Insomnia is difficulty falling asleep or staying asleep or a disturbance in sleep quality that makes sleep seem inadequate or unrefreshing.
Insomnia is usually a symptom that can have many different causes:
However, insomnia itself can be a disorder on its own. Some people have long-standing (chronic) insomnia that has little or no apparent relationship to any particular cause.
Difficulty falling and staying asleep and waking up earlier than desired are common among young and old. About 10% of adults have chronic insomnia, and about 50% have insomnia sometimes.
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 at night and to feel sleepier and to nap during the day. Stages 3 and 4 sleep, the periods of deep sleep that is most refreshing, become shorter and eventually disappear. Also, older people awaken more during all stages of sleep. Usually, these changes alone do not indicate a sleep disorder in the elderly.
There are several types of insomnia:
Symptoms and Diagnosis
Symptoms include irritability, fatigue during the day, and problems concentrating or performing under stress.
To diagnose insomnia, doctors ask people about their sleep patterns, habits around bedtime, use of drugs (including illicit drugs), use of other substances (such as alcohol, caffeine, and tobacco), degree of psychologic 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 the sleep habits, including sleep and wake times, use of naps, and any problems with sleeping.
Some people need less sleep than others, so the diagnosis of insomnia is based on individual needs.
A physical examination is done to check for disorders that can cause insomnia. Occasionally, if insomnia persists despite measures to correct it, people may be referred to a sleep disorders specialist for evaluation and sometimes tests such as polysomnography. For this test, brain activity, heart rate, breathing, muscle activity, and eye movements are monitored while people sleep.
The treatment of insomnia depends on its cause and severity. If insomnia results from another disorder, treatment of that disorder may improve sleep. For most people who have insomnia, some simple changes in lifestyle, such as following a regular sleep schedule and avoiding caffeine after lunch time, can improve sleep.
When a sleep disorder interferes with normal activities and a sense of well-being, taking sleep aids (also called hypnotics) occasionally for up to a few weeks may help. Most sleep aids require a prescription. Some 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 drowsiness or sometimes nervousness, agitation, falls, and confusion, especially in older people (see Over-the-Counter Drugs). 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.
For people with insomnia related to a “stressed mind,” the most effective and safest treatment is usually talk therapy, done by trained specialists. This approach helps people understand the problem, unlearn bad sleeping habits, and eliminate unhelpful thoughts, such as worry about losing sleep or the next day's activities. Older people who have interrupted sleep can benefit from regular bedtimes, lots of environmental light exposure 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.
People who have insomnia and depression should be evaluated by a doctor, and the depression should be treated. Treating depression often relieves the insomnia, but some antidepressants can improve sleep directly because they have sedating effects. Usually, the antidepressant relieves depression but does not improve sleep. Then doctors may prescribe a sleep aid in addition.
Melatonin (see Medicinal Herbs and Nutraceuticals: Melatonin) is sometimes used to treat insomnia, especially in older people, who may have a low levels of melatonin. However, its use is controversial. Melatonin 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. Many other medicinal herbs and dietary supplements, such as skullcap and valerian, are available in health food stores, but their effects on sleep and side effects are not well understood.
Last full review/revision March 2008 by Karl Doghramji, MD