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    Insomnia

    Introduction
    Causes and Risk Factors
    Symptoms
    Diagnosis
    Treatment
    Where to Seek Treatment
    Singapore General Hospital
    Contributed by Sleep Disorders Unit

    Introduction

    Insomnia is one of the most common sleep problems in the general population. In Asia, a survey of the South Korean population found that 17% had at least three nights of insomnia each week. Another study in Hong Kong found 11.9% with insomnia.

    Causes and Risk Factors

    There are many causes of insomnia and it can be due to a single factor or combination of factors. Women, older people and worriers are at higher risk of having insomnia.

    Jetlag, shift work or a noisy sleeping environment are common reasons for insomnia.

    Life stressors such as difficulties at work or the death of loved ones can also cause insomnia.

    Unhealthy sleeping practices termed as ’poor sleep hygiene’ can also result in insomnia. Some examples include drinking caffeinated drinks in the evening. Some people may also take frequent naps during the weekends leading to insomnia on Sunday nights.

    Insomnia can be a hint of a more serious underlying psychiatric condition such as depression or an anxiety disorder.

    Long-term misuse of medications like sleeping pills or alcohol can also result in insomnia.

    Health problems like physical illnesses can also cause insomnia. These conditions can be those that result in pain (like chronic back pain) or frequent urination (like enlarged prostate gland in older men). Sometimes, no specific causes can be pinpointed. These are termed as ’Primary Insomnia’.

    Symptoms

    You may have difficulty falling asleep, frequent awakenings in the middle of the night or waking up in the wee hours of the morning. You may also experience non-restorative sleep i.e. feeling unrefreshed in the morning.

    This can, in turn, lead to feelings of irritability, tiredness and poor concentration. As a result, productivity at work may dip. You may feel less fulfilled and get less satisfaction from hobbies and relationships.

    Diagnosis

    The doctor will take a full sleep history from you and your sleeping partner, if any. This may be followed by a physical examination. Laboratory tests including blood tests may also be ordered.

    In a specialist clinic dealing with sleep disorders, the doctor may want to admit you to observe the sleep to see if specific medical conditions (e.g. obstructive sleep apnoea where there are abnormal pauses in breathing during sleep) are suspected. This is known as a sleep study.

    In the sleep history, the doctor may ask for information on the following:

    1. Duration: Whether the insomnia has persisted for days, weeks or months
    2. Frequency: How many days in the week it occurs
    3. Type: Whether you have difficulty falling asleep, maintaining sleep or experience early awakening
    4. Environmental factors such as noise level, whether the surroundings are uncomfortable or if you work shifts
    5. Evidence of poor sleeping habits such as frequent naps, lying in bed throughout the day or drinking caffeinated drinks at night

    Treatment

    The doctor will deal with the underlying causes that are working together to cause the insomnia.

    Behavioural Methods

    The doctor may also employ behavioural methods to improve sleep. However, these methods require time and effort to see results. These methods include:

    1. Good sleep hygiene
    2. Relaxation techniques (e.g. deepbreathing exercises)
    3. Hypnosis
    4. Learning how to cope with stress
    5. Engaging a trained therapist for Cognitive Behavioural Therapy

    Medication

    There are many different medications for insomnia. These range from milder ones like antihistamines (more commonly used for the common cold or itch) to stronger medications that can also be used for anxiety and depression. Lastly, there are medications that are used purely for sleep and some of these can be very addictive. Therefore, this last category of medication is usually used only for short periods.

    While medications can offer rapid relief, they confer only short-term benefits. Many of them also have side effects. Some sleeping pills are highly addictive. In elderly patients, the drowsiness from the sleeping pills can lead to a higher risk of falls. This, in turn, leads to a higher risk of hip fractures that have devastating consequences for older people. The doctor will advise you carefully before starting you on these medications.

    Sleep Hygiene Advice

    Don't surft the internet in bed

    Good sleep hygiene is a behavioural method that can be used to improve sleep. The sleep hygiene advice listed below can be easily practiced at home. However, you may need to keep to them for many days or even weeks before any improvement can be seen. They are:

    1. Keep to the same sleeping and waking time, even during weekends
    2. Exercise regularly but not three to four hours before bedtime
    3. Avoid taking naps
    4. Avoid activities like reading or surfing the internet in bed
    5. Avoid caffeinated drinks like coffee, tea or colas
    6. Avoid heavy meals, alcohol or smoking before sleep
    7. Have a conducive sleep environment that is cool and quiet

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