Medical Edge Newspaper Column

Insomnia Can Be A Primary Condition Or Just A Symptom

Oct. 1, 2006
DEAR MAYO CLINIC:
I am 80 years old and have trouble sleeping. I generally sleep two to five hours at night or, a lot of nights, not at all. I have had two stents put into my coronary arteries and am concerned that lost sleep will cause another heart problem. I'm also getting so forgetful. I tell my doctor that I can't sleep but get no help. Can you help me? -- Fort Wayne, Ind.

ANSWER:
You need to consult a doctor who is well trained in diagnosing and treating sleep disorders. And it's likely that the first thing the physician will do is explore whether your problem is primary insomnia or secondary insomnia. In primary, the sleep problem is not caused by any discernible health condition; in secondary, sleeplessness results from something else -- an underlying physical problem or a particular medication. It makes sense to begin by looking into the possibility of secondary insomnia. Dealing with an underlying cause, if one is present, is a much more efficient strategy than just treating the symptom of sleeplessness.

Given that most of the time you are getting some sleep, it seems that one problem is having your sleep disrupted by some factor, leading you to wake prematurely. The problem could be as simple as urinary urgency, a common condition of aging. A possible culprit in your case is obstructive sleep apnea -- breathing that stops and starts during sleep, causing restlessness. This problem is quite common in older people, not necessarily because of aging per se but from factors that often accompany aging -- excess weight, high blood pressure and use of some medications.

If sleep apnea is the cause of your sleep problem, the first-line treatment is a continuous positive airway pressure, or CPAP, machine, which delivers just enough air pressure through a mask to keep your upper airway passages open. Other options include an oral appliance to keep your throat open or surgery to remove excess tissue from your throat. But it's best to try simpler and more conservative options first. Losing excess weight, sleeping on your side or abdomen rather than on your back, keeping your nasal passages open at night (with the use of a saline nasal spray), and avoiding tranquilizers and sleeping pills are worthwhile to try. However, CPAP is generally viewed as the most effective treatment. Your physician can help decide what's best for you.

Please note that while tranquilizers and sleeping pills may be used for treating primary insomnia, certain ones actually make secondary insomnia worse.

Also be aware that if sleep apnea is the culprit in your case, failure to deal with it could worsen a heart condition, as sudden drops in blood-oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system.

Other causes of secondary insomnia could include restless leg syndrome, stress or anxiety, but such factors are less likely to be critical in your situation because they would prevent you from falling asleep in the first place. Your problem seems to be one of interrupted sleep.

Sleeping pills can be used to treat primary insomnia, though they have been used with caution in the past because they were habit-forming and lost effectiveness over time. As such, sleeping pills were meant only as transitional therapy. Newer medications, such as eszopiclone (Lunesta) and zolpidem (Ambien), do not appear to share these properties. Nevertheless, they should be taken only as long as needed.

The best way to deal with insomnia, whether primary or secondary, is to adopt practices such as exercising and staying active; finding ways to relax; avoiding or limiting caffeine, alcohol and nicotine; sticking to a bedtime/wake-time schedule that works for you; avoiding or limiting naps; hiding the bedroom clocks; and not trying to sleep when sleep does not come. In the latter case, it's best to get up and do something else, such as read or watch TV, until you are drowsy.

-- Lois E. Krahn, M.D., Psychiatry & Psychology, Mayo Clinic, Scottsdale, Ariz.