Chapter 22 Insomnia and sleep disorders
Epidemiology of insomnia
Insomnia is the most common sleep disorder across all stages of adulthood, and is often associated with significant medical, psychological and social disturbances.1, 2 It is a prevalent health complaint associated with daytime impairments, reduced quality of life, and increased health care costs. The epidemiological data indicate occasional episodes of insomnia symptoms are reported by one-half of all adults in the US,3, 4 while multiple studies have documented the prevalence of chronic insomnia in 10–15% of the US adult population, and that an additional 25–35% has transient or occasional insomnia identified in various countries.4–7 Reported rates of insomnia in other countries include 21% in Japan,8 19% in France,9 and 18% in Canada.10 Among those people who experience insomnia at least a few nights per week, the most frequent symptoms reported are 1) waking up feeling unrefreshed (34%) and 2) awakening often during the night (32%).3, 4 Less often, adults with insomnia report difficulty falling asleep or awakening early (23–24%).4 Furthermore, up to 25% of children seen in general practice11 and 60% of adults older than 60 years of age experience sleep problems.12, 13
In a telephone survey about sleep and insomnia, in randomly selected French-speaking adults in Quebec, of the total sample 25% were dissatisfied with their sleep, 30% reported insomnia symptoms, and 10% met criteria for an insomnia syndrome.3 Of the respondents, 13% had consulted a health care provider specifically for insomnia in their lifetime, with general practitioners being the most frequently consulted. Daytime fatigue (48%), psychological distress (40%) and physical discomfort (22%) were the main determinants prompting individuals with insomnia to seek treatment. Fifteen percent had used at least 1 herbal/dietary products to facilitate sleep and 11% had used prescribed sleep medications in the year preceding the survey. Other self-help strategies used to facilitate sleep included reading, listening to music and relaxation.3
Symptoms of insomnia
As insomnia is a frequent symptom in the general population, classifications have gradually given more emphasis to its daytime repercussions and to their consequences on social and cognitive functioning.14 The criteria for the diagnosis of insomnia include at least 1 of the following complaints:
(For reviews see Ramakrishnan and Scheid;15 American Academy of Sleep Medicine.16)
Risk factors
General
There are various root causes of insomnia, such as drugs and stimulants that are known to cause insomnia, hormonal problems (e.g. menopause and pregnancy), adjustment sleep disorder (e.g. grief and major stress), environmental changes (e.g. moving house, excessive noise) and limit-setting sleep disorder (e.g. children who need clear boundaries for sleep).4 These need to be addressed and treated in their own right.
Psychological factors
One study exploring sleep patterns in 472 children aged 4–12 years found a higher incidence of depression, anxiety, somatic complaints, attention problems, enuresis, frequent falls, ADHD, pica and fatigue in children suffering insomnia compared with those who do not suffer insomnia.17
School transition
Data from a longitudinal study of 4460 children aged 4–5 years and 6–7 years found sleep problems during school transition are common and are significantly associated with poor health-related quality of life, behaviour, language and learning scores compared with children reported not to have sleep problems.18
Pain
Clearly pain is a common cause of insomnia and is best treated by controlling the pain. Opiates are valuable in pain-associated insomnia.15
Smoking
In a randomly selected sample of 769 individuals (379 men and 390 women, aged 20–98), participants completed 2 weeks of sleep diaries.19 They provided a global report on their sleep, indicated the number of cigarettes smoked per day, and supplied information on health, depressive symptoms, anxiety, caffeine and alcohol use. After controlling for demographic, health, psychological and behavioural variables, light smoking (< 15 cigarettes per day), but not heavier smoking, was associated with self-reported chronic insomnia and reduced sleep (diary recorded as total sleep time and time in bed). Smokers did not differ significantly from non-smokers on diary measures of sleep–onset latency, number of awakenings during the night, wake-time after sleep onset, or sleep efficiency.19
The ARIC study20 is a well-characterised population-based study that specifically correlated sleep complaints in adults to differing covariates. Difficulty falling asleep and difficulty staying asleep was demonstrated to have different causes and outcomes and smoking was a significant correlate. Table 22.1 summarises some of the risk factors for insomnia.
Table 22.1 Risk factors for insomnia
| Life stages |
| Travel and work |
| Drugs and stimulants |
| Sleep disturbance |
| Grief and stress |
| Poor sleep habits and patterns |
| Environmental |
| Mind–body |
| Medical illness |
Pharmacological treatments
The most common treatment for sleep disorders (particularly insomnia) is pharmacological. The efficacy of non-drug interventions has been suggested to be slower than pharmacological methods, but with no risk of drug-related tolerance or dependency. A recent meta-analysis of 24 studies21 of more than 2400 patients found that whilst improvements in sleep with sedative use are statistically significant the magnitude of this effect is small. The analysis demonstrated risk of adverse events as statistically significant particularly in older people at risk of falls and cognitive impairment. In people using any sedatives, the risk of adverse events compared with placebo, was 4.78 times more common for cognitive events, 2.61 times more common for adverse psychomotor events and daytime fatigue was 3.82 times greater than placebo.21 Based on these concerns, the authors concluded that, in people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.
A survey of 100 insomnia cases in hospital found 51% were younger than age 65 and 40% of patients had started experiencing insomnia whilst in hospital.22 Short-acting benzodiazepine medication was used in 88% of the cases and only 11% of patients received information about non-drug alternatives for insomnia. Eighty-two patients felt that the alternatives were healthier, and the majority (n = 67) responded that if an alternative were offered in the hospital, they would be willing to accept it. Female patients were more willing to consider alternatives (P<0.01). First time users of benzodiazepines were more receptive to alternatives compared with chronic users (P<0.002). Preferred alternatives for insomnia included massage therapy, sleep hygiene, music and relaxation techniques (P<0.001). The authors concluded that educational programs are needed for appropriate evidence-based management protocols for insomnia.
Behavioural interventions such as developing healthy sleep patterns, avoiding over-stimulation before sleep, such as watching too much TV14, 20, 23 good sleep hygiene tips, reducing stress levels, and avoiding over-work would appear to be useful first-line advice.
Insomnia and health risks
Cardiovascular
Long-term sleep deprivation may also increase risk of coronary heart disease (CHD) due to sympathetic overdrive and increases in blood pressure according to data from 71 617 women.24 The association between sleep and CHD persisted after adjusting for age, smoking, obesity, hypertension, diabetes and other cardiovascular risk factors. According to this study, women who were getting 5 or fewer hours of sleep per night had a 39% increased risk of CHD at 10 week follow-up compared to those on 8 hours sleep. Sleep of 6–9 hours was linked to an 18% increase link of CHD.
The integrative approach to the management of insomnia
Lifestyle and behavioural changes
Developing good sleep habits can help. These include:
In a trial of 36 community-dwelling patients with Alzheimer’s disease and their family caregivers, all received written materials describing age- and dementia-related changes in sleep and standard principles of good sleep hygiene.25 The patients and caregivers were then randomised to either an active group (n = 17) receiving specific recommendations about setting up and implementing a sleep hygiene program for the dementia patient or a control group, receiving training in behaviour management skills. Also, the patients in the active group were instructed to walk daily and increase daytime light exposure with the use of a light box. Control participants (n = 19) received general dementia education and caregiver support. Sleep outcomes were derived at baseline, post-test (2 months), and 6-month follow-up. Patients in the active group showed significantly greater (P<.05) post-test reductions in number of night-time awakenings, total time awake at night, and depression, and increases in weekly exercise days than control subjects. At 6-month follow-up, treatment benefit was maintained, with further improvement in reduced night awakenings. The control subjects were noted to spend more time in bed at 6 months than the active group. The authors’ concluded:
Mind–body medicine
Behaviour modification
It has been recently reported that non-drug therapies, such as using sleep diaries and dispelling dysfunctional beliefs about sleep patterns, may be as effective as hypnotics.26 It is important to educate patients about normal sleep patterns for age. For example, the elderly can function on sleep of up to 6 hours per night. Actually counting the number of hours patients sleep can be reassuring. For instance, waking up in the early hours such as 5 a.m. might be considered abnormal for a person, but when counting the total hours of sleep, this might actually be adequate. Also, establishing a proper bedtime routine and avoiding daytime naps might help (see clinical tips at the end of this chapter).
Cognitive behaviour therapy (CBT)
A recent Cochrane review identified 6 trials to examine the effectiveness of CBT for sleep problems.27 The final total of participants included in the meta-analysis was 224. The data suggests only a mild effect of CBT for sleep problems in older adults, best demonstrated for sleep maintenance insomnia. The authors’ concluded that, whilst more research is required, ‘when the possible side-effects of standard treatment (hypnotics) are considered, there is an argument to be made for clinical use of cognitive behavioural treatments’.27
Despite these findings, a recent randomised, double-blinded placebo-controlled trial that was not included in the Cochrane review but published in JAMA,28 found CBT was superior to a hypnotic. The study compared CBT with the pharmaceutical zopiclone for the treatment of chronic primary insomnia in older adults (mean age 61 years). The participants (n = 46) were randomised over 6 weeks to either CBT (sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and relaxation; n = 18), sleep medication (7.5mg zopiclone each night; n = 16), or placebo medication (n = 12). The 2 active treatments were followed up at 6 months. CBT resulted in improved short- and long-term outcomes compared with zopiclone and, overall for most outcomes, zopiclone did not differ from placebo. Participants receiving CBT improved their sleep efficiency from 81.4% at pre-treatment to 90.1% at 6-month follow-up compared with a decrease from 82.3% to 81.9% in the zopiclone group. Participants in the CBT group spent much more time in slow-wave sleep (stages 3 and 4) compared with those in other groups, and spent less time awake during the night. Total sleep time was similar in all 3 groups; at 6 months, patients receiving CBT had better sleep efficiency using polysomnography than those taking zopiclone. Based on these results CBT is superior to zopiclone treatment both in short- and long-term management of insomnia in older adults.
Another study compared, for 8 weeks, CBT alone with the pharmaceutical agent zolpidem alone, a CBT/zolpidem combination, and a placebo in 63 adults, aged 25–64.29 Therapists taught CBT participants how to identify and curb thoughts that elevate arousal and interfere with sleep. They were advised to reserve the bedroom for sleep and sex, to go to bed only when drowsy, arise at the same time each day, and use other behavioural tactics known to benefit sleep. At 1-year follow-up, the CBT group demonstrated marked improvement with sleep, superior to the zolpidem group, and combination treatment offered no advantage over CBT alone.
Hypnosis
Several studies suggest hypnosis may be useful in managing insomnia, however most of these trials are dated and of poor quality.30 A small study randomised 45 participants and compared hypnotic relaxation technique to stimulus control and placebo as a means of reducing sleep onset latency (SOL).31
The hypnotic group involved 4 weekly sessions of 30-minutes duration and compared stimulus control and placebo from baseline assessment. The subjects in this group were able to sleep more quickly. A similar case study also found hypnotherapy to assist with insomnia.32 Factors that seemed to contribute to long-term response in this small group of patients included a report of sleeping at least half of the time while in bed, increased hypnotic susceptibility and no history of major depression.
A recent study reported on a retrospective chart review performed for 84 children and adolescents with insomnia, excluding those with central or obstructive sleep apnoea.33
All children (mean age 12 years) were offered and accepted instruction in self-hypnosis for treatment of insomnia, and for any other symptoms that was suitable for hypnosis. Seventy-five patients returned for follow-up after the first hypnosis session. If the first session was not useful, patients were offered the opportunity to use hypnosis to gain insight into the cause of their insomnia. The younger children were more likely to report that the insomnia was related to fears. Two or fewer hypnosis sessions were provided to 68% of the patients. Of the 70 patients reporting a delay in sleep onset of more than 30 minutes, 90% reported a reduction in sleep onset time following hypnosis. Of the 21 patients reporting night-time awakenings more than once a week, 52% reported resolution of the awakenings and 38% reported improvement. Of the 41% of children with somatic complaints such chest pain, dyspnoea, functional abdominal pain, habit cough, headaches, and vocal cord dysfunction, 87% reported improvement or resolution of the somatic complaints following hypnosis. The authors concluded the use of ‘hypnosis appears to facilitate efficient therapy for insomnia in school-age children’.33
Meditation and relaxation
Relaxation techniques may be useful when stress and worry cause sleep disruption. An assessment of the literature by an expert panel found a number of well-defined behavioural and relaxation interventions now exist and are effective in the treatment of chronic pain and insomnia.34 The panel found strong evidence for the use of relaxation techniques in reducing chronic pain conditions and behavioural techniques (relaxation and biofeedback) for sleep improvement. However, they concluded ‘it is questionable whether the magnitude of the improvement in sleep onset and total sleep time are clinically significant’.34
A recent pilot study of 14 patients aimed to test mindfulness-based meditation for persistent insomnia.35 Despite methodological limitations, meditation had significant benefit on improving quality of sleep.
Music therapy
Several studies have explored the effect of music on sleep patterns. One study of 28 abused women residing in domestic violence shelters was assessed for anxiety and sleep quality.36 They were randomised to music therapy procedure (music listening paired with progressive muscle relaxation) or to a control. Results from pre- and post-testing indicated that music therapy constituted an effective method for reducing anxiety levels and had a significant effect on sleep quality for the music therapy group, but not for the control group. In another study, 60 Taiwanese elderly men and women aged 60–83, with difficulty sleeping, were randomised to a music group or a control group.37 The music group involved participants listening to their choice of six 45-minute sedative music tapes at bedtime for 3 weeks. Sleep quality was measured before the study and at 3-weekly post-tests. Groups were comparable on demographic variables, anxiety, depressive symptoms, physical activity, bedtime routine, herbal tea use, napping, pain, and pre-test overall sleep quality. Music resulted in significantly better sleep quality, better perceived sleep quality, longer sleep duration, greater sleep efficiency, shorter sleep latency, less sleep disturbance and less daytime dysfunction in the music group compared with the control and pre-testing groups. Sleep improved weekly, indicating a cumulative dose effect.
Physical activity
Exercise
A number of studies with healthy participants have documented the benefits on sleep patterns of exercise during the day. Whilst several reasons are provided, regular physical exercise may promote relaxation and raise core body temperature in ways that are beneficial to initiating and maintaining sleep. A study that surveyed a randomly selected population of adults (mean 54–59 years of age, n = 319 men and 403 women), found that when participating in an exercise program and walking at a normal pace for more than 6 blocks per day, both women and men had significantly reduced risk of developing sleep disorders.38 The findings suggest that a program of regular exercise may be a useful therapeutic modality in the treatment of sleep disorders. A small randomised controlled trial (RCT) conducted over 16 weeks reported that participants with sedentary lifestyles and moderate sleep problems experienced significant improvement in sleep from baseline with an exercise program comprised of four 30–40 minutes of endurance training per week when compared with wait-listed controls.39
Exercise for the elderly
Exercise for the elderly may be more difficult, but may also enhance sleep and contribute to an increased quality of life. An early study demonstrated that in older adults with moderate sleep complaints self-rated sleep quality was improved by initiating a regular moderate-intensity exercise program.39
A recent Cochrane review identified 1 trial of 43 participants over 60 years of age with insomnia, to examine the effectiveness of exercise.40 The findings at post-treatment found that total sleep duration, sleep onset latency and scores on a scale of global sleep quality showed significant improvement, but improvements in sleep efficiency were not significant. The Cochrane reviewers conclude:
… when the possible side-effects of standard treatment (hypnotics) are considered, there is an argument to be made for clinical use of alternative treatments in the elderly. Research involving exercise programs designed with the elderly in mind are needed.40
Yoga
A small 8-week trial of 20 people suffering chronic insomnia found a simple daily yoga treatment was useful in statistically improving sleep-onset, sleep efficiency, total sleep time and sleep quality compared with pre-treatment values.41 Participants practiced the treatment on their own following a single training session with subsequent brief interview and telephone follow-ups. In a recent study with 120 residents from a home for the aged, 69 were stratified based on age (5-year intervals) and randomly allocated to 3 groups, namely the yoga group (physical postures, relaxation techniques, voluntarily regulated breathing and lectures on yoga philosophy), a group for Ayurveda herbal preparation, and a wait-list control (no intervention). The groups were evaluated for self-assessment of sleep over a 1-week period at baseline, and after 3 and 6 months of the respective interventions.42 It was concluded that yoga practice improved different aspects of sleep in a geriatric population as compared to herbal and control groups.
Sunshine and bright light therapy (BLT)
Exercise combined with sunshine may provide additional benefit for sleep disorders. It is generally advisable to increase daytime exposure to the sun and avoid bright lights at night. Darkness and daylight help to control the natural circadian rhythm and the production and release of the pineal hormone melatonin (N-acetyl-5-methoxytryptamine). Rest–activity and sleep–wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. According to a Cochrane review,43 degenerative changes in the SCN may be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light.
A randomised, prospective trial compared the efficacy of 20-minutes versus 45-minutes bright light exposure (10 000 lux for 60 days) for relieving insomnia in the elderly.44 Compared with baseline, improvement was significantly higher in the 45-minutes versus 20-minutes exposure group at 3 months. At 6 months, variables returned toward baseline in the 20-minutes but not in the 45-minutes group. Another study found 2 evenings of BLT (2500 lux bright light) compared with control (dim red light) improved early morning awakening in insomniacs and day-time functioning up to 1 month after treatment.45
Findings are not so positive for the effectiveness of BLT in managing sleep, behaviour, or mood disturbances associated with dementia, according to a recent Cochrane review that found most studies were of poor quality and revealed inadequate evidence.46 The Cochrane review concluded when:
the possible side-effects of standard treatment (hypnotics) are considered, there is a reasonable argument to be made for clinical use of non-pharmacological treatments. In view of the promising results of bright light therapy in other populations with problems of sleep timing, further research into their effectiveness with older adults would seem justifiable.46
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