Medicine: Treating Insomnia

June 2, 2016

Hello there! Today I wanted to do a little (or not so little) overview of insomnia and how we like to approach it as primary care providers. Insomnia is one of the most common complaints in the clinical setting. 30 percent of adults suffer from insomnia, and 10% have such severe insomnia that it adversely impacts their daytime function. Chronic sleep deprivation has a wide variety of negative consequences including impaired cognitive function and memory, depression, anxiety, substance abuse, obesity, diabetes, and heart disease. In other words, getting your zzz’s is super important. Below you will find the recommendation for insomnia treatment, and the guidelines medical professionals follow.

Sleep Hygiene 

  • Establish a routine. Go to bed at the same time each night, wind down with a good book or meditation, avoid electronics in the hour leading to sleep.
  • Use your bedroom for sleep and sex only.
  • Avoid caffeine late in the day. This doesn’t mean just coffee and pop. Make sure you are on the look out for teas, coffee or mocha flavored ice creams, and chocolate.
  • Exercise every day. There are multiple reasons for this. Exercise decreases your stress level and a good work out will tire you out, so by the time you hit the hay, you’re exhausted. A study by the National Sleep Foundation also found a 65% improvement in the quality of research subjects’ sleep with consistent moderate to vigorous intensity exercise if subjects exercised just 150 minutes a week (just over 20 minutes a day). Researchers have also found that exercising early in the morning can reset your sleep-wake cycle.
  • Avoid napping, especially late in the day. The later you nap in the day, the higher the likelihood that you will have a difficult time falling asleep. The most beneficial length of naps is in general 10-20 minutes, with 10 minutes being associated with the greatest increase in stamina and alertness. Anything over 30 minutes is linked to sleep inertia, or that groggy feeling after you wake up.
  • If you can’t fall asleep, get up. Looking at the clock and the obsessing over getting to sleep by a certain time does you no favors. If you can’t fall asleep in 15-20 minutes, get up and do something until you are sleepy, then go to bed.

Cognitive Behavioral Therapy (CBT)

  • After changes to improve sleep hygiene, cognitive behavioral therapy should be the next step in management of insomnia.
  • Cognitive Behavioral therapy has demonstrated improvements in sleep latency (the time to transition from wakefulness to sleep), time awake after sleep onset (how long it takes you to fall asleep after waking up in the middle of the night), and sleep efficiency (how much of your time from going to bed to waking up in the morning is actually spent asleep).
  • Whereas the efficacy of most sleep medications decreases over time, cognitive behavioral therapy provides sustained improvements to sleep.
  • Types of therapy:
    • Progressive Relaxation. This involves learning how to isolate and tense specific muscle groups for a period of time, and subsequently fully relaxing them. You start from your toes, and work your way up to your neck. This forces you to focus on the difference in sensation between muscles being tense versus relaxed. Tense muscles for 5 seconds and relax for 30. This was actually the first relaxation method I used to fall asleep when I started having issues falling asleep in college. Most of the time, I’d be lights-out before I got to my upper body. Here is more information on this technique.
    • Guided Imagery & Meditation. In this technique, you use visualization to embark on a calming journey in a peaceful place. The key is to imagine the place in great detail, utilizing multiple senses to creat this image. For example, imagining walking along a beach, feeling the sand between your toes, tasting the salt from the ocean, and hearing the waves crash against the shore. Here is more information on this technique.
    • 4-7-8 Breathing, A technique created by Dr. Weil, this is the technique I ask most of my patients to try first, mostly because it’s the simplest and easiest to remember. Here is how it works: Inhale slowly through your nose for 4 counts. Hold your breath for 7 counts. Exhale slowly through your mouth for 8 counts. Totally simple right? This technique works by acting as a natural tranquilizer to the brain. Unlike medications, the efficacy of this technique increases the more you use it. I used this technique a lot during my last two years of medical school before test days when I was feeling anxious. It helps me to fall asleep quickly, without fail. Here is more information on this technique.

Pharmacologic Therapy

  • Sometimes CBT isn’t enough, and people may need some pharmacologic therapy, generally for a short period of time, and always in conjunction with CBT to regain control of their sleep cycles.
  • Melatonin. This is usually the first medication physicians will prescribe. Mainly because it’s effective and relatively inexpensive. Melatonin is a naturally occurring hormone in our bodies which regulates our sleep cycles. It is highest during the times of sleep, and lowest early in the morning upon waking. The key with Melatonin, is it must be taken correctly, Melatonin taken early in the evening is associated with an increase in sleep time. However, if taken 30 minutes before sleep, it has no impact on sleep time. They provide a significant benefit for the elderly, without residual effects upon waking.
  • Anti-Histamines. Originally created for their effects on allergies, the first generation of anti-histamines have been used as a sleep aid by many people. An example of this would be Benadryl, or diphenhydramine. The issue with this medication is that it often will make people feel sluggish in the morning. It is not indicated for treatment of insomnia, in other words, your medical professional should not advise you take these medications for sleep.
  • Zolpidem. This is one of the first line prescription medications used for primary insomnia (inability to sleep without another cause i.e. anxiety, sleep apnea, etc.) It should be used only in the short term and after a trial of CBT. This medication is in the safest drug class for insomnia currently on the market. This medication has also shown consistent efficacy over a period of 6-12 months in several studies. With elevated doses, there is a risk for next-morning impaired mentation. Abstinence from driving in the morning following taking this medication is advised.
  • Ramelteon. This is a melatonin receptor agonist. It has been shown to decrease sleep latency, but it does not have any next-morning residual effects. It also hasn’t been shown to have any effects on in mobility, balance, or memory in the elderly. It is specifically used for sleep-onset insomnia.
  • Benzodiazepines and Barbituates. These medications used to be used quite frequently both for sleep and anxiety. They have fallen heavily out of favor in the last few years. This is due to their decreased efficacy over time, and the risk of overdose. They are mentioned here purely for the sake of completion.

Other

  • Diet:
    • It is best to avoid large meals, especially those heavy in carbohydrates and sugar, late in the day, specifically 3 hours before bedtime.
    • Foods containing magnesium or tryptophan may help you to fall asleep. The most popular example of a tryptophan containing food to help with sleep is warm milk.
    • Alcohol should be avoided in those who suffer from insomnia, especially in the evenings. Although alcohol does help people to fall asleep, alcohol has adverse and long lasting impacts on the circadian rhythm.
  • Yoga or Meditation. Done for 20 minutes before bed, yoga and meditation have a beneficial effect on one’s ability to fall asleep and stay asleep.
  • Temperature. The ideal temperature for optimal sleep is between 65-72 degrees Fahrenheit. This range varies. Experiment with the temperature, and find out what works best for you.
  • Sleep Diary. If you seek advice from a professional, consider keeping a sleep diary for 1-2 weeks before your appointement. This can be really helpful to discover if the issue is falling asleep, staying asleep, or if there are specific trends that may be preventing a good night’s sleep.
  • Acupressure. Although major studies are lacking, one randomized, controlled study of 50 residents in a long term care facility showed benefits lasting two weeks after a 5 week trial. The areas addressed are on each of the wrists.

I hope that answers any questions you may have about insomnia and how to manage it! If you have any others, feel free to leave a comment!

Have a great weekend!

XOXO – Emmy Lou Lou

 Sources:

 aasmnet.org

sleepfoundation.org

mayoclinic.org

emedicine.medscape.com

drweil.com

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