The Facts

Insomnia or trouble sleeping is very common – about 30% to 40% of adults will experience insomnia in any given year. Insomnia is a symptom and is not a medical condition in itself. Rather, it's your body's way of telling you that something is not working right.

There are different types of insomnia. Some people have trouble falling asleep, while others have trouble staying asleep or waking up too early. Also, sleep problems can be short-term, lasting a few days or weeks, or chronic, lasting for several months or more.

Insomnia is only considered a problem if it interferes with your life - if you wake feeling unrefreshed or find yourself dozing during the day. It is normal to sleep less as you age. If you're sleeping less than you did when you were younger but don't feel tired during the day, you should not worry.

Typical daily sleep requirements at different ages:

Age Hours of sleep needed
newborn13 to 17
2 years 9 to 13
10 years10 to 11
16 to 65 years 6 to 9
over 65 years6 to 8

The sleep of older people, as well as being shorter, is less deep. Only about 25% of the sleep of someone over 65 years is rapid eye movement (REM) sleep or stage IV (very deep) sleep, compared to over 50% in a young child. This probably means that older people dream less, since dreaming usually occurs during REM sleep.

As people get older, some get by with amazingly little sleep. Margaret Thatcher claimed to average 4 or fewer hours a night throughout her tenure as Prime Minister of Britain. Nevertheless, many people complain that a lack of sleep affects their daytime performance. At any given time, about 10% of the population consider themselves to have chronic insomnia. About half of us will suffer from insomnia at some point in our lives.


Insomnia usually has an underlying cause. Common causes of insomnia include:

  • air travel, especially when travelling from west to east (jet lag)
  • anxiety or depression
  • medical conditions such as gastroesophageal reflux, prostate enlargement, Parkinson's disease, Alzheimer's disease, and stroke
  • medications such as decongestants, stimulants (e.g., methylphenidate*) and some antidepressants
  • nicotine, caffeine, and alcohol
  • not being active enough during the day
  • pain from arthritis or other medical conditions
  • poor sleep habits
  • shift work
  • sleep problems such as sleep apnea
  • stress caused by work, family life, death or illness of a family member or friend, or financial difficulties

Symptoms and Complications

Symptoms of insomnia can include:

  • trouble falling asleep
  • trouble staying asleep
  • waking up too early in the morning and being unable to get back to sleep
  • not feeling rested or refreshed when you wake up despite getting enough hours of sleep
  • feeling tired and sleepy during the day
  • feeling irritable or anxious
  • headaches
  • difficulty focusing or concentrating during the day

Staying up for several days in a row can produce symptoms like hallucinations, but few people with insomnia reach that stage. Normally, insomnia isn't associated with serious complications. Sleep apnea or heavy snoring, however, is not good for long-term health. If you think you may be having breathing problems at night, you should see a doctor. These problems are most common in men, especially those who are middle-aged or overweight.

Complications of insomnia can include poor job and school performance and a higher risk of car accidents.

Making the Diagnosis

Since insomnia is a symptom, your doctor will want to determine what is causing it. To do this, your doctor will want to know what your sleep pattern is and how tightly you stick to the same schedule. Your doctor may ask you to keep a sleep diary for a week to get more information about your sleep pattern. You'll also be asked about any medications you may be taking (including herbal products and non-prescription medications), as well as nicotine use and your intake of coffee and alcohol. Your doctor will also ask you if you have any stresses in your life that might be affecting your sleep.

A general medical examination and history may provide clues about other conditions, such as depression, anxiety, or arthritis, which may be contributing to or causing insomnia. In addition, blood tests might be ordered to check for underlying medical conditions.

Your doctor may refer you to a specialized sleep disorder clinic that offers diagnostic tests for insomnia such as overnight polysomnography. In this test, you sleep the night at the clinic, wired to electrodes that measure the various stages of sleep from light (stage I) to deep sleep (stage IV) as well as REM ("dream") sleep. The polysomnograph can also detect sleep apnea.

Treatment and Prevention

A treatment plan for insomnia can include treating an underlying medical problem, learning about and practicing good sleep hygiene, learning about and making behaviour changes, and taking sleep medications. If insomnia is caused by an underlying medical condition such as arthritis or depression, the condition should be treated first, as this will likely alleviate the insomnia.

Sleep hygiene includes basic things you can do to increase your chances of having a good night's sleep. Changing certain behaviours can also help improve sleep. As part of a treatment plan, your doctor might recommend any of the following sleep hygiene or behaviour changes:

  • Develop a regular bedtime routine.
  • Don't use the bedroom for daytime activities – just for intimacy and sleep.
  • Don't consume coffee or chocolate before going to bed.
  • Don't go to bed thinking about work or other stressful matters – read a book for a while if this helps reduce stress.
  • Learn to replace worrying thoughts about sleep with more positive ones.
  • If you have a back disorder, try lying on your back with a pillow under your knees.
  • Keep the bedroom dark, quiet, and not too warm – white noise devices can help drown out traffic sounds or a partner's snoring.
  • Drink warm milk or have a warm bath before bed.
  • Minimize the use of medications that may affect your sleep, such as diuretics and appetite suppressants – if you must take them, don't take them before going to bed.
  • Exercise during the day – if exercising before bed keeps you up, then exercise earlier.
  • Try to cut down on smoking and alcohol, especially in the evening.
  • Avoid watching the clock – just set the alarm and turn the clock around so you can't see the time.
  • Use relaxation techniques

Your doctor may also prescribe a sleep medication, especially if your insomnia is caused by acute stress (e.g., loss of a loved one), or if non-medication approaches haven't helped. These medications can help in the short term (e.g., for a few weeks), but they are not a cure and may even worsen insomnia if used for long periods of time. This happens when sleeping medications are stopped and the insomnia comes back even worse than before.

Benzodiazepines (e.g., flurazepam*, nitrazepam, temazepam, triazolam, lorazepam, diazepam) are commonly used medications for insomnia. There are several benzodiazepines that can be used, although some have been studied more than others. Your doctor will consider your age, other medical conditions, and side effects of the benzodiazepine when selecting the one that is best for you. Some people can become physically dependent on benzodiazepines and experience withdrawal symptoms when they stop using them.

Many sleep medicines can also lead to tolerance (a reduced effect over time). For this reason, doctors don't like to prescribe them for long periods (more than 21 consecutive days) unless other treatments fail or it is clear that tolerance is not developing. Other medications used to treat insomnia include zopiclone and zolpidem, which are not benzodiazepines.

If you are prescribed a medication to help with sleep, it's important to continue to use non-medication approaches as well.

If odd working hours disturb your sleep rhythm, the best way to get back on track is to expose yourself to bright light in the morning. The evidence shows that this resets the body clock more effectively than the much-hyped hormonal medication melatonin. Natural light causes the brain to produce melatonin anyway. Melatonin supplementation hasn't been adequately researched and may have adverse effects that we are unaware of at this time.

L-tryptophan is another supplement that may be helpful for insomnia, but its effects are not as predictable as those of other medications.

Non-prescription medications that contain diphenhydramine are available. If you find that you have sleep problems, it is best to see your doctor for a proper assessment.

