[MOL] Sleep without sedation.... [01330] Medicine On Line

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[MOL] Sleep without sedation....

Health Focus: Sleep Without Sedation


New medications relieve insomnia without the hangover.

Most people with occasional insomnia just shrug it off and try to catch up the next night. But for those with persistent insomnia, the fatigue — and frustration — can be debilitating. Even so, many people are reluctant to take sleeping pills, for good reason: Some of the older pills left them feeling groggy and hung over the next day.

In recent years, there have been major advances in prescription sleep aids. The new generation of hypnotics includes zolpidem, approved by the Food and Drug Administration in 1993 and sold as Ambien. In 1999, the FDA approved zaleplon (Sonata).

"Both drugs are metabolized quickly by the body, affording the advantage of relatively short duration of action," explains David N. Neubauer, M.D., assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and associate director of the Sleep Disorders Center. "The two drugs usually help people fall asleep and stay asleep for a few hours, but the sedation wears off by the time they get up for the day." Of the two, zolpidem lasts somewhat longer, which helps people sleep for a longer stretch. On the other hand, zaleplon's shorter duration means it can be taken even later at night without residual sedation in the morning.

These short-acting sleep aids can be used in ways that earlier drugs could not. For example, a shift worker can take zaleplon in the afternoon, sleep for a few hours, and then report to work feeling refreshed and alert.

"Although those new developments are welcome," says Dr. Neubauer, "it's important to realize that various behavior changes and treatment approaches may be important in solving the insomnia problem."

Breaking The Sleepless Cycle

According to a poll conducted by the National Sleep Foundation, 56 percent of American adults experience insomnia at least twice a week. Chronic insomnia can lead to memory and concentration problems. Insomniacs are four times as likely to suffer from depression. Some research suggests they may have a higher risk of cardiovascular disease, as well.

Unfortunately, people suffering from insomnia usually do not see a doctor for help. That's a mistake, says Dr. Neubauer, because insomnia is treatable. Often, it's a symptom related to psychiatric or other medical problems. Major depression and painful arthritis are good examples. Anyone who feels unable to sleep adequately should see a doctor to rule out an underlying cause.

"Insomnia has a way of escalating," Dr. Neubauer says. "People naturally tend to get angry and frustrated when they can't sleep. Those emotions make it harder to relax on subsequent nights. After a while, just climbing into bed can cause a state of hyperarousal. That's when insomnia starts taking on a life of its own. For some people, it helps to spend more time out of bed, rather than remain there in a frustrated state waiting for sleep to arrive."

Sleeping pills are usually prescribed for short-term use - to help people sleep during particularly stressful times, for example. They may also help break the cycle of chronic insomnia. Once people discover they can sleep with the help of a medication, they tend to relax a bit, which also helps them sleep normally again even without the drug.

Most hypnotics used over the past few decades belong to a chemical family called benzodiazepines. These compounds are usually effective, but according to Dr. Neubauer, they have disadvantages. Several benzodiazepines have a very long duration of action and can cause daytime sleepiness. There are also concerns about abuse or withdrawal symptoms.

Although chemically different from benzodiazepines, the newer hypnotics, zolpidem and zaleplon, act primarily at the site of a benzodiazepine receptor in the brain. That apparently affords them some of the advantages of the traditional benzodiazepines, without some of the drawbacks.

Restoring Natural Sleep

Sleeping medications alone are usually not the ultimate solution for persistent insomnia. Rather, says Dr. Neubauer, underlying problems need to be identified and addressed. Simple changes in lifestyle and sleep habits can bring about major improvements in sleep:

  • Stay on schedule. Go to bed and get up around the same time every day. The body's natural sleep-wake patterns, called circadian rhythms, can be disrupted by abrupt schedule swings. Maintaining a regular bedtime schedule helps train the body to sleep at the desired time.

  • Sleep when you're sleepy. Go to bed when you're tired, but if you find you can't sleep, get out of bed. Go into another room and watch television or read a book. When you're truly sleepy, go back to bed.

  • Choose the right soundtrack. Use a fan or a white-noise generator in the bedroom to create a soothing sound and help mask other noises.

  • Cut back on caffeine and alcohol. Don't drink anything caffeinated after lunchtime. Avoid alcohol late in the evening, or give it up entirely for a while. Even though alcohol acts as a sedative, it disrupts normal sleep patterns and causes awakenings later during the night.

  • See the light. Properly timed light exposure can shift the body's sleep-wake cycle. People who wake up earlier than they'd like should minimize morning light with heavy curtains or comfortable eyeshades and maximize their exposure to bright light in the evening before bedtime. People who have trouble falling asleep at bedtime and then tend to oversleep in the morning can shift their rhythms earlier with the reverse strategy.

  • Try warm milk at bedtime. This old advice does seem to help some people. The effect may be strictly psychological — but so what, if it works? There may also be a physiological explanation: The warm beverage may temporarily increase the core body temperature, and the subsequent temperature drop may hasten sleep.

  • Check your medications. Many medications can cause insomnia, so ask your doctor or pharmacist about all the drugs you take. For example, the decongestants that many people take at bedtime can have a stimulating effect.

  • Don't self-medicate. There's little evidence that supplements and other over-the-counter "sleep aids" are effective. In some cases, there are safety concerns. Antihistamine sleep aids, in particular, have a long duration of action and can cause daytime drowsiness.

The important message is that people shouldn't suffer with insomnia without trying to get help for the problem. The quality of daytime life suffers as a result of nighttime sleep disturbance. Sometimes sleep will improve if associated disorders are treated. Lifestyle changes are almost always important, and in certain circumstances, hypnotic medications can be very helpful.