The Functions of Sleep

We really know very little about sleep and its function. It may be related to various anatomical structures in the brain and to certain chemical changes. It produces electrical charges in the brain, eyes and muscles. These can be measured by electrical tracings of muscles (electromyography, EMG), eye movements (electro-oculograph, EOG) and brain waves (electroencephalograph, ECG). From these tests two main kinds of ‘normal sleep’ activity have been defined: a stage of non-rapid eye movements (NREM sleep) which is followed by a stage of rapid eye movements (REM sleep). NREM sleep is called orthodox sleep and is the stage when we ‘think’; REM sleep is called paradoxical sleep and is the stage when we ‘dream’. It seems that both stages of sleep are essential for health.

Sleep Requirements

Sleep requirements vary from person to person and so ‘normal’ sleep is what suits you under ordinary everyday circumstances. The amount of sleep you need is as much a part of you as your appetite or your conscience. If your sleep is disturbed for only a night or two, this is usually of no consequence; but if the disturbance persists for two or more weeks then you have a sleep problem and need to take action.

Insomnia really means sleeplessness but nowadays it is used to describe most sleeping difficulties. These include difficulty in getting off to sleep, inability to stay asleep, frequent wakenings, restless sleep – often with nightmares, early morning wakening and sleep which is not refreshing (you wake up and feel as exhausted as you did when you went to bed).

Causes of Poor Sleep

There are many causes of sleep disturbance – these may be social, physical or mental. Among social causes are changes in your environment such as a strange bed or bedroom, changes in temperature, noise, motion and changes of routine like going on night work. Pain from any cause, irritation of the skin, discomfort from indigestion and muscle cramps are some of the physical causes of disturbed sleep. Cat-napping in the day is often a cause of insomnia in elderly people. Emotional disorders (e.g. anxiety, tension, depression) are a common cause of persistent insomnia. However, remember that social, physical and mental factors are all interrelated. Problems at work may produce anxiety which may produce insomnia. Persistent noise at night may interfere with sleep which may cause you to worry about lack of sleep, which then may produce tension and irritability resulting in further difficulty in sleeping. The death of a close friend or relative, the loss of a job, failure at work or in an examination may trigger psychological symptoms, a prominent one of which may be disturbed sleep.

Insomnia must always be regarded as a symptom of some underlying disorder. This is of particular importance in psychological disorders, especially in people who feel anxious, tense or miserable. In such individuals insomnia will be just one of a group of mental or physical symptoms that they may experience.

Many Drugs can Cause Insomnia

Drug misuse is a common cause of insomnia. For example, caffeine in tea, coffee, cocoa and colas may keep you awake, particularly as you get older. Regular alcohol drinkers may find themselves waking early and people who take heroin or morphine may find their sleep impaired. Amphetamines, most slimming medicines and some antidepressant medicines may keep you awake. So may some medicines used in decongestant cough and cold remedies.

Prescribing of Sleeping Tablets

The widespread use of sleeping tablets over the past 50 years has caused many problems. The situation may now be improving but, even so, millions of sleeping tablets and capsules are still prescribed every year.

In the early to mid seventies the barbiturates were progressively replaced by the benzodiazepines (e.g. Mogadon) because they are safer than the barbiturates and other sleeping tablets when taken in overdose. Unfortunately, they were prescribed extensively and were easily available on repeat prescriptions to thousands of patients for years on end, many of whom became addicted to them.

Repeat Prescription are one of the Biggest Causes of Insomnia

Insomnia is a symptom that should not be treated in isolation. Yet one of the biggest causes of ‘insomnia’ in the population is repeating sleeping tablets for months and years on end. This guarantees that you will not be able to sleep if you stop taking sleeping tablets.

After nightly use of a sleeping tablet for a few weeks it may take 6-12 weeks without the tablets before you can sleep ‘normally’ again without tablets. During this period you will suffer withdrawal effects and your sleep may be disturbed, you may have nightmares and you may feel anxious in the day-time. It is not surprising that you think you must go on taking the tablets because you think you are suffering from insomnia.

About three-quarters of all sleeping tablets are prescribed to elderly people, who may have been prescribed sleeping tablets at the time of their spouse’s death without counselling and support and then kept on sleeping tablets for years on end. For people living alone it must be very difficult to face the prospect of about 6-12 weeks of disturbed sleep in a lonely house if they try to come off sleeping tablets. It is not surprising that some elderly people are loath to stop them.

Sleep produced by tablets may be comforting in the first few days of bereavement but not if they have to be continued for weeks on end. What is more, after a few months of nightly use of sleeping tablets, sleep may become disturbed again. So any beneficial effects wear off but the ‘need’ to go on taking sleeping tablets remains strong.

Warnings on the use of Sleeping Tablets in Elderly People

All sleeping tablets depress brain function and can produce intoxication, tolerance and addiction. They can cause hangover and affect mood. They may be particularly harmful in elderly people, who are sensitive to their depressing effects on the brain and they may easily become confused. If old elderly people (i.e. over 75 years of age) are prescribed too high a dose, they may wet the bed and suffer hangover effects for most of the next day. These hangover effects occur more frequently with longer-acting sleeping tablets than with short-acting ones and high doses will produce more hangover effects than small doses. Furthermore, long-acting medicines may stay in the body for days on end so that each dose helps to build up the amount that is already in the body, which explains why old elderly people may easily become intoxicated because their liver and kidneys cannot get rid of the medicine as fast as a young fit person.

When to Take Sleeping Tablets

Very occasionally it may be appropriate to take sleeping tablets for a night or two during severe periods of stress (e.g. after a bereavement) or after prolonged periods of intense work when you just cannot relax, or intermittently through long periods of stress or when travelling overnight or working shifts. In such circumstances they should be taken for only a few nights in a row, because the sleeping tablet habit is a real risk after a few weeks of tablet-induced sleep.

Have you an Emotional Problem?

Do not forget that emotional problems are a common cause of sleep disturbance and these may produce many symptoms in addition to insomnia; for example, frequent headaches, feeling anxious or tense, sad, depressed or tearful, backaches, pains in the chest, indigestion, dizziness, no energy, feeling fed up, feeling irritable, fears about your health or about going out by yourself, loss of appetite, loss of interest in sex, loss of weight, palpitations, feelings of guilt, feeling not wanted or feeling that other people are talking about you. These are only some of the group of symptoms that would suggest that you are suffering from a psychological disorder and need appropriate treatment. Remember also that tension may produce anxiety in the day-time and insomnia at night.

Are You Depressed?

If you have a change in mood, the use of sleeping tablets or sedatives may aggravate your condition – especially if you are feeling sad or miserable. It is important to recognise what are labelled ‘depressive symptoms’. These include characteristic sleep disturbances such as difficulty in getting to sleep, restless sleep and early morning wakening. Fatigue is a particularly important symptom if you are depressed, and no matter how long you stay in bed you still feel exhausted. Sleeping tablets will not help; in fact they make you feel worse if you are depressed. However, antidepressant medicines may be very effective in relieving these symptoms. This again highlights the importance of not just treating insomnia on its own. You need to consider as many factors as possible for the cause of your insomnia. After all, the symptoms are telling you that there is something wrong in your life, and advice and counselling may be more effective than sleeping pills which solve nothing – they only temporarily relive the symptoms of insomnia.

Use Non-Medicine Treatments for Insomnia

There are safer alternative to sleeping tablets, such as a hot bath before retiring, reading a book, taking a walk, not having too large an evening meal, cutting out coffee, tea or cocoa in the evening, reducing smoking, reducing alcohol intake, trying to get some regular exercise and fresh air during the day and – preferably most important of all – being taught how to relax. The ritual just before going to bed may condition you to go to sleep – undressing, washing etc. A milk-cereal drink may help you sleep more peacefully.

Breaking the Sleeping Tablet Habit

Tests have shown that all sleeping tablets disrupt normal sleeping patterns although you may feel that you sleep well. They suppress what is called paradoxical sleep (i.e. the period of sleep when you dream a lot). This means that when you stop your sleeping tablets you will find it difficult to sleep, and when you do manage to sleep you will dream a lot and your sleep will be restless and you may have nightmares. This is why you may easily become convinced that you cannot sleep without taking a sleeping tablet; but the very fact that you have disturbed sleep if you stop them is why you should stop them. It shows that the tablets are affecting your normal brain function. In addition to experiencing difficulties with sleep, you may also experience other withdrawal symptoms if you try to suddenly stop taking sleeping tablets.

Gradually Reduce the Dose of your Sleeping Tablet

If you have been taking a sleeping tablet every night for several weeks or more and try to stop it suddenly, you may get disturbed sleep, dreams and nightmares. You may also develop anxiety symptoms and mood changes in the day-time. You should therefore reduce the nightly dose very slowly over several weeks to months. In this way the withdrawal symptoms will not be so severe, and gradually your general feeling of well-being will improve. For example, if you are taking nitrazepam (Mogadon) every night in a dose of two 5mg tablets, you should break the tablets in half (2.5mg) and then quarters (1.25mg). You should reduce the nightly dose by half a tablet every month for 2 months; you will then be down to one tablet (5mg) a night. Then reduce the nightly dose by a quarter of a tablet (1.25mg) once a month until you are taking only one-quarter of a tablet every night. After a month on this dose you can stop it or try breaking it in half and taking one eighth of a tablet every night for another month before stopping.

There is no hard and fast rule about how to stop sleeping tablets except to reduce your nightly dose very slowly over several months until you are completely off them. It is worth taking your time and being patient and not feeling guilty about taking sleeping tablets. As you slowly reduce the dose you should try non-medicine treatments to help you sleep (see earlier). If you find it difficult, see your doctor or a clinical psychologist. You will need support and counselling and to be taught how to relax.

What about elderly people who have developed the habit of taking sleeping tablets every night? Many of these individuals are widows, often living alone. Even if they are dependent on them, it would be wrong to make them feel guilty about taking sleeping tablets. Nevertheless they should be weaned off them if they are depressed, anxious or tense; if they drink alcohol regularly; if they have increased the dose; if they are incontinent; or if they show signs of intoxication or have impaired kidney, heart or liver function. In any of these situations they should slowly be weaned off their sleeping tablet. As for others in this situation, their general well-being would improve if they were to be slowly weaned off their sleeping tablets.