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Family Health Magazine - FAMILY MEDICINE

What to do when you can't sleep

Insomnia is a sleep disorder that affects as much as 30 to 35 per cent of the Canadian population. Insomnia can take many forms. Some people have trouble falling asleep, while other people have trouble staying asleep. Other people wake up too early, or have a restless sleep, leaving them feeling drained during the day.

In any form, insomnia can be very harmful to everyday living. A person simply cannot function without sleep. It is just as important as food and water to our well-being.

People in the health care field group insomnia into three types. The first type of insomnia is known as transient insomnia. This insomnia is very short lasting; it only lasts a few days. Jet lag and severe anxiety are two causes of transient insomnia.The second type of insomnia is short-term insomnia. This type of insomnia lasts less than three weeks. It often affects people experiencing physical pain or grief.The third type of insomnia is long-term insomnia. It is a constant sleep disorder that lasts longer than three weeks. Often there is a medical reason for the insomnia. Conditions such as depression or arthritis can lead to long-term insomnia.

Causes of Insomnia

The causes of insomnia are many and can sometimes be difficult to pinpoint. The list given below explores some of the more common causes.

Caffeine: coffee, tea, pop, and chocolate all contain caffeine. Caffeine is a stimulant and keeps you awake.

Nicotine: nicotine is found in cigarettes and is also a stimulant.

Alcohol: alcohol does make you drowsy at first, but it becomes a stimulant within a couple of hours.

Stress: stress and worry can make it very difficult to fall asleep and stay asleep.

Inactivity: the lack of physical activity can make it difficult to sleep.

Sleeping conditions: noise, temperature, light, the mattress, and even your bed partner, can disrupt your sleep.

Poor sleep patterns: daytime napping of more than 15 minutes, an irregular sleeping pattern, or going to bed too early all can cause insomnia.

Nightmares: bad dreams can cause a restless sleep or wake you during the night.

Heavy food or drink before bedtime: if you do feel hungry, have light snack or a glass of milk before going to bed. Be sure that it is not a big snack.

Aging: there is a natural change in sleep patterns as you age. The amount of non-REM (Rapid Eye Movement) sleep decreases. This means your sleep is not as deep. You wake up more easily and more often.

Medical conditions: pain and discomfort can make it difficult to fall asleep. It can also make it difficult to stay asleep throughout the night. Rheumatoid arthritis, cancer, lung problems such as chronic obstructive pulmonary disease (COPD) and asthma, gastroesophageal reflux disorder, heart conditions, and Parkinson’s Disease are all associated with pain and discomfort. Medical conditions that affect a person’s mental well-being can also cause insomnia. Examples include depression, schizophrenia, mania, dementia, anorexia, and post traumatic stress disorder. Leg jerks or a restless leg can cause insomnia, as can sleep-related apneas. Apnea is when a person stops breathing for several seconds. It causes the person to wake up so breathing can start again.

Drugs: certain drugs can make it difficult to get the amount of sleep that you need. These include drugs for epilepsy, Parkinson’s disease, cancer and thyroid disorders. Insomnia can also be caused by other drugs, such as beta-blockers, some anti-depressants (like selective serotonin reuptake inhibitors or SSRIs), bronchodilators for lung problems, central nervous system (CNS) stimulants, and diuretics (water pills). Your pharmacist may be able to identify a medication that is causing you to have trouble sleeping. If one is found, you should talk to your pharmacist or doctor about changing the time when you take that medication, or changing to a different medication. It is important that you do not change your medication on your own. Talk to your health care provider first.

Treating Insomnia

Once you have realized that you are suffering from insomnia, it is time to take action. There are three stages of treatment for insomnia.

1. Improve your sleeping habits.

The first stage involves the following good sleep habits:

  • Avoid caffeine after 4 p.m.
  • Avoid alcohol for at least two hours before bedtime.
  • Avoid nicotine for at least four hours before bedtime.
  • Do some physical exercise during the day. This is best done during the late afternoon or early evening. Avoid exercise close to bedtime, as it will keep you awake.
  • Try to avoid napping during the day or limit your nap to 15 minutes.
  • Only go to bed when you feel tired.
  • Wind down to relax before going to bed.
  • Have a regular sleeping pattern. Go to bed at the same time each night, and get up at the same time each morning, even on weekends.
  • Avoid heavy meals and drink fewer liquids before bedtime.
  • Improve your sleeping environment. Make your bedroom quiet, dark and cool. Ensure that your mattress is comfortable.

It may be necessary to sleep alone if your partner keeps you awake with their snoring or restlessness. It is also a good idea to keep your bedroom (and your bed) as a place to sleep. For example, do not pay your bills while sitting up in bed.

2. Check for a health problem.

If these measures do not help you to get a better sleep, it is time to find out if there are underlying health problems causing your insomnia. This is the second stage of treatment for insomnia. Talk with your doctor about possible medical conditions that could be keeping you awake at night. Mood conditions, like depression, should also be examined and treated.

3. Use herbal preparations, over-the-counter (OTC) sleeping aids, or prescription sleeping pills.

The third stage of treatment involves the use of herbal preparations or medications. Many people prefer to try an herbal preparation first, before considering an OTC sleeping medication or a prescription sleeping pill. If you are interested in trying an herbal remedy there are some options available. Discuss herbal remedies with your doctor and pharmacist to be sure they do not interfere with any other medications you may be taking or any medical condition you may have.

Herbal Preparations

Kava is an herbal preparation used to treat nervous anxiety, stress, and restlessness. For this reason, people find it useful as a sedative. Possible side-effects include stomach upset, headaches, dizziness, enlarged pupils and allergic skin reactions. Constant use of Kava can lead to a condition called Kawaism. Kawaism occurs at doses of 300 to 400 grams per week. It shows as dry and flaking skin, reddened eyes, and the temporary yellow discoloration of skin, hair and nails. If these symptoms do occur, Kava should be stopped right away. In order to avoid Kawaism, Kava should not be used for more than three months in a row. Kava can also affect some of the medications you may be taking. For example, Kava can interact with other sedative herbs and drugs, CNS depressant drugs, barbiturates, levodopa and alprazolam. It is not to be taken by people who have depression.

Valerian is an herbal preparation used for insomnia. It can be taken for restlessness and sleeping problems that stem from nervous conditions, such as anxiety. Valerian, in a liquid form, can also be added to a bath to treat the same problems. Valerian works to quicken the onset of sleep, help you stay asleep, and improve your mood. Side-effects include morning drowsiness, headaches, excitability, uneasiness, insomnia, and heart problems. It is not to be taken in pregnancy, and by people with liver or heart conditions. Valerian should not be taken by people already taking other sedative herbs, alcohol, barbiturates, benzodiazepines and drugs with sedative properties. It takes two to four weeks of continuous use of Valerian to see any significant improvement in insomnia.

St. John’s Wort is used for insomnia, depressed mood, anxiety, nervous unrest and excitability. Possible side-effects include upset stomach, tiredness, delayed allergic reactions, and increased sensitivity of the skin to the sun. It is not be used by people who have bipolar disorder, HIV/AIDS, severe depression or infertility. St. John’s Wort can affect the action of other herbs that have sedative properties. The action of some medications may also be affected. These are digitalis, antidepressants, barbiturates, digoxin, SSRIs like Prozac™ and Celexa™, narcotics, reserpine and other drugs that increase sensitivity of the skin to the sun (like tetracycline antibiotics).

Chamomile is another herbal remedy used for insomnia. Often it is used as a tea. Side-effects include allergic reactions and vomiting. Chamomile also acts to thin the blood, making it dangerous for those who are taking other blood-thinning drugs such as Coumadin™, Plavix™, or Aspirin™, or herbs such as garlic or Panax ginseng. It is also not to be taken with other sedative products such as benzodiazepines, or with alcohol. As well, it affects the action of some gout medications such as indomethacin. Chamomile is to be avoided during pregnancy and by those with asthma.

Over-the-Counter Sleeping Aids

Sleeping medications available without a prescription can be helpful for transient insomnia. They are only to be used on an occasional basis. They are not for regular use. If you feel that you need a sleeping medication, you should talk to your doctor. In many cases, there is a medical condition causing the insomnia. It is best to treat the medical condition that is causing the insomnia, and not mask the symptoms with a sleeping medication. Your doctor can help find the cause of your insomnia.

Several sleeping pills on the market do not require a prescription. The active ingredient in these products is an antihistamine.

Diphenhydramine: Diphenhydramine is an antihistamine that has sedative properties. For this reason, it is found in many of the over-the-counter sleeping medications. Some products contain 25 milligrams of diphenhydrame. Many are also available as extra-strength and contain 50 milligrams. A smaller adult usually requires 25 milligrams of diphenhydramine, while a larger adult may require 50 milligrams. Children should not use any sleeping medication without the advice of a doctor.

Doxylamine succinate: Doxylamine succinate is another antihistamine, with sedative properties.

There are some cautions for taking OTC sleeping pills. First, the medications can be very sedating. This is needed to help you get the sleep you need, but the sedative effect can sometimes last into the next day. You wake up feeling very drowsy and tired. This is called the hang-over effect. Thus, it is very important that you allow enough time for eight hours of sleep when you take a sleeping pill. It is also very important that you use a dose that does not leave you groggy in the morning. Try to use the smallest dose possible.

The second problem with sleeping pills is tolerance. Tolerance means that you get used to the effects of a medication. You gradually need more of the medication to have the same effect. Tolerance is very quick with sleeping pills. Instead of taking one tablet, you might now need two or three tablets to help you fall asleep. It can become very dangerous if a person takes too much medication. Non-prescription sleeping pills are not recommended if you have asthma, glaucoma (increased pressure in the eye), breathing problems, or prostate problems. They are also not to be used if you are pregnant or nursing. Non-prescription sleeping medications are drugs and can affect the action of other medications you are taking. Check with your pharmacist or your doctor before taking these medications.

Prescription Sleeping Medications

If your insomnia is constant and has lasted for a long time, your doctor may prescribe a sleeping pill for you. Some of the options are listed below.

Benzodiazepines: Alprazolam (Xanax™), lorazepam (Ativan™), nitrazepam (Mogadon™), oxazepam (Serax™), flurazepam (Dalmane™), and triazolam (Halcion™) are examples of hypnotic benzodiazepines. They act to bring on sleep, increase the time spent asleep, and decrease the number of times you wake up during the night. Sleep caused by benzodiazepines differs from normal sleep. It is not as deep as more time is spent in a light sleep. The REM phase is also delayed. Some benzodiazepines are short-acting while others are intermediate-acting or long-acting. The short-acting versions are best suited for people who have difficulty falling asleep and need to avoid daytime sedation. People who wake up early in the morning would find an intermediate-acting benzodiazepine more effective.

Long-acting benzodiazepines are normally for people who have trouble sleeping and also experience daytime anxiety. The most common side-effects associated with benzodiazepines are daytime sedation, confusion, loss of coordination, amnesia (loss of memory), tolerance and rebound insomnia (the insomnia returns once the medication is stopped). Benzodiazepines can increase the risk of falls and fractures, so they should be used with caution in elderly people.

Benzodiazepines can slow breathing, therefore they should not be used in people with apnea or severe COPD. They should also be avoided by people with a history of drug or alcohol abuse, as tolerance and dependence are possibilities. Tolerance can develop within one to two weeks of regular use.

Zopiclone: Zopiclone (Imovane™, Rhovane™) acts to quicken the onset of sleep, increase the total time spent asleep, and reduce the number of times you wake up during the night. Zopiclone is as effective as benzodiazepines, with possibly less tolerance. There are fewer reports of daytime sedation, amnesia, and confusion. It is a safe alternate to benzodiazepines, especially for the elderly. The common side-effects include bitter taste, dry mouth, difficulty getting up in the morning, nausea, and nightmares.

Zaleplon: Zaleplon (Starnoc™) is a hypnotic that works very quickly, but the effect lasts only for a short time. For this reason, it is helpful for falling asleep, but it does not prevent you from waking up during the night, nor does it increase the total time spent asleep. Common side-effects include headaches, dizziness, drowsiness, aching, and abdominal pain. There is less problem with tolerance with zaleplon when compared to benzodiazepines. There is also less daytime sedation.

Chloral hydrate: Chloral hydrate is rarely used as it can have toxic effects and interacts with many other drugs. Tolerance develops in two weeks.

Barbiturates: Barbiturates are rarely used to assist with sleep. They are not acceptable for safety reasons as it is quite easy to overdose on them. Highly addictive, there are many restrictions on their use and they frequently interact with other drugs.

L-tryptophan: L-tryptophan is one of the eight essential amino acids. This means the body needs it, and it must come from food. It is found in milk, turkey, tuna, and other food products. The body uses it to make the chemical serotonin. Low levels of serotonin are thought to contribute to depression. L-tryptophan is available in tablet form and has been found to be useful in treating insomnia. The possible side-effects include dry mouth, drowsiness, nausea, loss of appetite, dizziness, and headache. L-tryptophan is not to be taken in combination with certain drugs used for depression.

Insomnia can have very negative effects on a person’s life. Waking up feeling tired makes it difficult to function and to perform daily activities. Stress, worry, and anxiety are common causes of insomnia. Causes can also include underlying medical conditions, like arthritis or depression. Any underlying cause should be addressed and treated. If you are having trouble sleeping, visit your family doctor. Together, you can determine the problem and treat it properly.

FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [FM_FHd01]
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