December 7, 2023

Insomnia or the inability to sleep is a common medical problem. It can either be short-term or long-standing.
Short-term or acute insomnia lasts for less than three months and is due to stressors examples of which are the loss of a loved one, relationship problems, or loss of a job.
Chronic insomnia occurs at least three times a week and lasts for at least three months. There may be no obvious reason in some cases but more often there are medical or social or psychological stressors. It is also referred to as primary insomnia when there is no identifiable cause. It affects 20 to 40 percent of older adults.
An insomniac usually complains of difficulty in initiating sleep, poor quality of sleep, or short sleep duration. There are several factors that cause insomnia – medical, social, and psychological or psychiatric. These include depression, anxiety, and post traumatic stress disorders. Nocturia or frequency of urination at night is another common cause of sleep disturbance, like what is seen when a person has uncontrolled diabetes and kidney function impairment. Medications used in treating medical illnesses can also have effects on the body and cause insomnia like steroids (whether inhaled or taken by mouth), some antidepressants, diuretics, and stimulants.
Healthy patterns of sleep are associated with lower risk of medical problems like heart rhythm disorders. Irregular beating of the heart in atrial fibrillation predisposes to blood clot formation in the heart and this is a common cause of stroke. Untreated insomnia can lead to mood and anxiety disorders, mental impairment, worsening of health problems like hypertension and diabetes mellitus.
Treatment of insomnia requires consult and frequent follow-up with your attending physician. He will start by identifying the factors causing your inability to sleep. Insomnia cannot be solved with a one-time consult but through a series of follow-ups: After factors are identified, your physician will advice non-medical treatments and when necessary he will prescribe medications. Drug therapy is not the first step in the treatment of insomnia.
Cognitive behavioral therapy for insomnia (CBI) is the preferred treatment for chronic insomnia in adults. It addresses thoughts and behaviors that interfere with optimal sleep. It is usually done through face to face settings over four to eight sessions but it may also be done online or through telephone. It is recommended by the American Academy of Sleep Medicine as the first line of therapy for insomnia.
Cognitive behavioral therapy involves the following:
Establishment of a regular bedtime and wake time each day of the week. This is done with the help of a sleep diary, which will guide the physician in computing total sleep time and in assessing sleep efficiency. Excess time in bed contributes to insomnia, so do variations in bedtimes and wake times;
That a person should sleep only when sleepy, and to get out of bed if anxiety occurs while he is unable to sleep;
Avoidance of substances that interfere with sleep like caffeinated drinks;
Avoidance of naps to maximize sleep drive;
Provision of a comfortable environment that is conducive to good-quality sleep.
If a person does not improve, treatment with drugs is started. The choice is based on the person’s age, coexisting illnesses, side effect profiles, cost and availability, and patient’s preference.
Medications are benzodiazepines like estazolam and flurazepam, nonbenzodiazepine receptor agonists like zolpidem, histamine-receptor antagonists like doxepin, ramelteon a melatonin receptor agonist, and suvorexant orexin receptor antagonist.
These medications should only be taken when prescribed and only under a physician’s supervision.