Overview

While the rest of the world is sleeping, some people remain wide-awake due to insomnia. It’s the most common sleep-related problem, with about one-third of adults experiencing insomnia symptoms at any given time. Up to 10 percent have insomnia severe enough that it’s considered a full-fledged disorder.

Experts have different definitions of insomnia, says Johns Hopkins sleep expert Rachel Salas, M.D. But insomnia is generally characterized by trouble falling asleep or staying asleep, resulting in a lack of sleep that causes distress or difficulty with daily activities. If it happens at least three nights a week and lasts for at least one month, you may have what sleep experts call persistent insomnia disorder.

The condition compromises more than your energy levels, so it’s worth recognizing the symptoms and getting help from your health care team. Not getting enough high-quality sleep can increase your risk of depression, weight gain and obesity, type 2 diabetes, high blood pressure, heart disease, and memory and concentration problems. It can even make you look older.

Prevention

To help ensure that you can fall asleep when you want to—and stay asleep for the quality rest you need—make sleep a priority in your life.

Set aside time for sleep. Keep your cycle of sleeping and wakefulness steady throughout the week, including the weekends, recommends Salas. While most people need 7 to 9 hours of sleep at night, keeping a consistent cycle may be even more important than quantity, she says. Set a bedtime and a wake-up time for yourself, and stick to it.

Get your brain ready for sleep. You can’t make your brain fall asleep on command as if you were stepping on the brakes to stop your car, says Salas. Instead, your brain needs help shifting to sleep. Be sure to follow these recommendations:

• Establish a presleep ritual before bed. For example, taking a shower and putting on sleepwear might signal your brain that you’re heading to bed.
• In the evenings, avoid activities that can keep you awake, like drinking coffee, soda, or other caffeinated drinks; smoking; exercising; and eating heavy meals.
• Give your brain time to unwind. If you need to pay bills or settle an argument, do it during the day, not at bedtime.
• Avoid light in the late evening. Shut off your electronic devices at least 30 minutes before bedtime. Light keeps your brain primed for wakefulness.

Keep sleep problems from growing worse. Often when people start to have trouble sleeping, the steps they take to cope with their insomnia actually make the problem hang around longer, says Salas. If you have sleepless nights, avoid:

• Napping during the day. Too much daytime sleep makes you less inclined to fall asleep at bedtime.
• Drinking alcohol before bed. It may help you fall asleep at first, but it can keep you from sleeping well later in the night.
• Worrying about your sleep loss. Dwelling on your inability to fall asleep can make it worse. 

Diagnosis & Treatment

Diagnosis

If your insomnia is severe or chronic enough that it’s affecting your quality of life, it’s time to call a doctor. Your primary care provider may be able to treat your problem. However, a sleep-medicine specialist can likely dig deeper into the causes of your insomnia and offer more ways to resolve it.

“Many times my patients will come in with a report of poor sleep, but there are really several undiagnosed sleep disorders underlying that we can treat for them,” Salas says.

Your health care provider should talk to you about your sleep patterns. Be ready to discuss these issues (and perhaps track them in a sleep diary):

• What time you go to bed and when you get up
• How long it takes you to fall asleep
• How deeply you think you sleep
• How much of your time in bed you actually spend asleep (as opposed to getting up to use the bathroom or staring at the clock)

Your health care provider should ask about your daytime activities too:

• Do you smoke or drink coffee? How often do you exercise? Do you take naps?
• What’s going on in your bedroom besides sleeping? Your doctor may ask if you watch TV or run a small business from this room. If your spouse keeps irregular hours, or your dog sleeps—and barks—in your bedroom, mention it.
• Is your life peaceful right now, or are you worried about your job, a family conflict or another stressful issue?

Your discussion should also cover your mental and physical health:

• Do you have symptoms of depression, anxiety or bipolar disorder? Have you ever been diagnosed with an emotional or mental health problem?
• Do you have health issues that cause pain or discomfort, like headaches, heartburn, asthma or fibromyalgia?
• Could you have another sleeping problem, like apnea or restless legs syndrome?
• What medications are you taking? 

Treatment

“A lot of people with insomnia are struggling through life, not realizing there is help available,” Salas says. Health care providers can offer many solutions to relieve insomnia. But you’ll have to help them do some detective work to discover why you aren’t sleeping well. You may also need to change the way you think about sleep, Salas says. Here’s how.

Change your approach to sleep. Your health care provider may suggest that you work with a psychologist who specializes in sleep problems, Salas says. That’s because the way you think about your insomnia can make it worse. If you spend too much time in bed worried that you can’t doze off, or you’re lying awake frustrated that you keep waking up, you’re going to start seeing your bed as a stressful place, which feeds the cycle.

A sleep psychologist, working with your sleep doctor, may recommend these approaches:

• Relaxation techniques before bedtime, such as deep breathing.
• Identifying your sleep-related worries and learning to set them aside.
• Encouraging yourself to sleep while you’re in bed. You may need to get out of bed at a set time no matter how poorly you slept, go to bed at a set time even if you’re sleepy earlier in the evening, and avoid daytime naps. In addition, you may need to get out of bed and go to another room if you can’t fall asleep shortly after going to bed. This gets you out of the habit of lying in bed awake.
• Giving your brain extra help with getting on the right sleep cycle.Exposing yourself to bright light during the day, keeping the lights dim during the evening, and taking the sleep hormone melatonin may be useful, Salas says.

Use medications wisely. “I think patients today are less interested in using medications to aid sleep than in the past,” Salas says. But if you want to pursue a medication to help you sleep, keep these tips in mind:

• Even if you’re taking a medication, it’s still best to work with your doctor to make other lifestyle changes that will help you sleep better.
• Most over-the-counter sleep aids contain antihistamines. One effect of these is drowsiness. They’re not a good choice for long-term use, as they can cause dizziness, memory problems, and daytime sleepiness.
• A number of prescription sleep medications are available. They can have side effects, such as headaches and daytime sleepiness. They may also raise the risk of falls at night, especially in older people. In addition, some sleep aids, particularly older ones, can result in dependence. In general, these are intended for short-term use, not months or years. 

Learn more about the symptoms, diagnosis and treatment of insomnia in the Health Library.

Living With...

If you’ve been having trouble sleeping for a few weeks due to stress in your life, it’s likely to resolve once you get past the troubling event.

However, if you have a stubborn case of insomnia that’s been going on for years, you’ll need to put effort and commitment into resolving it, Salas says. A sleep expert can help you learn the causes of your insomnia and recommend a plan to treat it. “But you still may need months to get to a better place,” she says. “The good news is that the research shows you can get past insomnia with the help of your health care providers.”

Remember that insomnia can raise your risk of accidents, including car accidents. If you aren’t sleeping well, use care when driving or operating machinery. Since drugs for insomnia can also lead to daytime sleepiness, follow any warnings about engaging in these activities when taking them. 

Research

Johns Hopkins experts continue their work in understanding and treating sleep disorders in ways that can translate into better health today. Notable research you can access includes these findings:

Calm legs don’t stop restless sleep. Restless legs syndrome can persist even when the nighttime urge to move the legs is treated successfully with medication. In a 2013 study, Salas’s colleague Richard Allen, Ph.D., found that elevated levels of glutamate—a brain chemical involved in arousal—may play a role.

Insomnia is not simply a nighttime condition. Salas and her team found differences in the part of the brain that controls movement (the motor cortex) in those with chronic insomnia compared to a group of good sleepers. They also found more “excitability” among neurons in the same region of the brain among those with chronic insomnia, adding evidence to the notion that insomniacs are in a constant state of heightened information processing that may interfere with sleep. 

For Caregivers

If you’re providing caregiving, you’ll need to watch out for sleep issues in both your loved one and yourself, says Salas. While sleep issues may increase as your loved one ages or experiences changes in health, you may also be at a higher risk of sleep problems due to stress or odd hours. Caring for people with dementia may be especially challenging, since they often sleep poorly and may wander or make noise at night. Along with discussing any sleep concerns (about yourself or your loved one) with a health care provider, take these healthy steps.

Listen for your loved one. Sleep apnea is more common in older age. People with sleep apnea frequently stop breathing while they sleep, which causes them to wake up for a short time. This can happen many times at night, but the person with apnea may not remember it. If you hear symptoms of apnea, such as loud snoring and gasping, be sure to bring it to a doctor’s attention.

Moderate naps. It’s best for you and your loved one to get all 8 hours of sleep at one time. But if either of you must take a nap, set an alarm so no one sleeps more than 20 to 30 minutes.

Try a day program. Some research suggests that people with dementia who attend adult day centers have fewer behavioral problems and sleep better on the days they attend. Caregivers may experience less stress on those days as well, so the whole household sleeps better.

Reset rhythms. Is a loved one falling asleep too early and then unable to sleep through the night? Some older adults may actually benefit from a little bright light exposure in the evening—look for full-spectrum bulbs, which mimic natural daylight. Speak with a sleep specialist to initiate a plan using light, since exposure at the wrong times can worsen things.

Soothe into sleep. If your loved one has Alzheimer’s disease or another type of dementia, these steps can help:

• Keep a consistent schedule in terms of bedtime, wake-up time and meals.
• Encourage the person to be physically active during the day (but to avoid exercise in the evening).
• Help your loved one avoid caffeine, nicotine and alcohol.
• Remind your loved one to use the restroom before bed.
• Provide some very low lighting in the evening—darkness can be upsetting to people with dementia.
• Speak in a calm, soothing tone if your loved one wakes up at night. 

Definitions

Dementia (di-men-sha): A loss of brain function that can be caused by a variety of disorders affecting the brain. Symptoms include forgetfulness, impaired thinking and judgment, personality changes, agitation and loss of emotional control. Alzheimer’s disease, Huntington’s disease and inadequate blood flow to the brain can all cause dementia. Most types of dementia are irreversible.

Restless legs syndrome (RLS): A disorder that creates a strong urge to move your legs often because you notice strange or unpleasant sensations: creeping, crawling, pulling, itching, tingling, burning, aching and even electric shocks. When you move your legs, it relieves the strange sensations. The unpleasant feelings are strongest when you are resting or inactive, and they can make it difficult to fall or stay asleep.

Sleep apnea (ap-ne-ah): A disorder in which your breathing repeatedly stops or becomes very shallow as you sleep. Your breathing may pause anywhere from a few seconds to a few minutes. This ongoing condition disrupts your sleep, making you tired during the day and increasing your risk for heart problems, diabetes, obesity and driving or work-related accidents.