Insomnia

Insomnia is an inability to get to sleep, or to stay asleep for long enough to feel fresh and rested the next morning.  It’s a very common problem, thought to affect one in every five people in the UK, with a particular prominence among the elderly.

There is no definitive guide for how much sleep is required each night because everyone is different. On average the recommended amount of sleep a person should aim for is between seven and nine hours. Children and babies generally sleep for longer than this, whereas the elderly tend to sleep for less.   

Sometimes the causes of insomnia can be unclear. However, the onset of the condition is often associated with the following:

• Stress and anxiety.
• Depression or schizophrenia.
• Lifestyle factors, such as shift work.
• Consumption of alcohol or caffeine before going to bed.
• An unsuitable sleeping environment, such as an uncomfortable bed, or too much light or noise.
• Certain physical conditions, such as chronic pain, heart problems or disorders.
• Certain medicines such as steroids, antidepressants or epilepsy drugs. 

For a lot of people, bouts of insomnia can come and go without causing any serious problems. However, for others the condition can last for months or years at a time. This persistent form of insomnia will likely impact on a sufferer’s quality of life, affecting mood, temperament and energy levels. This can easily lead to relationship problems with family, friends and colleagues.

An insomnia sufferer will likely experience some of the following symptoms:

• A difficulty in falling asleep.
• Long periods of lying awake at night.
• Restless sleep, punctuated by several instances of waking up.
• Not feeling refreshed in the morning.
• A difficulty in napping during the day.
• Feelings of tiredness or irritability.
• A difficulty concentrating.

It is recommended to visit your doctor if you are regularly finding it difficult to get to sleep, or to stay asleep during the night. To perform an informed diagnosis the doctor will ask relevant questions regarding your sleeping routine, caffeine and alcohol intake and general lifestyle habits, such as exercise and diet. They will also review your medical history to check for any medication that may be contributing to your trouble sleeping. Your doctor will also try to establish whether any underlying health conditions may be causing insomnia; such as depression or anxiety.

In most cases, your doctor will ask you to keep a sleep diary for a couple of weeks, which will help them gain further insight into your sleeping patterns. A sleep diary will involve making a note of the times you go to sleep and wake up, how long it took to fall asleep, and the number of times you awoke during the night.

Insomnia does not need a diagnosis if it is short-term and caused by a known reason such as a recent bereavement or occasional shift work.

In many cases, insomnia can be treated by making simple changes to your bedtime habits, which is also known as ‘sleep hygiene’ (see ‘Prevention’). If these prove unsuccessful, and your symptoms have persisted for longer than four weeks, your doctor may suggest other treatments. These can include:

Cognitive behavioural therapy-insomnia (CBT-I)

This form of treatment aims to change the unhelpful thoughts and behaviours that may be causing your insomnia. It has been proven to be an effective form of treatment, providing long-lasting results for many people. CBT-I can include the following:

• Stimulus-control therapy – uses an association method to link the bedroom environment with sleep. This aims to establish a consistent sleep/wake pattern.
• Sleep restriction therapy – this therapy aims to limit the amount of time spent in bed for any purpose other than sleeping. This can create a mild form of sleep deprivation, which in time can be reduced as the sleeping patterns improve. 
• Relaxation training – this method looks to reduce any tensions or intrusive thoughts that may be interfering with sleep.
• Paradoxical intention – this approach is used if a person has trouble achieving sleep, rather than those who cannot maintain their sleep. It uses the technique of encouraging the sufferer to try and stay awake for as long as possible; deliberately avoiding the intention of falling asleep. 
• Biofeedback – this uses sensors that are placed on the body. They measure bodily functions, such as muscle tension and heart rate. These sensors then relay the data to an accompanying machine, which produces pictures and sounds to help the sufferer identify when they are not relaxed. 

In some cases, CBT-I can be carried out by a specially trained doctor. Alternatively, you will be referred to a clinical psychologist. 

Sleeping tablets

Sleeping tablets can also be referred to as hypnotics. These are medicines that are designed to encourage sleep. They are generally not the first line of treatment and will only be considered should the following apply:

• The insomnia is severe.
• If good sleep hygiene and CBT-I have been attempted and failed.
• For use as a temporary measure to help ease short-term symptoms.

Doctors are normally reluctant to recommend sleeping tablets for long-term use as they only mask the symptoms without tackling any underlying causes. Also, they can produce potentially harmful side-effects, such as dependency and excessive drowsiness the following morning. If they are recommended, it is advised to take the lowest possible dose for the shortest time necessary, which is usually two to four weeks. 

There are many different types of sleeping tablets. The differences are outlined below:

• Over-the-counter sleeping tablets – the majority of over-the-counter remedies contain a type of antihistamine, which helps to induce drowsiness. They can be a useful treatment for short-term insomnia of known cause. These remedies can cause unwanted side-effects, such as feeling drowsy the next morning, especially if the dose is too high. Examples of over-the-counter sleeping tablets include; Nytol and Sominex. 
• Benzodiazepines – These are prescription-only medicines that help to reduce anxiety and promote calmness, relaxation and sleep. Your doctor may prescribe Benzodiazepines for short-term use if a patient is suffering from severe insomnia. It isn’t recommended for long-term use as they carry the risk of dependency. Also, their effects can become less effective with continual usage. Examples of benzodiazepines include; Temazepam, Diazepam and Nitrazepam. 
• Z-drugs – these medicines are fairly new and work in a similar way to Benzodiazepines. They are prescription-only-medicines, which are usually only prescribed for a maximum of two to four weeks. Examples of Z-drugs include; Zaleplon, Zolpidem and Zopiclone.
• Melatonin (Circadin) – The active ingredient (Melatonin) occurs naturally in the body and is responsible for regulating the sleep cycle. Melatonin is sometimes used to help promote sleep for people over 55 years of age. Melatonin can also be used as a treatment for Jet Lag. This medicine is only available with a valid prescription. Melatonin helps to produce a more natural sleep than other insomnia treatments as it helps to mimic the body's natural rhythms.

In many cases, insomnia can be improved by making simple lifestyle changes. These changes generally revolve around your daytime and bedtime habits, and by making alterations to the bedtime environment. These small changes have proven to significantly improve the quality and length of sleep for many people. Details of these methods are outlined below:

Daytime habits

• Avoid napping during the day.
• Partake in at least 30 minutes of physical activity each day, such as walking, jogging or cycling. However, avoid exercising immediately before attempting to sleep. It is recommended not to exercise vigorously within four hours of the proposed sleep time.
• Set a specific time for waking up each morning. This routine should try to be enforced even if you feel you haven’t had enough sleep. This should make it easier to get off to sleep at night.

Bedtime habits

• Avoid caffeine for at least three to four hours prior to bedtime.
• Avoid alcohol and smoking, particularly shortly before bedtime.
• Avoid eating a big meal a couple of hours before going to bed.
• Only retire to your bed when you feel tired, even if this means staying up later. This should encourage falling asleep more quickly.
• Avoid using backlit devices an hour before going to bed. These devices include; TV’s, smartphones, tablets and computers.
• Attempt to create a relaxing bedtime routine. For example, taking a bath, listening to tranquil music, and drinking a warm, milky drink. These activities, through association with sleep, will help to induce drowsiness.
• Avoid regularly using over-the-counter insomnia medicines, as they fail to tackle the underlying problem.
• Avoid lying in bed feeling anxious about a lack of sleep. In these circumstances is it better to get up, go to another room for about half an hour and focus on doing something else, such as reading a book or listening to mellow music.
• Write a list of any worries and attempt to solve them before retiring to bed. This is designed to help the mind switch-off from any problems it has.

Bedroom environment

• Ensure the bedroom environment is a comfortable temperature for sleep.
• Use thick curtains or blackout blinds to create a suitably darkened environment. Alternatively, use an eye mask.
• Wear ear plugs, if noise is a problem.
• Restrict the use of the bedroom for only sleeping and sex. Avoid watching TV, using smart devices, eating or working whilst in bed.
• Ensure your mattress and pillows are comfortable and that your bedding is appropriate for the time of the year.