Friday, January 26, 2007

I can’t sleep at night. Should I take a pill?

Q: I have bouts of insomnia and occasionally I need a sleep aid. I’ve seen ads for several and it’s quite confusing. What are the differences?

A: You’re in good company: an estimated 40 percent of us are sleep deprived.

For most of us, a good night’s sleep means eight hours, though some do well with six and others need as many as ten. In order to feel refreshed when you wake, you need to have the right kind of sleep: REM (rapid eye movement) sleep — or dream sleep — and non-REM sleep, which actually consists of four different stages. But you don’t need to get a PhD in sleep physiology just to get a good night’s sleep!

Common sleep-depriving culprits include:
  • Caffeine (which has a half life of 7.5 hours, meaning even your afternoon coffee can disrupt your sleep at night)
  • Alcohol (a glass of wine with dinner may cause drowsiness in the short-term, but can later cause nighttime wakefulness)
  • Cigarettes (which act as a stimulant)
  • Sleep apnea, a condition in which repeated pauses in breathing are followed by gasps and often snoring. (In fact, one in four women over 65 are awakening whether they know it or not because of a disruption of oxygen and carbon dioxide levels in the brain.)
  • Restless leg syndrome, in which your legs tickle, ache and jerk while sleeping
  • Diseases (arthritis, lung disease and anything causing pain)
  • Medications (asthma medications containing stimulants, some anti-depression medications, drugs that treat attention deficit disorder)
  • Hot flashes in menopausal women.
If you think any of these conditions apply to you, discuss them with doctor.

Before I discuss sleeping pills, let’s first consider some non-medication ways to improve sleep:

  • Try getting more exercise. Brisk walking and low-impact aerobics have been shown to help adults over 50 sleep longer and fall asleep faster. (Just don’t exercise directly before bedtime.)
  • Keep a regular schedule. Try to sleep and wake at pretty much the same time every day.
  • You should also make sure your bedroom is as dark as possible; light affects melatonin secretion, which directs your brain when to sleep. In addition, use your bed for only two things: sleep and sex. Go elsewhere to read and relax; this will help you in associating beds with sleep.
  • When you get into bed, try to create a quiet, secure sleep environment where your bedroom and bed are not places to obsess over daytime issues. Focus instead on whatever calms you, be it ocean waves, black velvet, green forests or sleeping lambs.
Now let’s get to sleeping pills, which fall into two categories — short-acting and long-acting — and work on different receptors in the brain.

Short-acting sleeping pills
Short-acting medications include Sonata (zaleplon), Ambien (zolpidem) and Lunesta (eszopiclone). These don’t suppress deep sleep or REM sleep and so have minimal effects on next-day activities and seem not to be addictive.

There are some reports of withdrawal symptoms from Ambien, such as anxiety, tremors, agitation and rebound insomnia. However, if you do a meta-analysis (in other words, look at a bunch of studies), most of these side effects were minimal or absent except for some mild rebound insomnia.

When I prescribe a sleeping pill, I try to assess whether the patient has a problem falling asleep or instead falls asleep easily but awakes before she should and loses the last few hours of her night’s sleep. If she just needs to “catch” those two or three hours, I’ll prescribe the shortest acting pill, Sonata. It peaks in blood levels after one hour and its half life (when half of its active component is out of circulation) is an hour. Next up in duration of effect is Ambien, which peaks in 1.6 hours and has a half life of 2.6 hours. According to studies given to the FDA, the longest acting “short-acting” pill is Lunesta, which peaks in one hour and has a half life of six hours.