Insomnia and Daytime Sleepiness

Insomnia: from the Latin insomnis, meaning sleepless
Sleep is absolutely essential for repair and rejuvenation, and those with chronic insomnia must find a solution in order to maintain quality of life. Most people don't know that chronic insomnia predisposes people to early death. Therefore, from a perspective of extending life, it is absolutely essential that good sleep patterns be restored.

Insomnia is a frequent symptom indicative of overt or underlying depression. In this case, it is essential to treat the depression in order to produce healthier sleep patterns. Improving sleep often alleviates depression and vice versa.

Insomnia can be described as either difficulty initiating or maintaining sleep or both. It affects millions of people and is often difficult to treat. Those who suffer from insomnia feel as though they have not had sufficient sleep when they awaken. Over the long-term it may cause fatigue, irritability, and decreased concentration just to name a few symptoms. Elderly people may require less sleep than younger adults, on average 6-8 hours per day. This is a normal, age-related change and should not be considered to be a sleep disorder in a healthy individual.

Sleep is not a static condition, but actually a fluid condition with changes occurring throughout the sleep period. These stages demonstrate different brain wave patterns. In particular, the period of so-called rapid eye movement (REM) sleep is when we dream. There are about five periods of REM during the night. The deepest periods of sleep, stages 3 and 4, occur early in the night. It is the deeper phases of sleep that decrease in duration as we age.

Implications of Sleep Deprivation in Degenerative DiseaSE

In studies on insomnia and sleep deprivation, researchers have concluded that lack of sleep raises levels of two adrenal hormones (cortisol and ACTH) associated with the proinflammatory cytokine, interleukin-6 (IL-6). Inflammatory cytokines have been linked to numerous degenerative diseases, such as cancer, cardiovascular disease, rheumatoid arthritis, osteoporosis, and neurodegenerative disorders, such as Alzheimer's disease. In a carefully controlled study, sleep deprivation caused an average increase of 40-60% of IL-6 in both men and women. Another inflammatory cytokine called tumor necrosis factor (TNF) was also elevated 20-30% in sleep-deprived men (Vgontzas et al. 1999; 2001). At the annual meeting of the Endocrine Society held in San Francisco June 19-22, 2002, lead researcher Dr. A.N. Vgontzas reviewed his findings, noting that missing only two or three hours of sleep will cause a person to function poorly the next day. Dr. Vgontzas concluded that getting a full night's rest of eight hours sleep is a necessity, due to the link to serious physical illnesses associated with chronic inflammation (see the Chronic Inflammation protocol for suggestions on lowering levels of pro-inflammatory cytokines).

Diagnosis and TreatmeNT

The diagnosis of insomnia is based on a person's individual needs for sleep. It may be classified as primary insomnia, a condition with no apparent relationship to stress or other upset, or secondary insomnia, a condition related to another cause. Treatment will depend on the underlying cause, if any, and the severity of the sleeplessness. The more common reasons for difficulty initiating sleep are anxiety, stress, and depression.

A difficulty maintaining sleep may be caused by the same factors just mentioned, as well as a sleep disorder caused by obstructive or central apnea when a disturbance in breathing wakes the individual up. Another common condition is nocturnal myoclonus, which causes the individual to "twitch" large muscle groups periodically and to awaken.

Often people will complain of being tired and sleeping poorly, yet they do not recall awakening. This is because not all awakenings are full awakenings. In the language of those who study sleep, this refers to full versus partial arousals. A person's sleep may be grossly disturbed with multiple partial arousals even in the absence of full arousals.

To find the cause of insomnia, one first attempts to find out whether the insomnia is initiation or maintenance of sleep. One looks for the more common reasons, such as new things that are causing stress. An increase in caffeine consumption includes not only tea and coffee, but carbonated beverages as well. Shift workers often have a problem resetting their biological clock to deal with a topsy-turvy schedule. The use of alcohol as a sedative before bed can have the opposite effect, resulting in further impaired sleep.

It is good to ask one's bed partner about heavy snoring or periods where there is gasping for air or kicking of the legs. Your physician may refer you for a sleep study which monitors your brain waves and limb movements, as well as looking for sleep apnea.

The Age-Related Decline in Melatonin ProductiON

• How to Use Melatonin
• Melatonin Plus Cofactors

As people age, their sleep quality often undergoes significant deterioration, commonly characterized by frequent and longer-lasting nighttime awakenings. In many older people, sleep disturbance is correlated with a decline in melatonin secretion. A number of published studies also show that decreased melatonin production is also associated with the onset of a host of degenerative diseases.

One report discusses the role of melatonin in reversing partially degraded proteins that lead to the accumulation of lipofuscin (age-pigments in the skin and the brain), cataracts, and crosslinked collagen. The scientist who wrote this article stated that the nighttime rise in melatonin is one way the body "cleans" itself of partially glycated proteins (Yin 2000). If this hypothesis is correct, it helps explain the numerous published studies showing that melatonin protects against a wide range of aging-related diseases.

In older people, peak nighttime melatonin levels are only 30-40 pg/mL of blood (Waldhauser et al. 1988), whereas younger people often secrete 100-200 pg/mL of blood at night. This age-related decline in melatonin secretion has been demonstrated in all but one (Zeitzer et al. 1999) of more than 20 studies that have examined this issue.

The vast majority of melatonin is produced in the pineal gland. During normal aging, calcification of the pineal tissue is thought to cause the decline in melatonin synthesis.

A number of studies show that melatonin deficiency may be an underlying cause of insomnia in older people. When melatonin is administered to humans in clinical trials, it induces sleep sooner and produces better sleep patterns compared to placebo (Garfinkel et al. 1995; Saletu 1997; Zisapel 1999; Blaicher et al. 2000).

Scientists have stated that a common cause for insomnia in people over the age of 35 or 40 is deficiency of the hormone melatonin (Garfinkel et al. 1997; Haimov et al. 1997). Melatonin is used by the body to induce drowsiness and enables one to enter the deep-sleep patterns characteristic of youth.

After darkness, young pineal glands secrete melatonin slowly for about 5 hours to enable the body to enter the various stages of deep sleep, so people can feel revitalized and rejuvenated the next morning. Further, melatonin supplementation has been shown in many scientific studies to be a safe and effective sleep-enhancing therapy (Brown 1994; Garfinkel et al. 1995; Haimov et al. 1995; Zhdanova et al. 1995; Zisapel 1999).

How to Properly Use Melatonin
Based on studies indicating a significant disease prevention potential, melatonin has become a popular dietary supplement in the United States. There is a debate, however, as to what the optimal nightly dose of melatonin should be.

One study tested 10 mg of melatonin for 28 consecutive nights in human volunteers. At this relatively high dose, there was no evidence of toxicity and those receiving melatonin (10 mg) had a better sleep score compared to the placebo group (de Lourdes et al. 2001).

There are experts who advocate that lower doses of melatonin are better than higher doses. These scientists point to another study on elderly human subjects where only 300 mcg of melatonin induced better sleep than 3000 mcg (3 mg) over a 7-day period (Wurtman 2000).

A review of all the published literature reveals that a wide range of melatonin doses has been used to produce better sleep patterns in human subjects (Garfinkel et al. 1995; 1997; 1999; Zhdanova et al. 1995; 1999; Jan et al. 1996; 1997; Dagan et al. 1997; Hughes et al. 1997; Kunz et al. 1997; 1999; Lushington et al. 1997; Middleton et al. 1997; Nakamura et al. 1997; Avery et al. 1998; Dawson et al. 1998; Jean-Louis et al. 1998; Jorgensen et al. 1998; Kato et al. 1998; Okawa et al. 1998; Pillar et al. 1998; Rosenberg et al. 1998; Shochat et al. 1998; Suhner et al. 1998; Brusco et al. 1999; Fauteck et al. 1999; Matsumoto 1999; Miyamoto et al. 1999; Dalton et al. 2000; Domzal et al. 2000; Gordon 2000; Sack et al. 2000).

The Life Extension Foundation introduced melatonin to the general population in 1992. The dosage unit of the first melatonin supplement offered was 3 mg. Over the years, The Foundation has introduced new melatonin supplements starting in dosage units of 300 mcg and going up to 10 mg.

For those who are not sleeping well, despite taking higher doses of melatonin, it should be emphasized that there is a basis for using lower doses (300 mcg-1 mg) to induce better sleep in some people.

Unlike in Canada, Europe, and Japan, where melatonin is regulated as a drug, citizens of the United States can buy pharmaceutical-grade melatonin at extraordinarily low prices.

As already stated, the optimal dose of melatonin has considerable individual variability. Many people find as little as 300 mcg is ideal, while others take 3-6 mg of melatonin before bedtime to solve their sleep problems. Too much melatonin can interfere with sleep in some persons, so the lowest effective dose of melatonin needed to get to sleep and stay asleep is often the best course of action to follow.

Melatonin Plus Cofactors
Some people still wake up too frequently during the night or too early in the morning, even after taking melatonin. In order to duplicate the mechanisms by which the young pineal gland induces youthful sleep patterns, a formula called Natural Sleep was developed in 1995, and it has produced a good track record in helping alleviate chronic insomnia problems. This formula contains two different melatonin delivery systems that work together to generate the same kind of secretion of melatonin that occurs naturally in young people.

First, the Natural Sleep capsule bursts open in the stomach within 5 minutes after swallowing to provide immediate-release melatonin. That induces the drowsiness needed to get to sleep. Then, Natural Sleep gradually introduces tiny beadlets of sustained-release melatonin into the digestive tract, to enable the person to stay asleep and avoid the nocturnal tossing and turning characteristic of age-related sleep disturbances.

Each capsule of Natural Sleep contains 2.5 mg of immediate-release melatonin plus 2.5 mg of sustained-release melatonin. Many people find this dose effectively enables them to enjoy a complete night's rest every night. Natural Sleep also contains vitamin B12 because of studies that show it can normalize circadian rhythms, thereby enabling people to enter sleep without stress or tension (Chang et al. 1995; Kohsaka 1998; Yamadera et al. 1998). Chromium picolinate and chromium polynicotinate are included in this formula to help lower blood sugar levels that can inhibit the ability to fall asleep. Niacinamide ascorbate, magnesium, calcium, and inositol are included as well in Natural Sleep to help induce a state of relaxation (Tramer et al. 1996; Hornyak et al. 1998).

Natural Sleep does not contain any potentially toxic herbal extracts. Insomnia often is a lifelong affliction, requiring the continuous need for nightly self-medication. The ingredients in Natural Sleep have been investigated for long-term safety and can be taken for an indefinite period of time without any risk of toxicity or tolerance.

Some people who occasionally wake up in the middle of the night will take another dose of melatonin to get back to sleep.

Other Natural Sleep-Inducing TherapiES

Some people find that commercially available GABA taken before bedtime is helpful. Tryptophan is available at compounding pharmacies and can be taken before bed. 5-Hydroxytryptophan is available at most health food stores and can be taken before bed as well. Avoid taking vitamin B6 supplements within 6 hours of taking 5-hydroxytryptophan (5-HTP) because vitamin B6 can cause the conversion of 5-HTP to serotonin in the blood before it has a chance to cross the blood-brain barrier to increase serotonin in the brain. Excessive serotonin in the blood can be dangerous, which is why it may be safer to use tryptophan rather than 5-hydroxytryptophan (5-HTP). Both of these compounds can be converted to serotonin in the brain, which plays a role in sleep (Birdsall 1998). Patients taking SSRI antidepressants, such as Prozac, should consult with their physicians prior to taking these agents because the dose of antidepressant may need to be reduced. This is true for St. John's Wort as well.

Although the long-term administration of valerian is not recommended, passion flower or valerian extract taken in moderation for short- to medium-term treatment of insomnia in conjunction with the other therapies mentioned may be helpful. A study with mice and an aquaeous extract of passion flower showed sedative properties (Soulimani et al. 1997). It is available as a tea, in capsules, and as a tincture.

Some people use the herb valerian to fall asleep. Valerian produces a drug-like hypnotic effect within the central nervous system similar to benzodiazepine drugs, such as Valium and Halcion. Because valerian-containing products often are promoted as natural herbal remedies, the public mistakenly believes they are safe to take on a regular basis (Donath et al. 2000). Studies indicate, however, that there is a possible toxicity risk when taking valerian over an extended period of time (Chan et al. 1995). Because a tolerance effect occurs with valerian due to its Valium-like properties, people often need to take greater and greater amounts of it as time goes by in order to continue to obtain the desired hypnotic (sleep-inducing) effect.

Use of Prescription DruGS

The use of tranquilizing drugs to solve chronic insomnia is not recommended by conventional or alternative medicine. The first problem cited by critics is addiction. It's not that the patient necessarily gets addicted to the drugs themselves. The problem arises when the insomniac becomes accustomed to the good night's sleep the drugs induce and does not want to stop taking the medication. The other problem is tolerance, which means the drug slowly stops working, even when higher doses are taken. The dual problems of addiction and tolerance cause physicians to be extremely cautious when prescribing sleep medications. Other reasons for avoiding these drugs include increasing the risk of sudden death for the following individuals: (1) sleep apnea patients, (2) those who consume alcohol, and (3) some elderly people. Elderly people slowly metabolize sedative drugs, meaning that clearance from their body can take too long, and they experience fatigue the next day. It should also be noted that benzodiazepine drugs frequently used to induce a sedative effect can impair mental function.

Having said all of the above, we want to make the argument that for the chronic insomniac who cannot find relief by safer natural therapies, long-term, prescription drug therapy should be considered.