Quality of sleep is a necessity ! Are you getting enough sleep?

What is Insomnia?

Insomnia is a fancy word that describes the problem when people are having trouble falling or staying asleep, or they do not feel rested when they wake up. The American Academy of Sleep Medicine defines insomnia as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment. Insomnia affects 10% to 30% of the U.S. population with a total estimated cost of $92.5 to $107.5 billion annually. Risk of experiencing insomnia increases with age and additional stress factors.

Are you getting enough sleep?

What are the signs and symptoms of insomnia?

• Have trouble falling or staying asleep

• Early awakening

• Feeling tired or sleepy during the day

• Difficulty with concentrating or remembering things during the day

• Get cranky, anxious, irritable, or depressed

• Have less energy or interest in doing things

• Make mistakes or get into accidents more often than normal

• Worry about their lack of sleep

Who is at high risk of experiencing Insomnia?

• Risk of developing insomnia increases with age

• Female are more at risk

• People with coexisting psychological disorders such as depression, anxiety etc

• Patients with chronic pain

• Patients with other cormorbid illness such as Diabetes, heart failure, lung disease

• Low socioeconomic status

• People with substance abuse (alcohol, smoking, illicit drugs)

• People going through stressful life events

• Divorced, separated or widowed people are more susceptible compared to others

• People who does shift work

• People who use certain medications to treat ADHD or use steroid medications

• People with Obstructive Sleep Apnea

What happens if you do not get enough sleep ?

If you do not get adequate sleep your quality of life will be compromised. Have you ever noticed difficulty in concentrating at work , or getting angry and irritable for no reason? Does your family or friends say that you're moody and angry all the time? Do you find yourself falling asleep behind the wheels? There is more to not having quality of sleep. There are many medical conditions that are associated with lack of sleep. A number of studies have shown a relationship between insomnia and increased cardiovascular risk including hypertension and Heart attack (myocardial infarction). Lack of sleep have also been linked to weight gain, seizure disorder and depression. In addition patients with insomnia are at increased risk of developing dementia.

Sleep Hygiene to treat Insomnia

Behavioral interventions are the mainstay of therapy to manage insomnia. Compared to pharmacological therapies behavioral intervention is proven to be as effective with no side effects. This is especially important if you are an older adult, I would highly recommend treating your insomnia with behavioral interventions. If you are experiencing signs and symptoms of insomnia, the first step is to maintain a sleep diary. Sleep Diary provides information regarding the patient's activities and bedtime routine, sleep quality, daytime symptoms, and use of causative substances. Information gained from the sleep diary can confirm insomnia and allows the physician to provide specific behavioral guidance.

• Sleep only long enough to feel rested and then get out of bed

• Go to bed and get up at the same time every day

• Do not try to force yourself to sleep. If you can't sleep, get out of bed and try again later.

• Have coffee, tea, and other foods that have caffeine only in the morning

• Avoid alcohol in the late afternoon, evening, and bedtime (a common misconception is that alcohol can make you fall asleep. Although alcohol is a sedative it interrupts with the REM sleep and it affects the quality of sleep)

• Avoid smoking, especially in the evening

• Keep your bedroom dark, cool, quiet, and free of reminders of work or other things that cause you stress

• Solve problems you have before you go to bed

• Exercise several days a week, but not right before bed (do not exercise within 4 hours of sleeping)

• Tai chi and low-impact aerobic exercise reduce daytime sleepiness and improve sleep quality in older adults with moderate sleep problems

• Yoga, acupuncture, and acupressure, especially auricular therapy can provide some benefits with insomnia

• Avoid looking at phones or reading devices ("e-books") that give off light before bed. This can make it harder to fall asleep.

• Don't take work to bed, bed is only for sleeping.

• Avoid large meal at bedtime and limit fluid intake before bed

• Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom

• Avoid day time naps

If you have already tried the behavioral interventions and are still experiencing insomnia and it is affecting your quality of life, you can consider trying medications. Keep in mind that medications have its own side effects, and do not use them unless you have tried all the other interventions. Even the over the counter sleep medications have side effects. Consult with your physician prior to starting medications for sleep.

What are the types of medications available in the market for insomnia?

• Melatonin: Melatonin is a comparably a safer option compared to other pharmacological agents. It is especially helpful if you are a shift worker and having difficulty falling asleep. Low dose over the counter melatonin (3mg) itself is good enough to help treat the insomnia. I have seen it widely used in pediatric population due to its safety profile.

• Benzodiazepines (Xanax): Although benzodiazepines improve short-term sleep outcomes, they have significant adverse effects and may be addictive. Benzodiazepines can cause impairment of memory, cognitive function, and psychological function, and rebound insomnia. Benzodiazepines are listed in Beers criteria (a list of medications that are considered not safe in older population) as a medication to avoid. They may increase the risks of accidents, falls, and hip fractures in older persons. I stay away from prescribing Xanax and I will never recommend any of my patients or family members to take Xanax for insomnia. The additive potential of the drug creates more serious complications than insomnia and on a day to day basis I see many of the patients struggling to escape from the addiction. STAY AWAY FROM XANAX!!!!

• The z-drugs (zolpidem [Ambien], eszopiclone [Lunesta], and zaleplon [Sonata]) improve sleep outcomes in the general population. However, their side effect profile is as similar to benzodiazepines and it can cause rebound insomnia. Similar to benzodiazepines Z-Drugs are also listed in Beers criteria as a medication to avoid in patients 65 years or older. Studies have also documented that patients who take these Z-drugs had increased visits to Emergency rooms due to adverse effects.

• Ramelteon (Rozerem) is a melatonin agonist and is only modestly effective compared with placebo, but it has few adverse effects. The most common side effects are somnolence, dizziness, nausea, fatigue, and headache.

• Low-dose doxepin (Silenor) improves sleep outcomes and has no significant adverse effects compared with placebo. Doxepin is an antidepressant and it has been approved by the FDA at doses of 3 and 6 mg primarily for the treatment of insomnia.

• Diphenhydramine (Nyquil) - Some people self-treat insomnia with over the counter medications that contain diphenhydramine. There is little evidence that diphenhydramine improves insomnia and it may cause sedation the next day (due to its long half-life). Additional side effects include decreased alertness, diminished cognitive function, delirium, dry mouth, blurred vision and urinary retention.

In addition i have seen some patients on Seroquel (antipsychotic) or Trazadone (antidepressant). However these medications are not FDA approved for insomnia.