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 50% sometimes have insomnia.
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 several types of insomnia:
Insomnia and 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
Sleeping late or napping to make up for lost sleep may make sleeping during the night even harder.
EDS is most often caused by
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.
Any disorder that causes pain or discomfort, particularly if worsened by movement, can cause brief awakenings and interfere with sleep.
Less common causes:
Drugs, when used for a long time or when stopped (withdrawal), can cause insomnia and EDS.
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 apnea is often first identified when people report insomnia or disturbed or unrefreshing sleep. This disorder causes breathing to become shallow or to stop repeatedly throughout the night.
Narcolepsy (see Narcolepsy) is a sleep disorder characterized by EDS with uncontrollable episodes of falling asleep during normal waking hours and sudden, temporary episodes of muscle weakness.
Periodic limb movement disorder (see Periodic Limb Movement Disorder and Restless Legs Syndrome) interrupts sleep because it causes repeated twitching or kicking of the legs during sleep. As a result, people are sleepy during the day.
Restless legs syndrome (see Periodic Limb Movement Disorder and Restless Legs Syndrome) makes 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:
When to see a doctor:
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 see Changes in Behavior to Improve Sleep). If these changes do not help after a week or so, people should see a doctor.
What the doctor does:
The doctor asks people about their sleep patterns, habits around bedtime, use of drugs (including illegal drugs), use of other substances (such as alcohol, caffeine, and tobacco), degree of stress, medical history, and level of physical activity. 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 EDS, the doctor may ask them to fill out a questionnaire 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.
A physical examination is done to check for disorders that can cause insomnia or EDS.
Doctors sometimes refer people to a sleep disorders specialist for evaluation in a sleep laboratory. Reasons for such a referral include
Tests are not needed if symptoms suggest a cause such as restless legs syndrome, poor sleep habits, stress, or shift work disorder.
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. Electrodes are pasted to the scalp and face to record the brain's electrical activity (electroencephalography, or EEG—see Electroencephalography) as well as eye movements. These 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).
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.
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
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If stress is the cause, reducing stress, if possible, typically eliminates the symptoms. If symptoms persist, talk therapy (cognitive-behavioral therapy), done by trained specialists, may be the most effective and safest treatment. It helps people understand the 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. But if daytime sleepiness and fatigue develop, especially if they interfere with daytime functioning, treatment with sleep aids is warranted for a short time. 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.
Prescription sleep aids:
When a sleep disorder interferes with normal activities and a sense of well-being, taking prescription sleep aids (also called hypnotics or sleeping pills) occasionally for up to a few weeks may help.
Nonprescription sleep aids:
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, falls, and confusion, especially in older people (see 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 (see see Melatonin) is sometimes used to treat insomnia, especially in older people, who may have a low level of melatonin. 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 syndrome. 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.
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.
Essentials for Older People
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 regular bedtimes, lots of exposure to light during the day, regular exercise, and less napping during the day (because napping may make getting a good night's sleep even harder).
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 Thus, caution is required.
Last full review/revision January 2013 by Karl Doghramji, MD