Patient Handout for Insomnia




Family Practice

Sleep and Sleep Problems

Sleeping problems are not uncommon and can often be solved relatively easily. First of all let us look at what is normal.   Usually we go to bed at the same time every day and after getting into bed and putting out the light we should be asleep within ten or twenty minutes. We should stay asleep for six to eight hours, but often wake once for a trip to the bathroom. As we get older we need less sleep – that is not to say that we desire less sleep. A baby sleeps twenty hours a day and children should get ten to twelve hours. Most adults would feel best with eight hours of sleep but can get away with six hours a night. It is hazardous to get less than four hours a night – there are many studies that suggest that a person is impaired at this level. Once a person is over seventy the sleep drops off to six hours a night and this is usually interrupted.

There are many types of sleep disorder, but they can be divided into five main types.

  1. Initial insomnia – this is difficulty in getting off to sleep when first going to bed. This is common and the easiest to treat. Usually it is because the mind finds it hard to slow down due to acute stressful situations – or chronic stress.
  1. Early morning waking – after initially falling to sleep one awakes and cannot get back to sleep again for several hours. Quite often this results in the person eventually falling asleep just before the alarm goes off and hence having difficulty in getting up and going in the morning.
  1. Disturbed sleep due to varying factors, traffic noise, teething babies and sick family members for example.
  1. Secondary insomnia – medical conditions such as toothache, back pain, frequent bladder voiding, arthritis and heartburn interrupt the normal sleep.
  1. Circadian disturbance due to shift work. This can be a really difficult condition to treat

I will deal with each of these individually, though much of the advice will overlap. The single most important advice, common to all these, is to avoid physical stimulants for several hours before bedtime – these include caffeine (coffee, tea, cola drinks and chocolate), cigarettes and many over-the-counter medications.

  1. Initial Insomnia – obviously the important thing here is to reduce the stress as much as possible and try to unwind before going to bed. A regular bed time is helpful, if possible. It is a good idea to avoid strong mental stimulation for an hour or so before retiring – for example card games or computer work. A warm bath can be very effective and there is good evidence that hot milk can promote going to sleep.
  1. Early morning waking. In short this is the most serious type of sleep disturbance and may well reflect an underlying depressive illness. The general measures outlined may help a little, but usually this requires a prescription medication for a while to re-educate the sleep centre in the brain.
  1. Disturbed sleep is annoying but is usually self limiting – by this I mean that eventually the cause of the disturbance will end.. The invalid will get better, children grow up etc. Noise can be dealt with by the use of ear plugs – they work well. The snoring partner (not an infrequent problem) can now be helped with relatively simple laser surgery from the ENT surgeon. If the problem is prolonged then respite should be sought – examples of this are to take turns with your spouse to care for babies at night – and seek help from family members and friends to nurse sick members of the family. One undisturbed night a week will work wonders. Don’t be afraid to ask for help – people are often kinder than we realise. It will also be a good idea to take a nap of not longer than one hour during the day – this will refresh and rest you, but will not interfere with your night-time sleep.
  1. Secondary Insomnia – this will require dealing with the primary cause of the problem. Pain can be dealt with by fixing the cause (e.g. pulling a sore tooth) or the use of the safest effective painkiller. Bladder problems almost always require the help of your family physician or urologist. Men may find some relief from the herb, saw pimento, and women cranberry extract pills. Avoiding snacking and drinking before bedtime will go a long way to relieving indigestion.
  1. – Circadian Insomnia. This is a serious problem and may well continue long after retirement. Because of the effect that this has on workers, it is becoming the focus of much research. One important discovery is that is that it is much less destructive to the sleep pattern if shifts are rotated forwards rather than backwards – that is to say evenings nights days. It is better still if arrangements can be made to stay on just one shift permanently. The use of some form of sedative medication is almost always needed in this type of situation.

Finally, no matter what the cause of the sleep problem these few tips will help.

One is that a quiet background noise may be very helpful – total silence is not always restful. A radio that will turn itself off can be used though a tape player is better. There are many tapes with relaxation music available, and the library has a good store of spoken-word tapes that are very interesting and can really help in distracting you into sleep (this sounds a paradox, but it works).

It is important, too, that your bed is comfortable. Warm, but not hot, and with a comfortable pillow. Nightwear should not be tight nor uncomfortable.

Relaxation exercises, with practice, will help to induce sleep quickly. This is almost a form of self-hypnosis. The following is a progressive relaxation technique first described by a Dr Jamieson early in this century.   Following all the above advice, lie in a comfortable position – usually best flat on your back. Beginning at the toes and ending with the face, all the muscle groups of the body are worked and then relaxed.

First of all the toes are flexed for a slow count of three and then relaxed. (Dr Jamieson observed that muscles will relax after this type of slow contraction). Then the toes are extended for the same count and again relaxed. This flex-and-relax is progressed all the way up the body. The ankles are flexed and extended, then the knees. The hips are next and then the abdominal and back muscles. This is done by tensing the abdomen as though you were about to sit up, and the back muscles are tensed by arching the back. Now we progress to the fingers, wrists and elbows.

The next exercises are very important because these are the muscles in which we usually feel tension. The shoulders are shrugged and relaxed and then the neck muscles are all worked. Extension is achieved by pushing your head into the pillow and flexion by beginning to raise the head off the bed. Finally, if you are not yet asleep screw up the face and then relax these muscles as well. With practice this whole exercise will take about five minutes.

While doing it breath easily and evenly, but don’t concentrate too hard on this – nor too hard on the stretches – it will defeat the whole object of the exercise!


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