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A patient's longstanding problem is getting worse - Dr Tanvir Jamil discusses

A patient's longstanding problem is getting worse - Dr Tanvir Jamil discusses

Case History

Anthony is a 67-year-old retired security guard who has been having problems with insomnia for years. For the last six months the problem has worsened and he is now getting tired and irritable during the day. He does not like taking tablets and asks you if there is anything else that can be done about his sleep.

What actually is a 'good night's sleep' and how much of a problem is insomnia?

Sleep habits vary but in general most of us who sleep adequately should fall asleep within 30 minutes of going to bed and sleep should last about six to eight hours with fewer than three brief awakenings. We should feel rested and refreshed on awakening.

Patients' definitions of insomnia will vary but generally it is not getting enough satisfying sleep. About 10-15 per cent of the population suffers from insomnia. It increases with age and women are twice as likely as men to suffer.

By the age of 65 almost one in two of us is affected. Only one in five people with this condition consult their doctor, probably because they believe they will not be taken seriously, they believe there is no effective remedy or that they will be given potentially addictive 'sleeping tablets'.

Apart from tiredness what are the other effects of insomnia?

Patients often complain of loss of concentration, poor memory, poor work performance, irritability and mood disturbance. Anxiety and/or depression may also result from (as well as cause) insomnia.

Physical symptoms include muscular aches and pains as well as being tired all the time. Interestingly, few patients fall asleep during the day even though they may be tired. This is probably due to the presence of hyperarousal states such as anxiety.

Studies have also shown that mortality rate is increased if sleep is two hours shorter or longer than the age-adjusted norm.

What are the main causes of insomnia?

  • Short-term causes are:
  • emotional events such as bereavement, exams, family issues
  • disruption of sleep-wake cycle such as jet lag, shift work
  • change in sleep environment – such as noise
  • excessive caffeine – over five cups per day can interfere with sleep
  • alcohol – as levels fall to zero at night there may be a withdrawal effect with arousal
  • nicotine – high levels of nicotine increase arousal, and smoking more than one cigarette within half an hour of going to bed will interfere with getting to sleep.

Long-term causes are:

  • anxiety, depression
  • poor sleep environment such as extraneous noise, snoring partner, uncomfortable bed
  • neurological problems: dementia, restless legs syndrome
  • non-neurological problems: chronic pain, cough, breathlessness, tinnitus, asthma, prostatism, allergies
  • medication – cimetidine, propranolol, steroids and digoxin can all cause nightmares. Non-psychotropics such as antiemetics, antihistamines, appetite suppressants, antihypertensives and diuretics can all cause night-time waking

What are the best sleep-hygiene measures to advise the patient?

  • Set a rigid sleep schedule: go to bed at the same time every day, set a sleeping time of, say, midnight to 6 am. When you are sleeping soundly through this six-hour period add 15 minutes each week to it. You will know when you are getting good sleep – you will wake up refreshed and energetic. Be sure to wake up at the appointed time. DO NOT LIE IN
  • Don't cat-nap during the day. This will stop you sleeping at the proper time
  • Don't waste time waiting to go to sleep: read a magazine, watch TV, knit or listen to something soothing on the radio. When you feel drowsy go back to bed again. If you can't fall asleep repeat the procedure. But always wake up at the same time every morning
  • Avoid coffee, cola and tea after 4pm. Avoid alcohol at dinner. A glass of warm milk or a caffeine-free chocolate drink may help you relax. Snacks before bedtime should be light
  • Avoid smoking
  • Avoid strenuous exercise or emotional excitement immediately before you go to bed. Sex before bedtime, however, can help you sleep soundly
  • Exercise during the day or early evening. This will tire your muscles and help you sleep. Fit people sleep better
  • Have a 'quiet time' before going to bed: one to two hours before bedtime give yourself 10 minutes to think about the day's activities – including all the stresses, strains and problems. This will help clear your mind, ease anxiety and help you get off to sleep
  • Meditation: a few minutes before bedtime will help relaxation
  • Other useful tips: a warm bath; changing to a more comfortable bed; dark curtains to block out the light; get rid of distracting clocks; wear loose-fitting clothes; keep the bedroom temperature comfortable (ideally about 18°C); earplugs to block out noisy neighbours/cars/snoring partners
  • Maintain a routine

What about medication?

Drugs such as zopiclone and zolpidem cause less daytime sedation than longer-acting benzodiazepines. They are not benzodiazepines themselves but act on the same receptors (or receptor sub-types).

They are not licensed for long-term use and there is evidence of dependence in a small number of patients. Since they are short-acting they are ideal for patients who have difficulty getting to sleep.

Temazepam (intermediate duration of action) may be better for a patient who has difficulty in maintaining sleep. A two-week course is useful for re-establishing a sleep pattern together with self-help advice.

This can be repeated but patients should not be on sleeping tablets for longer than one month continuously because of the risk of dependence. Sedating antidepressants (10-25mg amitriptyline) can also be useful, particularly if depression is present. They have the advantage of having less addictive potential and can therefore be used for longer.

Are there any particular concerns about insomnia in patients like Anthony?

In the elderly there is more likely to be an underlying cause for insomnia so the GP needs to search more diligently for physical and psychological causes. There might even be more than one problem – medication, bereavement and depression.

You also need to be more careful when prescribing as older patients are more sensitive to the effects of medication. Use half the recommended dose initially.

Tanvir Jamil is a GP trainer in Burnham, Bucks


Most of us should fall asleep within 30 minutes of going to bed and sleep six to eight hours

insomnia cause

In the elderly there is likely to be an underlying cause for insomnia

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