Insomnia and Excessive Daytime Sleepiness (EDS)
The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness (EDS).
Difficulty falling and staying asleep and waking up earlier than desired are common among young and old. About 10% of adults have long-standing (chronic) insomnia, and about 30 to 50% sometimes have insomnia.
When sleep is disturbed, people sometimes cannot function normally during the day. People with insomnia or EDS are sleepy, tired, and irritable during the day and have trouble concentrating and functioning. People with EDS may fall asleep when working or driving.
There are different types of insomnia:
Difficulty falling asleep (sleep-onset insomnia): Commonly, people have difficulty falling asleep when they cannot let their mind relax and they continue to think and worry. Sometimes the body is not ready for sleep at what is considered a usual time for sleep. That is, the body’s internal clock is out of sync with the earth’s cycle of light and dark—as can occur with many types of circadian rhythm sleep disorders, such as delayed sleep phase disorder, shift work disorder, and jet lag.
Difficulty staying asleep and waking up earlier than desired (sleep maintenance insomnia): People with this type of insomnia fall asleep normally but wake up several hours later and cannot fall asleep again easily. Sometimes they drift in and out of a restless, unsatisfactory sleep. Sleep maintenance insomnia is more common among older people, who are more likely to have difficulty staying asleep than are younger people. It may occur in people who use certain substances (such as caffeine, alcohol, or tobacco) or who take certain drugs and in people who have certain sleep disorders (such as sleep apnea or periodic limb movement disorder). This type of insomnia may be a sign of depression in people of any age.
Insomnia and excessive daytime sleepiness (EDS) may be caused by conditions inside or outside the body. Some conditions cause insomnia and EDS, and some cause one or the other. Some people have chronic insomnia that has little or no apparent relationship to any particular cause.
Insomnia is most often caused by
Poor sleep habits, such as drinking a caffeinated beverage in the afternoon or evening, exercising late at night, or having an irregular sleep-wake schedule
Mental health disorders, particularly mood, anxiety, and substance abuse disorders
Other disorders such as heart and lung disorders, disorders that affect muscles or bones, or chronic pain
Stress, such as that due to hospitalization or loss of a job (called adjustment insomnia)
Excessive worrying about sleeplessness and another day of fatigue (called psychophysiologic insomnia)
Sleeping late or napping to make up for lost sleep may make sleeping during the next night even harder.
EDS is most often caused by
Insufficient sleep despite having ample opportunity to sleep (called insufficient sleep syndrome)
Obstructive sleep apnea (a serious disorder in which breathing frequently stops during sleep)
Various disorders, particularly mental health disorders, brain or nerve (neurologic) disorders (such as encephalitis, meningitis, a brain tumor, or narcolepsy), and disorders that affect muscles or bones
Disorders that disrupt people's internal sleep-wake schedule (circadian rhythm disorders), such as jet lag and shift work disorder
Most major mental health disorders are accompanied by insomnia and EDS. About 80% of people with major depression have EDS and insomnia, and about 40% of people with insomnia have a mental health disorder, usually a mood disorder (depression or anxiety).
Any disorder that causes pain or discomfort, particularly if worsened by movement, can cause brief awakenings and interfere with sleep.
Drugs, when used for a long time or when stopped (withdrawal), can cause insomnia and EDS.
Some Drugs That Interfere With Sleep
Many mind-altering (psychoactive) drugs can cause abnormal movements during sleep and may disturb sleep. Sedatives that are commonly prescribed to treat insomnia can cause irritability and apathy and reduce mental alertness. Also, if a sedative is taken for more than a few days, stopping the sedative can make the original sleep problem suddenly worse.
Sometimes the cause is a sleep disorder.
Central sleep apneais often first identified when people report insomnia or disturbed or unrefreshing sleep. It also occurs in people who have other disorders (such as a heart disorder) or who take certain drugs. Central sleep apnea causes breathing to become shallow or to stop repeatedly throughout the night.
Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness (EDS) with uncontrollable episodes of falling asleep during normal waking hours and sudden, temporary episodes of muscle weakness (called cataplexy).
Periodic limb movement disorder (PLMD) interrupts sleep because it causes repeated twitching or kicking of the legs during sleep. As a result, people are sleepy during the day. Typically, people with PLMD are unaware of their movements and the brief awakenings that follow.
Restless legs syndromemakes falling and staying asleep difficult because people feel as if they have to move their legs and, less often, their arms when they sit still or lie down. People usually also have creepy, crawly sensations in the limbs.
Usually, the cause can be identified based on the person's description of the current problem and results of a physical examination. Many people have obvious problems, such as poor sleep habits, stress, or coping with shift work.
Certain symptoms are cause for concern:
Falling asleep while driving or during other potentially dangerous situations
Frequently falling asleep without warning
Stopping breathing during sleep or waking up with gasping or choking (reported by a bed partner)
Moving violently or injuring self or others during sleep
A heart or lung disorder that is constantly changing (is unstable)
Continuous attacks of muscle weakness (continuous cataplexy attacks)
A recent stroke
People should see a doctor if they have warning signs or if their sleep-related symptoms interfere with their daily activities.
If healthy people have sleep-related symptoms for a short time (less than 1 or 2 weeks) but do not have warning signs, they can try changes in behavior that can help improve sleep (see Table: Changes in Behavior to Improve Sleep). If these changes do not help after a week or so, people should see a doctor.
The doctor asks people about the following:
People may be asked to keep a sleep log. In it, they record a detailed description of their sleep habits, with sleep and wake times (including awakening during the night), use of naps, and any problems with sleeping. When considering the diagnosis of insomnia, the doctor considers that some people need less sleep than others.
If people have excessive daytime sleepiness (EDS), the doctor may ask them to fill out a questionnaire, such as the Epworth Sleepiness Scale, indicating how likely they are to fall asleep in various situations. The doctor may ask their sleep partner to describe any abnormalities that occur during sleep, such as snoring and pauses in breathing.
Epworth Sleepiness Scale
A physical examination is done to check for disorders that can cause insomnia or EDS.
Tests are not needed if symptoms suggest a cause such as poor sleep habits, stress, or shift work disorder.
Doctors sometimes refer people to a sleep disorders specialist for evaluation in a sleep laboratory. Reasons for such a referral include
An uncertain diagnosis
Suspicion of certain disorders (such as sleep apnea, a seizure disorder, narcolepsy, and periodic limb movement disorder)
Insomnia or EDS persisting despite basic measures to correct it (changing behavior to improve sleep and taking sleep aids for a short time)
Presence of warning signs or other symptoms such as nightmares and twitching of the legs or arms during sleep
Dependence on sleep aids
An irresistible urge to move the legs or arms just before or during sleep (restless legs syndrome)
The evaluation consists of polysomnography and observation (and sometimes video recording) of unusual movements during an entire night's sleep. Other tests are sometimes also done.
Polysomnography is usually done overnight in a sleep laboratory, which may be located in a hospital, clinic, hotel room, or other facility that is equipped with a bed, bathroom, and monitoring equipment. Electrodes are pasted to the scalp and face to record the brain's electrical activity (electroencephalography, or EEG) as well as eye movements. Applying these electrodes is painless. The recordings help provide doctors with information about sleep stages. Electrodes are also attached to other areas of the body to record heart rate (electrocardiography, or ECG), muscle activity (electromyography), and breathing. A painless clip is attached to a finger or an ear to record oxygen levels in the blood. Polysomnography can detect breathing disorders (such as obstructive sleep apnea), seizure disorders, narcolepsy, periodic limb movement disorder, and unusual movements and behaviors during sleep (parasomnias). Polysomnography can also be done in the home, but only breathing, heart rate (with ECG), and oxygen levels are typically recorded.
A multiple sleep latency test is done to distinguish between physical fatigue and EDS and to check for narcolepsy. People spend the day in a sleep laboratory, taking four or five naps at 2-hour intervals. Polysomnography is used as part of this test to assess how quickly people fall asleep. It detects when people fall asleep and is used to monitor the stages of sleep during the naps.
The maintenance of wakefulness test is used to determine how well people can remain awake while sitting in a quiet room. This tests helps determine how severe daytime sleepiness is and whether people can safely do their usual daily activities (such as driving a car).
Tests to evaluate the heart, lungs, and liver may be done in people with EDS if symptoms or results from the physical examination suggest that another disorder is the cause.
Treatment of insomnia depends on its cause and severity. If insomnia results from another disorder, that disorder is treated. Such treatment may improve sleep.
If insomnia is mild, general measures may be all that is needed. They include
Changes in Behavior to Improve Sleep
If stress is the cause, reducing stress, if possible, typically eliminates the symptoms. If symptoms persist, talk therapy (cognitive-behavioral therapy) may be the most effective and safest treatment. But if daytime sleepiness and fatigue develop, especially if they interfere with daytime functioning, treatment with sleep aids is warranted. A combination of cognitive-behavioral therapy and sleep aids is often best.
If people have insomnia and depression, the depression should be treated, which often relieves the insomnia. Some antidepressant drugs also have sedative effects that help with sleep when the drugs are given before bed. However, these drugs may also cause daytime sleepiness, particularly in older people.
Some sleep aids are available without a prescription (over-the-counter, or OTC), but an OTC sleep aid may be no safer than a prescription sleep aid, especially for older people. OTC sleep aids contain diphenhydramine or doxylamine, both antihistamines, which may have side effects, such as daytime drowsiness or sometimes nervousness, agitation, difficulty urinating, falls, and confusion, especially in older people.
OTC sleep aids should not be taken for more than 7 to 10 days. They are intended to manage an occasional sleepless night, not chronic insomnia, which could signal a serious underlying problem. If these drugs are used a long time or stopped abruptly, they may cause problems.
Melatonin is a hormone that helps promote sleep and that regulates the sleep-wake cycle. It is sometimes used to treat insomnia. It may be effective when sleep problems are caused by consistently going to sleep and waking up late (for example, going to sleep at 3 am and waking up at 10 am or later)—called delayed sleep phase disorder. To be effective, melatonin must be taken when the body normally produces melatonin (the early evening for most people). Otherwise, melatonin can worsen sleep problems. Use of melatonin is controversial. It appears to be safe for short-term use (up to a few weeks), but the effects of using it for a long time are unknown. Also, melatonin products are unregulated, and thus purity and content cannot be confirmed. A doctor should supervise the use of melatonin.
Many other medicinal herbs and dietary supplements, such as skullcap and valerian, are available in health food stores, but their effects on sleep and their side effects are not well understood.
Cognitive-behavioral therapy, done by a trained sleep therapist, may help people when insomnia interferes with daily activities and when changes in behavior to help improve sleep are ineffective.
The therapist asks people to keep a sleep diary. In the diary, they record how well and how long they sleep as well as any behavior that might interfere with sleep (such as eating or exercising late at night, consuming alcohol or caffeine, feeling anxious, or being unable to stop thinking when trying to sleep).
Cognitive-behavioral therapy can help people understand their problem, unlearn bad sleeping habits, and eliminate unhelpful thoughts, such as worrying about losing sleep or the next day’s activities. This therapy also includes relaxation training.
Because sleep patterns deteriorate as people age, older people are more likely to report insomnia than younger people. As people age, they tend to sleep less and to awaken more often during the night and to feel sleepier and to nap during the day. The periods of the deep sleep that is most refreshing become shorter and eventually disappear. Usually, these changes alone do not indicate a sleep disorder in older people.
Older people who have interrupted sleep can benefit from the following:
Many older people with insomnia do not need to take sleep aids. But if they do, they should keep in mind that these drugs can cause problems. For example, sleep aids can cause confusion and reduce daytime alertness, making driving hazardous. Thus, caution is required.
Poor sleep habits, stress, and conditions that disrupt people's internal sleep-wake schedule (such as shift work) cause many cases of insomnia and excessive daytime sleepiness.
However, sometimes the cause is a disorder, such as obstructive sleep apnea or a mental disorder.
Polysomnography done in a sleep laboratory or at home is usually recommended when doctors suspect the cause is obstructive sleep apnea or another sleep disorder, when the diagnosis is uncertain, or when general measures do not help.
If insomnia is mild, general measures, such as following a regular sleep schedule, may be all that is needed.
If insomnia interferes with daily activities and if general measures are ineffective, cognitive-behavioral therapy or a sleep aid taken for up to a few weeks may help.
Sleep aids are more likely to cause problems in older people.