Difficulty sleeping is an common concern we hear about in primary care. Many of us will have trouble sleeping on occasion, but when that is a persistent pattern causing distress or functional impairment, we call it insomnia. Insomnia can mean difficulty falling asleep, difficulty maintaining sleep, or waking early unable to fall back asleep.
First and foremost, is the difficulty sleeping causing problems? If it is not resulting in problems with daily functioning, we may need to manage expectations around sleep. Not every person needs 8 hours per night, and if your imperfect sleep is perfectly tolerable, it is probably best to leave it alone. As we age, we need less hours of nighttime sleep; again, as long as you feel well during the day, that is just fine.
For those whose poor sleep is resulting in intolerable drowsiness or difficulty functioning at work or home, I have more questions. Is an acute illness or stressor contributing? Might there be another sleep disorder like sleep apnea or restless leg syndrome? Is pain, an urge to urinate, or some other physical symptom causing your awakenings? Is there underlying depression, anxiety, or other mental health concerns? Are you taking any medications or substances that might cause sleep disruption? Addressing any of these may significantly improve sleep. Alcohol is a common culprit; often assumed to help people fall asleep, alcohol actually yields poor quality rest.
Most patients with insomnia can be helped with behavior changes alone, or “sleep hygiene.” There are a few basic tenets, some more intuitive than others. First, optimize the sleep environment; ideally this means a dark, cool, quiet bedroom. Second, a consistent bedtime and wake time are very important, even on the weekends. This is particularly difficult for our patients who have jobs requiring rotating shifts. Next, find a bedtime routine which helps your brain wind down; think less screen time, and more reading, meditating, or listening to calming music.
Finally, and less intuitive to most, if you do find yourself lying in bed for 20 minutes without falling asleep, get out of bed, try a calming routine over again, then get back into bed. More time spent not sleeping in your bed is more time your brain spends learning the bed is a place to be awake. Furthermore, it fuels anxiousness when we lie awake yearning for sleep, so it is best to break that cycle.
I see a lot of people tracking sleep with their smartwatch or other wearable device, and my advice is to be aware of potential pitfalls. We don’t have good evidence that the information all devices provide on sleep is accurate, and for most people tracking those statistics actually tends to increase anxiety around sleep which may worsen the problem.
Have you followed all the above advice but still suffer from insomnia? The gold standard treatment is cognitive behavioral therapy for insomnia (CBT-I) provided by a mental health professional. Beyond that we do have pharmacologic options, but medications for sleep can be fraught with potential problems, especially for our patients over age 65. Even some over-the-counter sleep medications can have significant risks in older patients, so please use caution and talk you your primary care provider.
Dr. Kelly Evans Hullinger practices internal medicine at Avera Medical Group in Brookings, SD. She serves as one of the Prairie Doc Volunteer Hosts during its 24th Season providing Health Education Based on Science, Built on Trust. Follow The Prairie Doc® at www.prairiedoc.org facebook, youtube, Instagram and Tik Tok. Prairie Doc Programming includes On Call with the Prairie Doc®, a medical Q&A show (most
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