Insomnia is a sleep problem that involves a change in one's normal sleep with a reduced ability to function
the next day. It is the consequences of the daytime sleepiness and fatigue that makes insomnia potential y
dangerous. Approximately one third of the population experience a sleep problem in any given year. More
women seem to experience insomnia than men, and its prevalence increases with age.
Normal Sleep Patterns The human body requires sleep to refresh and rejuvenate itself, but the amount of time needed for this restorative process varies greatly from individual to individual. Some individuals need just a few hours sleep each day, while others require ten hours or more. Regardless
of the amount of sleep an individual needs, most healthy individuals have a sleep pattern which consists of
two distinct stages. The first stage is cal ed non-rapid-eye movement (NREM) sleep since few eye
movements are observed at this stage. The second stage is cal ed rapid-eye movement (REM) sleep
because it is general y associated with characteristic involuntary eye movements. As an individual fal s
asleep, they begin the NREM sleep stage. During NREM sleep, they pass from a lighter sleep to a deep
sleep. When the individual reaches the deepest NREM sleep, REM sleep occurs. REM sleep is the most
NREM and REM sleep occur cyclical y throughout the night. A ful NREM/REM cycle takes about 1.5 hours.
As the night progresses, the proportion of the cycle composed of NREM sleep decreases while the
proportion of REM sleep increases. Overal , the majority of sleep is actual y spent in NREM sleep with REM
sleep accounting for only about 1/4 of total sleep time.
Sleep Patterns & Insomnia
Insomnia usual y presents as an inability to fal asleep, frequent awakenings during the night or waking up
early in the morning. While there is general agreement that insomnia involves a change in normal sleep
patterns, no consistent alterations in sleep stages have been identified. Younger people who experience
insomnia tend to have trouble fal ing asleep, while older people with insomnia have difficulty maintaining
Causes of Insomnia Insomnia is not a disease. It is a symptom or effect of some underlying cause. As table 1 il ustrates, the Causes of Insomnia Psychological Factors:
Stress, depression, schizophrenia, dementia, sleep state misperception, reinforcement of
Restless legs syndrome, periodic limb movement disorder (nocturnal myoclonus), sleep apnea
syndrome, hyperthyroidism, fibromyalgia, arthritis, chronic pain, headache, pruritus,
gastroesophageal reflux, asthma, chronic obstructive pulmonary disease, Parkinson's disease,
Huntington's chroea, Tourette's syndrome, cardiac problems.
Alcohol caffeine, nicotine, medications (See table 2)
Circadian Rhythm Problems
Jet lag, sudden changes in shift work times, delayed sleep phase syndrome, advances sleep
Poor Sleep Environment:
Bed partner, bed, light, temperature, noise
Poor Sleep Habits
Irregular sleep/wake schedule, lying in bed, naps, bed as a cue for arousal.
Psychological factors are the biggest contributors to insomnia. Stress, in the form of anxiety, excitement,
worry or anger, causes a state of hyperarousal and makes fal ing asleep difficult. Insomnia is a commonly
associated symptom of depression as wel as other mood anxiety and thought disorders such as
schizophrenia and dementia. Sleep state misperception is a condition in which an individual, presented with
the prospect of bedtime, experiences stimulation rather than relaxation. Many insomniacs add to their
problem by worrying about whether they wil be able to fal asleep. This reinforces the insomnia. Panic
attacks during sleep or recurrent nightmares causes frequent awakenings and are destructive to sleep.
Insomnia often results from a number of physical disorders. Restless legs syndrome is a non-painful
discomfort in the lower legs which produces an extreme urge to move the legs when resting or fal ing sleep.
Periodic limb movement disorder, also cal ed nocturnal myoclonus, is characterized by repetitive short
jerking movements of the limbs (usual y the feet) which occur during the light stages of sleep and result in
frequent awakenings. Individuals with sleep apnea syndrome suffer from periods of sleep-associated
interruptions of breathing. Their sleep is fragmented because of repeated awakenings to resume breathing.
In hyperthyroidism, the body's increased metabolic rate adversely affects normal sleep patterns. Numerous
other medical problems listed in table 1 result in pain or physical discomfort which prevents or disrupts
The use of substances such as alcohol, caffeine, nicotine and medications can cause insomnia. While
alcohol causes short term sleepiness, this fol owed by rebound excitement which results in frequent
awakenings later in the night. Nicotine and caffeine are ventral nervous system (CNS) stimulants. Smoking
the consumption of coffee, tea, chocolate, cola beverages or caffeine-containing medications near bedtime
may cause insomnia. As listed in table 2, many medications have the potential to interfere with sleep. While
most of these medications produce insomnia through a CNS stimulant effect, a few exceptions should be
noted. Diuretics taken late in the afternoon or evening and excessive laxative use cause frequent
awakenings to go to the toilet. Cimetidine, in addition to being a CNS stimulant, has been associated with
agitation and confusion. The beta-blockers listen in table 2 have been known to cause nightmares.
Circadian rhythm problems occur when the body's internal sleep timing mechanism is disrupted. This may
occur as a result of jet lag or sudden changes in shift work times. Delayed sleep phase syndrome is a
condition in which the individual's internal timing for sleepiness is delayed. People with delayed sleep phase
syndrome have difficulty fal ing asleep at night and are tired in the morning. Advanced sleep phase syndrome is characterized by the opposite phenomenon. The individual awakes early in the morning and
Insomnia is often the result of a poor sleep environment. For example, a bed partner who snores or is
restless in the night, an uncomfortable bed or a bedroom that is too bright, stuffy, hot, cold or noisy can
affect one's ability to fal asleep and the quality of sleep.
Sleep patterns change with age. As an individual grows older, they spend more sleep time in the light
stages of sleep. This means there are more and longer awakenings and a lower threshold for arousal by
noise. The elderly often experience a circadian rhythm advancement so they go to bed earlier and wake
earlier. Alterations in circadian rhythm are aggravated by daytime napping.
Poor sleep habits are behaviours that can contribute to sleep problems. They are often acquired in the early
years when an individual's sleep system is relatively powerful. As the individual ages and the sleep system
is not as strong, poor sleep habits become a problem. Poor sleep habits include an irregular sleep/wake
schedule; lying in bed daydreaming or worrying; daytime napping; and watching television, eating or
working in bed so the bed becomes a cue for arousal.
Medications which may interfere with sleep (where appropriate, brand name examples are provided in brackets)
o metoprolol (Lopressure™, Betaloc™)
• quinidine (Biquin™, Quinidex™, Quinate™, Carioquin™)
• theophyl ine (Quibron™, Theo-Dur™, Theolair™, Uniphyl™)
• thyroid preparations (Eltroxin™, Synthroid™)
Since insomnia is a symptom or effect of an underlying cause, the first step in the management of insomnia
is to identify the cause. Management efforts should then be directed at eliminating the cause. This might
mean correcting an underlying psychological or physical disorder; eliminating stress and emotional causes;
refraining from smoking or ingesting alcohol - or caffeine-containing foods, beverages or medications near
bedtime; discontinuing a medication which causes insomnia; or altering sleep habits and/or environment.
Nonpharmacologic Treatments A number of nonpharmacologic approaches have been found to be effective for treating insomnia. These include sleep hygiene, sleep restriction, bright light therapy, chronotherapy, relaxation training, meditation, biofeedback and cognitive therapy. Sleep hygiene is a term which refers to a routine set of behaviours that promote natural restorative sleep.
• Avoid daytime napping or spending extended amounts of time in bed awake
• Avoid al forms of caffeine and alcohol within 3 or 4 hours of bedtime
• Avoid consuming heavy meals or smoking before bedtime
• Avoid heavy exercise or emotional y upsetting activities close to bedtime but continue to exercise regularly during the day or evening
• Try to relax for one hour before bedtime. A warm bath, a light snack or some reading can be relaxing
• Make the bedroom and bed as comfortable as possible
• Establish a consistent bedtime and wake-up time
• If you can't fal asleep after 15 to 20 minutes, get out of bed and return only when you are sleepy
• Use the bedroom only for activities associated with sleep and intimacy. Watching television, eating, paying bil s or working should be done in another room
Providing the insomniac with basic information about sleep and sleep hygiene is the cornerstone of the
Sleep restriction is a technique by which insomniacs are instructed to limit the time they spend in bed to the
number of hours of sleep they think they normal y obtain. Since insomniacs general y underestimate how
much sleep they get, this technique usual y results in sleep deprivation. The sleep deprivation helps the
individual to consolidate sleep. As they subsequently fol ow a gradual schedule of increasing the amount of
sleep, sleep efficiency improves. Sleep restriction is useful for treating individuals who have difficulty
Bright light has a powerful effect on resetting the body's "clock". Properly timed exposures to particular light
intensities can shift the clock backward or forward. Bright light therapy is very useful for treating delayed or
advanced sleep phase syndrome. Chronotherapy provides another treatment for these syndromes. Bedtime
is successively delayed by daily increments of three hours until sleep onset coincides with the desired
bedtime. Once the bedtime has been established, the individual must maintain a regular sleep/wake
Relaxation training, meditation and biofeedback are procedures designed to relax the individual at bedtime
so they wil fal asleep faster. Depending on the procedure, progressive relaxation, autogenic training,
transcendental meditation, yoga, hypnosis and electromyogram (EMG) biofeedback are used.
Cognitive therapy provides the insomniac with psychological tools to cope with insomnia. Therapy focuses
on getting the insomniac to see themselves in control of their problem, instead of seeing themselves as a
Pharmacologic Treatments When nonpharmacologic treatments fail to adequately manage the sleep problem, consideration can be given to adding a sleeping medication.
Pharmacologic options are listed in table 3. Al of these medications have a CNS depressant effect which
can be enhanced by other CNS depressant substances or medications and none are recommended for
individuals who suffer from sleep apnea syndrome.
Once the mainstay of treatment for insomnia, ethclorynol and barbiturates such as amobarbital and
secobarbital are no longer recommended for treating insomnia. They have been replaced by safer and
Long-acting benzodiazepines, such as flurazepam and nitrazepam, have the potential to accumulate with
continuous use and may cause residual daytime drowsiness. The intermediate-acting benzodiazepines
listed in table 3 also have the potential for accumulation but this can be minimized by using the lowest dose.
Lorazepam, oxazepam and temazepame are in the products of choice for treating insomnia in the elderly
because the metabolism of these three benzodiazepines is not affected by age. Their slower onset of action
makes them ideal for treating insomnia characterized by frequent awakenings. When used to treat delayed
sleep onset, lorazepam and temazepam should be taken one-half hour and oxazepame taken one hour
before bedtime. Despite negative publicity, triazolam, when used in low doses, is very effective for treating
delayed sleep onset insomnia. Zopiclone, although chemical y different from the benzodiazepines, is very
similar to triazolam in its therapeutic action. Al benzodiazepines and zopiclone may cause anterograde
type of acute memory loss. Once again, this can be minimized by using the lowest possible dose.
Chloral hydrate is an effective sleeping medication when used for a few nights to treat transient insomnia.
However, tolerance to its hypnotic effect develops within two weeks so it is recommended only for
Tolerance may develop with al the prescription medications used to treat insomnia. Tolerance means the
medication becomes less effective so the dose has to be increased to to get the same effect. Increasing the
dose increases the potential for side effects, particularly residual daytime drowsiness. The "rule of thumb"
for prescription sleeping medications is: use the lowest effective dose with intermittent dosing (two to for
times weekly) for a short period of time (no more than two to four weeks) and withdraw the medication
slowly, paying close attention to rebound insomnia. Elderly individuals should always be started with one-
When insomnia is a symptom of depression, antidepressants are useful. However, in the absence of
depression, there is no rationale for utilizing an antidepressant as a sleeping medication. In fact, as
indicated in table 2, antidepressants may actual y cause insomnia.
L-tryptophan is an essential amino acid found in foods such as tuna and milk. It possesses a sedating
effect, but there is little scientific evidence to support l-tryptophan supplementation as a treatment for
Diphenhydramine is a highly sedating antihistamine which is effective for initiating sleep, but not very
effective for maintaining sleep. It can cause daytime drowsiness and has troublesome anticholinergic side
effects which make it a poor choice as a sleeping medication for the elderly. It must be used cautiously by
individuals with epilepsy, narrow angle glaucoma, prostatic hypertrophy, cardiovascular disease, peptic
ulcers and gastric or bladder obstruction.
Herbal Sleep Aids
In recent years, herbal sleep aids have become very popular. Table 3 lists the most common herbs reputed
to have sedative and relaxant properties. Although little scientific evidence of their efficacy exists, the herbs
listed in table 3 appear to be safe when used appropriately in healthy individuals.
Pharmacologic treatments for insomnia (Brand name examples are provided in brackets) Intermediate-acting Benzodiazepines Short-acting Benzodiazepines Herbal Sleep Aids PHARMAwise is authored and published by Dawn M. Frail, B.Sc. (Pharm), M.Sc. and made possible through the support of the Pharmacy & Apotex Continuing Education (PACE) program, the Apotex Advisory Board and your pharmacist. Reference to articles contained in this
infoletter are available by contacting the Apotex Professional Affairs Department at 1-800-268-4623, extension 8456. PHARMAwise is intended to provide drug and health information to care providers. The publisher, sponsor, and distributor are not responsible for losses arising from the use of information in this publication.
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