night, the process should be repeated. It may seem a bit contrived, but it does work, though it takes some discipline (and several books).
Sleep restriction is designed to increase sleep efficiency, which is the time a person is asleep relative to the time he is in bed. The physician should determine a patient’s usual bedtime and rise time to estimate his total hours in the bed. Next, ask the patient the total amount of sleep he thinks he actually gets, (or consider using a sleep diary for a more accurate estimate). Then, while maintaining the same rise time, adjust the patient’s bedtime to a later hour such that the time in bed approximates the estimated sleep time, (just be sure to allow at least five hours of time in bed). This process will typically lead to a mild state of sleep deprivation. The patient should avoid the temptation to nap during the day to preserve an adequate sleep pressure at the scheduled bedtime. Once it becomes easier to fall asleep at night, the bedtime can be set 15” earlier every few days until a more desirable bedtime is achieved. Again, this technique takes a fair amount of motivation and discipline on the part of the patient.
The other arm of management of chronic insomnia is what’s known as Cognitive Behavioral Therapy, or CBT. CBT addresses a patient’s ideas about sleep. Chronic insomniacs often harbor faulty beliefs about the reasons for their sleep problems and hold unrealistic expectations about what they should consider a good night’s sleep. Altering these beliefs may require several sessions using such techniques as biofeedback and relaxation training. CBT is often best handled by a psychologist with expertise in dealing with sleep issues.
To summarize, when your next patient comes in complaining of the inability to sleep, resist the urge to simply write a prescription for a hypnotic. Give such patients a list of good sleep habits. Assess their caffeine, tobacco, and alcohol intake. Review their medications. Ask about their sleep environment. Determine if they could be depressed, anxious or have new life stressors. Finally, ask if they snore or have daytime sleepiness, which may suggest OSA or another sleep disorder.
If your patient fails to respond to treatment, or if Sleep Apnea or another sleep disorder is suspected, consider referral to a sleep specialist.
Insomnia is common and often very treatable. If you can help your patient enjoy restful nights on a consistent basis, you will have earned yourself a good night’s sleep to boot.