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Sleeplessness

sleeplessness

Difficulty with sleeping is quite a common problem. However, a lot of things can help.

What is normal sleep?

A normal night's sleep has three main parts:

  • Quiet sleep. This is divided into stages 1-4. Each stage becomes more deep. Quiet sleep is sometimes called deep sleep.
  • Rapid eye movement (REM) sleep. REM sleep is when the brain is very active, but the body is limp, apart from the eyes, which move rapidly. Most dreaming occurs during REM sleep.
  • Short periods of waking for 1-2 minutes.

Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. In addition, several short periods of waking for 1-2 minutes occur about every two hours or so, but occur more frequently towards the end of the night's sleep. Normally, you do not remember the times that you wake if they last less than two minutes.

What do understand by insomnia?

Insomnia means lack of sleep. This can mean:

  • Not being able to get off to sleep.
  • Waking up too early.
  • Waking for long periods in the night.
  • Not feeling refreshed after a night's sleep.

If you have poor sleep, you may be tired in the daytime, have reduced concentration, become irritable, or just not function well.

What amount of normal sleep is required?

Different people need different amounts of sleep. Some people function well and are not tired during the day with just 3-4 hours' sleep a night. Most people establish a pattern that is normal for them in their early adult life. However, as you become older, it is normal to sleep less. Many people in their 70s sleep less than six hours per night.

What is important is that the amount of sleep that you get should be sufficient for you, and that you usually feel refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is ... 'difficulty in getting to sleep, difficulty staying asleep, early wakening, or non-restorative sleep despite adequate time and opportunity to sleep, resulting in impaired daytime functioning, such as poor concentration, mood disturbance, and daytime tiredness'.

What are the reasons of poor sleep?

Poor sleep may develop for no apparent reason. However, there are a number of possible causes which include the following:

  • Concern about wakefulness that you may feel that to wake in the night is not normal, and worry about getting back off to sleep.
  • Temporary problems like stress, a work or family problem, jet-lag, a change of routine, a strange bed, etc. Poor sleep in these situations usually improves in time.
  • Anxiety or depression
  • Sleep apnoeaoccurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly.
  • Other illnesses may keep some people awake. For example, illness causing pain, leg cramps, breathlessness, indigestion, cough, itch, hot flushes, mental health problems, etc.
  • Stimulantscan interfere with sleep. There are three common culprits.
    • Alcohol - many people take an alcoholic drink to help sleep. Alcohol actually causes broken sleep and early morning wakefulness.
    • Caffeine - which is in tea, coffee, some soft drinks such as cola, and even chocolate. It is also in some painkiller tablets and other medicines (check the ingredients on the medicine packet). Caffeine is a stimulant and may cause poor sleep.
    • Nicotine (from smoking) is a stimulant, and it would help not to smoke.
    • Street drugs, for example, ecstasy, cocaine, cannabis and amfetamines can affect sleep.
  • Prescribed medicines can sometimes interfere with sleep. For example, diuretics ('water tablets'), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies containing pseudoephedrine.
  • Unrealistic expectations that some people just need less sleep than others.

Some classifications

Doctors sometimes classify poor sleep (insomnia) into the following categories:

  • By type:
    • Primary insomnia is insomnia that occurs when no illness or other secondary cause (comorbidity) is identified.
    • Secondary (or comorbid ) insomnia is when insomnia occurs as a symptom of, or is associated with, other conditions.
  • By duration:
    • Short-term if insomnia lasts between one and four weeks.
    • Long-term (or persistent) if insomnia lasts for four weeks or longer.
Things to do to improve poor sleep?
  • Understanding some facts like, short periods of waking each night are normal. Also, remember that worry about poor sleep can itself make things worse. Also, it is common to have a few bad nights if you have a period of stress, anxiety or worry.
  • General tips for sleeping better (often called sleep hygiene)
    • Reduce caffeine - do not have any food that contain for six hours before bedtime.
    • Do not smoke within six hours before bedtime.
    • Do not drink alcohol within six hours before bedtime.
    • Do not have a heavy meal just before bedtime (although a light snack may be helpful).
    • Do not do any strenuous exercise within four hours of bedtime (but exercising earlier in the day is helpful).
    • Body rhythms - try to get into a routine of wakefulness during the day, and sleepiness at night. The body becomes used to rhythms or routines. If you keep to a pattern, you are more likely to sleep well.
    • No matter how tired you are, do not sleep or nap during the day.
    • It is best to go to bed only when sleepy-tired in the late evening.
    • Switch the light out as soon as you get into bed.
    • Always get up at the same time each day, seven days a week, however short the time asleep. Use an alarm to help with this. Resist the temptation to lie in - even after a poor night's sleep. Do not use weekends to catch up on sleep, as this may upset the natural body rhythm that you have got used to in the week.
    • The bedroom should be a quiet, relaxing place to sleep.
    • It should not be too hot, cold, or noisy.
    • Earplugs and eye shades may be useful if you are sleeping with a snoring or wakeful partner.
    • Make sure the bedroom is dark with good curtains to stop early morning sunlight.
    • Don't use the bedroom for activities such as work, eating or television.
    • Consider changing your bed if it is old, or not comfortable.
    • Hide your alarm clock under your bed. Many people will clock watch and this does not help you to get off to sleep.
    • Mood and atmosphere - try to relax and wind down with a routine before going to bed.
Relaxation techniques

These aim to reduce your mental and physical arousal before going to bed. Relaxation techniques may help even if you are not anxious, but find it hard to get off to sleep. There are a number of techniques.

Daytime exercise

Regular daytime exercise can help you to feel more relaxed and tired at bedtime. This may help you to sleep better. Even a walk in the afternoon or early evening is better than nothing. However, ideally, you should aim for at least 30 minutes of moderate exercise on five or more days a week.

Behavioural and cognitive therapies

If you have severe persistent poor sleep, your doctor may refer you to a psychologist or other health professional for behavioural and/or cognitive therapies. Research studies have found that there is a good chance that behavioural and cognitive therapies will improve sleep in adults with insomnia.

There are various types or therapy and they include the following:

  • Stimulus-control therapy, helps you to re-associate the bed and bedroom with sleep, and to re-establish a consistent sleep/wake pattern.
  • Sleep restriction therapy, is that you limit the time that you spend in bed at night. As things improve, the time in bed is then lengthened. An example of the way that this may be done in practice is as follows:
    • First, you may be asked to find out how much you are actually sleeping each night. You can do this by keeping a sleep diary.
    • You may then be advised to restrict the amount of time that you spend in bed to the time that you actually sleep each night. For example, if you spend eight hours in bed each night but you sleep for only six hours, then your allowed time in bed would be six hours. So, in this example, say you normally go to bed at 11 pm, get to sleep at 1 am, and get up at 7 am. To restrict your time in bed to six hours, you may be advised to go to bed at 1 am, but still get up at 7 am.
    • You then make weekly adjustments to the allowed time in bed, depending on the time spent asleep. (You need to keep on with the sleep diary.)
    • When 90% of the time spent in bed is spent asleep, then the allowed time spent in bed is increased by 15 minutes, by going to bed 15 minutes earlier. In the above example, you would then go to bed at 12.45 am.
    • Adjustments are made each week until you are sleeping for a longer length most nights.
  • Relaxation training This teaches you ways of reducing tension.
  • Paradoxical intention This involves staying passively awake, avoiding any intention to fall asleep. Its use is limited to people who have trouble getting to sleep (but not maintaining sleep)
  • Biofeedback This provides visual or auditory feedback to help you control certain body functions (such as muscle tension)
  • Cognitive therapy is based on the idea that certain ways of thinking can trigger or fuel certain health problems, such as poor sleep. The therapist helps you to understand your thought patterns. In particular, to identify any harmful or unhelpful ideas or thoughts which you have that can contribute to you not sleeping well. The aim is then to change your ways of thinking and/or behaviour to avoid these ideas. Also, to help your thoughts to be more realistic and helpful. Cognitive therapy is often used in combination with a behavioural intervention (such as stimulus control, sleep restriction, or relaxation training); this is then called cognitive behavioural therapy (CBT).
Do you really require sleeping tablets?

Sleeping tablets are not usually advised The main types of sleeping tablets are in a class of medicines called benzodiazepines, or in a class of medicines called Z medicines. In the past, sleeping tablets were commonly prescribed. However, they have been shown to have problems, and are now not commonly prescribed.

What are the complications of sleeping tablets?

Drowsiness the next day.

Clumsiness and confusion in the night if you have to get up.

Tolerance to sleeping tablets may develop if you take them regularly. This means that, in time, the usual dose has no effect. You then need a higher dose to help with sleep. In time, the higher dose then has no effect, and so on.

Some people become dependent (addicted) on sleeping tablets, and have withdrawal symptoms if the tablets are stopped suddenly.

Sometimes a sleeping tablet is advised.

If a sleeping tablet is prescribed, it is usually just a short course (a week or so) to get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents tolerance or dependence to the tablet from developing.

Melatonin

Melatonin is, strictly speaking, not a sleeping tablet. Melatonin is a naturally occurring hormone made by the body. The level of melatonin in the body varies throughout the day. It is involved in helping to regulate the circadian rhythms (daily cycles) of various functions in the body. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia. The recommended duration of treatment is for three weeks only.


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