The Mystery of Sleep: Insomnia

What exactly is insomnia?
Dr. Stepanski: Well, insomnia is by far the most common type of sleep disorder in that it occurs anytime someone cannot get to sleep when they want to, they can’t stay asleep, or just feel like they have non-restorative, poor-quality sleep. And to the extent that it then causes them to have daytime impairment, it becomes a medical condition.

Do you know its incidence?
Dr. Stepanski: About a third of the entire adult population will report having difficulty sleeping at some point in the prior year, and about 10 percent to 15 percent of the population will say it’s a severe problem.

Wow, those are pretty big numbers.
Dr. Stepanski: Yeah. There are millions and millions of people that deal with insomnia on a regular basis.

What ages? Who’s at risk for this?
Dr. Stepanski: It can happen to anybody at any age. In general, not children — children are very good sleepers, and they can sleep pretty well despite a lot of circumstances. But once you reach adulthood, the amount of insomnia goes up, and especially older adults are at greater risk for poor sleep.

Why is that? Why are children good sleepers and older adults poor?
Dr. Stepanski: Developmentally, we get lighter and lighter sleep as we age. So children are getting very, very deep sleep, and so they’re difficult to awaken. Even if you want to wake them up, it’s very hard to awaken them, they’re sleeping so deeply. As our sleep gets lighter and lighter, it’s just easier for us to wake up. And then once we’re awake, it’s harder for us to go back to sleep.

That’s biological?
Dr. Stepanski: A biological event that occurs across the aging process. Now in addition, once you get older, you’ll have greater risk of multiple medical problems, taking medications that might interfere with sleep, and also a risk of primary sleep disorders like abnormal breathing during sleep. So those things further increase the likelihood you’re going to have bad sleep as you get older.

So that’s why everybody says, “I slept like a baby” when they have a good night sleep?
Dr. Stepanski: Yeah. It’s a real deal. When you’re sleeping as a kid, you get pretty much pure, slow-wave sleep and REM sleep. And those are the two kinds of most restorative sleep.

Why else, other than just biological change, is insomnia such a problem? Why is it that one third of adults are having these problems?
Dr. Stepanski: There are lots and lots of things that can disturb sleep. People talk about specific things in our society like that we’re a 24-hour society now. So you have the Internet that’s going to keep people up. You’ve got cable TV. You’ve got a lot more people doing shift work nowadays, so they’re actually working at night or at least part of the night. Recent estimates are 20 percent to 25 percent of the workforce will experience shift work at some point in their career. So a significant number of people that are trying to function at different times of day that didn’t used to before. On the other hand, we think insomnia has actually been a common problem for many, many decades — certainly prior to those kinds of stresses.

How easy is it to get used to shift work? Is that something you can do for a couple weeks and then you get used to it?
Dr. Stepanski: It’s never going to be very easy in that people who work at night and try to sleep during the day will never sleep as well as someone who works during the day and sleeps at night. Some of the reasons for that are obvious in terms of the light/dark cycle and trying to be lined up with that. If you’re trying to sleep and the sun is up, you’re just never going to have as easy a time.

On top of that, it’s going to be a lot noisier, and it’s harder to maintain that same schedule. People will interfere with it. You’ll have friends and family that’ll come over at 2 in the afternoon and wake you up, even though they know you’re supposed to be sleeping, that would never do that at 2 in the morning. It just would never happen. So it’s socially unacceptable to interfere with people’s sleep when they sleep at night. During the day it seems maybe an OK thing to do. So it’s very hard for people to protect their sleep.

The people who make the best adaptation to it are people who do sleep consistently on the same schedule during daytime hours. Unfortunately very few people do that. As soon as their night off comes, they sleep at night, because who wants to stay up all night while your family sleeps and then sleep the next day when your family is awake? So they go back to a nighttime schedule of sleep as soon as they get a day off, and that means they’re constantly shifting back and forth between two different types of sleep schedules.

I have lots of people come in with that circumstance and ask, “Well, how do I deal with this and make everything OK?” And it’s more of a situation of trying to make the best out of a bad situation.

What are current treatments for not being able to sleep?
Dr. Stepanski: All treatment for insomnia comes down to either pharmacologic treatment or behavioral treatments. The pharmacologic treatments would be prescription medications that are aimed at causing sedation or sleep. There are over-the-counter compounds, but those are mostly antihistamines. The downside of using antihistamines is that they’re long-acting, people tend to be groggy the next morning, and they last longer than the whole sleep period. So it may help them get to sleep that night, but then it’s also going to make them groggy when they’re driving to work the next day. The tendency has been toward shorter and shorter-acting medications in order to avoid that kind of problem, so it gets people to sleep at night, but then is metabolized and out of their system by the time they need to get up and function the next morning. That’s the real trick to it.

OK. Are there any dangers with prescription sleep aids right now?
Dr. Stepanski: Prescription medicines as a treatment for insomnia are very good and may be the treatment of choice in a short-term situation. So if someone is in the hospital, for instance, and experiencing post-surgical pain or some other kind of acute stress, then this will deliver improved sleep immediately as opposed to other kinds of treatments that may take longer to work. So they can be useful in that situation. But if you think of it long term — if it’s a chronic insomnia that’s been going on for years — use of medication may not be the best answer to it. It may not deliver the best sleep. People can become dependent upon medication and, in some cases with some medicines, may actually get tolerant to it so it no longer works as well.

So what is your recommendation when someone wants to go on sleeping pills and you get the impression that they’re going to be on them for a long time or want to be on them for a long time? What’s your thought on that?
Dr. Stepanski: Well in general, we try to not have people on medications like that chronically or for a long period. But there are situations where that’s the only treatment that’s going to be affective. So we’ve got, for instance, patients with chronic pain syndromes, where they really experience a lot of pain and that pain at night is disruptive of their sleep. Now we’ll try to control the pain in order to help their sleep improve, but it may be that even with maximum optimal pain treatment they still are having very disruptive sleep at night. If the sleep medication is effective in that instance, then that would be an example of someone where maybe it’s appropriate to go ahead and use sleeping pills on a chronic basis.

The main thing I like to see is that people are getting effective benefit from the sleep medication. And if they’re getting benefit from it, even over long periods of time, then that’s a reasonable approach. Where it’s problematic is when people are no longer sleeping any better with medication but continuing to take the medication or even escalating the dose — so they’re taking perhaps two- or three-times the recommended amount of medication in order to get a night’s sleep. In that case, they really need a different treatment.

Let’s talk a little bit more about the over-the-counter sleep aids, like Tylenol PM and Excedrin PM. How well do they work, and how effective and long-lasting are they?
Dr. Stepanski: The over-the-counter medications, again, are using antihistamines for the most part as the sleep-inducing component of the compound. That will allow them to fall asleep faster for a few nights, but then after that they do get tolerance to those compounds. And so after that period of time, they aren’t really getting any more benefit than they would from just skipping the medication.

Is there harm in taking those — the same kind of harm that might be there if you were taking long treatments of sleeping pills?
Dr. Stepanski: There may be some risk of psychological dependence. Mostly the harm would be, in my view, the morning grogginess that people feel. They’re more tired when they wake up, and maybe they don’t get out of bed as quickly as they should. They tend to lounge around, drive or engage in other activities when they’re not fully awake. That would be the main downside, I think, to that approach.

Source: Ivanhoe News

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