Drugs Expert

Insomnia is a symptom that can accompany several sleep, medical and psychiatric disorders, characterized by persistent difficulty falling asleep and/or difficulty staying asleep. Insomnia is typically followed by functional impairment while awake.

Both organic and non-organic insomnia without other cause constitute a sleep disorder, primary insomnia. One definition of insomnia is “difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.”

According to the United States Department of Health and Human Services in the year 2007, approximately 64 million Americans regularly suffer from insomnia each year. Insomnia is 41% more common in women than in men.

What causes Insomina?

Insomnia most often stems from some other problem, such as a medical condition that causes pain or use of substances that interfere with sleep. Common causes of insomnia include:

• Stress. Concerns about work, school, health or family can keep your mind active at night, making it difficult to sleep. Stressful life events, such as the death or illness of a loved one, divorce, or a job loss, may lead to insomnia.
• Anxiety. Everyday anxieties as well as more-serious anxiety disorders may disrupt your asleep.
• Depression. You might either sleep too much or have trouble sleeping if you’re depressed. This may be due to chemical imbalances in your brain or because worries that accompany depression may keep you from relaxing enough to fall asleep. Insomnia often accompanies other mental health disorders as well.
• Medications. Prescription drugs that can interfere with sleep include some antidepressants, heart and blood pressure medications, allergy medications, stimulants (such as Ritalin) and corticosteroids. Many over-the-counter (OTC) medications, including some pain medication combinations, decongestants and weight-loss products, contain caffeine and other stimulants. Antihistamines may initially make you groggy, but they can worsen urinary problems, causing you to get up more during the night.
• Caffeine, nicotine and alcohol. Coffee, tea, cola and other caffeine-containing drinks are well-known stimulants. Drinking coffee in the late afternoon can keep you from falling asleep at night. Nicotine in tobacco products is another stimulant that can cause insomnia. Alcohol is a sedative that may help you fall asleep, but it prevents deeper stages of sleep and often causes you to awaken in the middle of the night.
• Medical conditions. If you have chronic pain, breathing difficulties or need to urinate frequently, you might develop insomnia. Conditions linked with insomnia include arthritis, cancer, congestive heart failure, diabetes, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, stroke, Parkinson disease and Alzheimer’s disease. Making sure that your medical conditions are well treated may help with your insomnia. If you have arthritis, for example, taking a pain reliever before bed may help you sleep better.
• Change in your environment or work schedule. Travel or working a late or early shift can disrupt your body’s circadian rhythms, making it difficult to sleep. Your circadian rhythms act as internal clocks, guiding such things as your wake-sleep cycle, metabolism and body temperature.
• Poor sleep habits. Habits that help promote good sleep are called “sleep hygiene.” Poor sleep hygiene includes an irregular sleep schedule, stimulating activities before bed, an uncomfortable sleep environment and use of your bed for activities other than sleep or sex.
• ‘Learned’ insomnia. This may occur when you worry excessively about not being able to sleep well and try too hard to fall asleep. Most people with this condition sleep better when they’re away from their usual sleep environment or when they don’t try to sleep, such as when they’re watching TV or reading.
• Eating too much late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down, making it difficult to get to sleep. Many people also experience heartburn, a backflow of acid and food from the stomach to the esophagus after eating. This uncomfortable feeling may keep you awake.

Insomnia and aging

Insomnia becomes more prevalent with age. As you get older, changes can occur that may affect your sleep. You may experience:

• A change in sleep patterns. Sleep often becomes less restful as you age. You spend more time in stages 1 and 2 of non-rapid eye movement (NREM) sleep and less time in stages 3 and 4. Stage 1 is transitional sleep, stage 2 is light sleep, and stage 3 is deep (delta) sleep, the most restful kind. Because you’re sleeping more lightly, you’re also more likely to awaken. With age, your internal clock often advances, which means you get tired earlier in the evening and wake up earlier in the morning. But older people still need the same amount of sleep as younger people do.
• A change in activity. You may be less physically or socially active. Activity helps promote a good night’s sleep. You may also be more likely to take a daily nap, which also can interfere with sleep at night.

• A change in health. The chronic pain of conditions such as arthritis or back problems as well as depression, anxiety and stress can interfere with sleep. Older men often develop noncancerous enlargement of the prostate gland (benign prostatic hyperplasia), which can cause the need to urinate frequently, interrupting sleep. In women, hot flashes that accompany menopause can be equally disruptive.

Other sleep-related disorders, such as sleep apnea and restless legs syndrome, also become more common with age. Sleep apnea causes you to stop breathing periodically throughout the night and then awaken. Restless legs syndrome causes unpleasant sensations in your legs and an almost irresistible desire to move them, which may prevent you from falling asleep.

• Increased use of medications. Older people use more prescription drugs than younger people do, which increases the chance of insomnia caused by a medication.

Sleep problems may be a concern for children and teenagers as well. Some children and teenagers simply have trouble getting to sleep or resist a regular bedtime because their internal clocks are more delayed. They want to go to bed later and sleep later in the morning.

Besides the conditions listed previously, there are other types of insomnia that are not necessarily linked to an underlying condition. Some of the common types of insomnia are listed in this section.

Psychophysiological insomnia

Psychophysiological insomnia or primary insomnia is a type of insomnia in which learned behaviors prevent sleep. Individuals with this condition are unable to relax their minds (racing thoughts) and have an increased mental function when they try to fall sleep. This may become a long-term issue, and going to bed becomes associated with an increased level of anxiety and mental arousal, leading to chronic insomnia. This condition may be present in about 15% of people who undergo formal sleep studies for evaluation of chronic insomnia.

Idiopathic insomnia

Idiopathic insomnia (without an obvious cause) (childhood onset insomnia or life-long insomnia) is a less common condition (1% of young adults or adolescents) that starts in childhood and may continue into adulthood. These individuals have difficulty initiating and maintaining sleep and have chronic daytime fatigue. Other more common conditions need to be evaluated and ruled out before this diagnosis is made. This condition may run in families.

Paradoxical insomnia

Paradoxical insomnia is also called subjective insomnia or sleep state misconception. In this condition, individuals may report and complain of insomnia;, however, they would have a normal pattern of sleep if they were to have a formal overnight sleep study done.

What are the Risk Factors?

Nearly everyone has an occasional sleepless night. But your risk of insomnia is greater if:

• You’re a woman. Women are twice as likely to experience insomnia. Hormonal shifts during the menstrual cycle and in menopause play a role. Many women report problems sleeping during perimenopause, the time leading up to menopause. During menopause, night sweats and hot flashes often disturb sleep. In postmenopausal women, lack of estrogen is thought to contribute to sleep difficulties.
• You’re over age 60. Because of changes in sleep patterns, insomnia increases with age. According to some estimates, insomnia affects nearly half of all older people.
• You have a mental health disorder. Many disorders, including depression, anxiety, bipolar disorder and post-traumatic stress disorder, disrupt sleep. Early-morning awakening is a classic symptom of depression.
• You’re under a lot of stress. Stressful events can cause temporary insomnia, and major or long-lasting stress, such as the death of a loved one or a divorce, can lead to chronic insomnia. Being poor or unemployed also increases the risk.
• You work night or changing shifts. Working at night or frequently changing shifts increases your risk of insomnia.
• You travel long distances. Jet lag from traveling across multiple time zones can cause insomnia.

What are the Symptoms of Insomnia?

Insomnia signs and symptoms may include:

• Difficulty falling asleep at night
• Awakening during the night
• Awakening too early
• Not feeling well rested after a night’s sleep
• Daytime fatigue or sleepiness
• Irritability, depression or anxiety
• Difficulty paying attention or focusing on tasks
• Increased errors or accidents
• Tension headaches
• Gastrointestinal symptoms
• Ongoing worries about sleep

Diagnosis

Evaluation and diagnosis of insomnia may start with a thorough medical and psychiatric patient history taken by the physician. As mentioned above, many medical and psychiatric conditions can be responsible for insomnia.

A general physical examination to assess for any abnormal findings is also important, including assessment of mental status and neurological function; heart, lung and abdominal exam; ear, nose and throat exam; and measurement of the neck circumference and waist size. Assessment of routine medications and use of any illegal drugs, alcohol, tobacco, or caffeine is also an important part of the medical history. Any laboratory or blood work pertinent to these conditions can also be a part of the assessment.

The patient’s family members and bed partners also need to be interviewed to ask about the patient’s sleep patterns, snoring, or movements during sleep.

Specific questions regarding sleep habits and patterns are also a vital part of the assessment. A sleep history focuses on:

• duration of sleep,
• time of sleep,
• time to fall sleep,
• number and duration of awakenings,
• time of final awakening in the morning, and
• time and length of any daytime naps.

Sleep logs or diaries may be used for this purpose to record these parameters on a daily basis for more accurate assessment of sleep patterns.

Sleep history also typically includes questions about possible symptoms associated with insomnia. The physician may ask about daytime functioning, fatigue, concentration and attention problems, naps, and other common symptoms of insomnia.

Other diagnostic tests may be done as part of the evaluation for insomnia, although they may not be necessary in all patients with insomnia.

Polysomnography is a test that is done in sleep centers if conditions such as sleep apnea are suspected. In this test, the person will be required to spend a full night at the sleep center while being monitored for heart rate, brain waves, respirations, movements, oxygen levels, and other parameters while they are sleeping. The data is then analyzed by a specially trained physician to diagnose or rule out sleep apnea.

Actigraphy is another more objective test that may be performed in certain situations but is not routinely a part of the evaluation for insomnia. An actigraph is a motion detector that senses the person’s movements during sleep and wakefulness. It is worn similar to a wrist watch for days to weeks, and the movement data are recorded and analyzed to determine sleep patterns and movements. This test may be useful in cases of primary insomnia disorder, circadian rhythm disorder, or sleep state misconception.

Methods of Treatment

In many cases, insomnia is caused by another disease, side effects from medications, or a psychological problem. It is important to identify or rule out medical and psychological causes before deciding on the treatment for the insomnia. Attention to sleep hygiene is an important first line treatment strategy and should be tried before any pharmacological approach is considered.

Non-pharmacological

Non-pharmacological strategies are superior to hypnotic medication for insomnia because tolerance develops to the hypnotic effects. In addition, dependence can develop with rebound withdrawal effects developing upon discontinuation. Hypnotic medication is therefore only recommended for short term use, especially in acute or chronic insomnia. Non pharmacological strategies however, have long lasting improvements to insomnia and are recommended as a first line and long term strategy of managing insomnia. The strategies include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education and relaxation therapy.

EEG biofeedback has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as quality of sleep.

Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene. Examples of such environmental modifications include using the bed for sleep or sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not result in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during nighttime hours, and eliminating daytime naps.

A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, only sleeping at certain times of the day and for specific amounts of time to induce mild sleep deprivation. Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when sleep efficiency improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. Bright light therapy, which is often used to help early morning wakers reset their natural sleep cycle, can also be used with sleep restriction therapy to reinforce a new wake schedule. Although applying this technique with consistency is difficult, it can have a positive effect on insomnia in motivated patients.

Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).

Cognitive behavior therapy

A recent study found that cognitive behavior therapy is more effective than hypnotic medications in controlling insomnia. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:

(1)   unrealistic sleep expectations (e.g., I need to have 8 hours of sleep each night),

(2)   misconceptions about insomnia causes (e.g., I have a chemical imbalance causing my insomnia),

(3)   amplifying the consequences of insomnia (e.g., I cannot do anything after a bad night’s sleep), and

(4)   performance anxiety after trying for so long to have a good night’s sleep by controlling the sleep process.

Numerous studies have reported positive outcomes of combining cognitive behavioral therapy treatment with treatments such as stimulus control and the relaxation therapies. Hypnotic medications are equally effective in the short term treatment of insomnia but their effects wear off over time due to tolerance. The effects of cognitive behavior therapy have sustained and lasting effects on treating insomnia long after therapy has been discontinued. The addition of hypnotic medications with CBT adds no benefit in insomnia. The long lasting benefits of a course of CBT shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short term hypnotic medication such as zolpidem (Ambien), CBT still shows significant superiority. Thus CBT is recommended as a first line treatment for insomnia.

Medications

Many insomniacs rely on sleeping tablets and other sedatives to get rest, with research showing that medications are prescribed to over 95% of insomniac cases. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully tapered down. The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side effects such as day time fatigue, motor vehicle crashes, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side effects. The non-benzodiazepines zolpidem and zaleplon have not adequately demonstrated effectiveness in sleep maintenance. Some benzodiazepines have demonstrated effectiveness in sleep maintenance in the short-term but in the longer term is associated with tolerance and dependence. Drugs are in development which may prove more effective and safer than existing drugs for insomnia.

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was not significantly more than for antidepressants. Benzodiazepines did not have a significant tendency for more adverse drug reactions. Chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs who do not take medications. In fact, chronic users of hypnotic medications actually have more regular nighttime awakenings than insomniacs who do not take hypnotic medications. A further review of the literature regarding benzodiazepine hypnotic as well as the nonbenzodiazepines concluded that these drugs caused an unjustifiable risk to the individual and to public health and lack evidence of long term effectiveness. The risks include dependence, accidents and other adverse effects. Gradual discontinuation of hypnotics in long term users leads to improved health without worsening of sleep. Preferably hypnotics should be prescribed for only a few days at the lowest effective dose and avoided altogether wherever possible in the elderly.

Benzodiazepines

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABA_A receptor. These include drugs such as temazepam, flunitrazepam, triazolam, flurazepam, midazolam, nitrazepam and quazepam. These drugs can lead to tolerance, physical dependence and the benzodiazepine withdrawal syndrome upon discontinuation, especially after consistent usage over long periods of time. Benzodiazepines while inducing unconsciousness, actually worsen sleep as they promote light sleep whilst decreasing time spent in deep sleep such as REM sleep. A further problem is with regular use of short acting sleep aids for insomnia, day time rebound anxiety can emerge. Benzodiazepines can help to initiate sleep and increase sleep time but they also decrease deep sleep and increase light sleep. Although there is little evidence for benefit of benzodiazepines in insomnia and evidence of major harm prescriptions have continued to increase. There is a general awareness that long-term use of benzodiazepines for insomnia in most people is inappropriate and that a gradual withdrawal is usually beneficial due to the adverse effects associated with the long-term use of benzodiazepines and is recommended whenever possible.

Non-benzodiazepines

Nonbenzodiazepine sedative-hypnotic drugs, such as zolpidem, zaleplon, zopiclone and eszopiclone, are a newer classification of hypnotic medications. They work on the benzodiazepine site on the GABA_A receptor complex similarly to the benzodiazepine class of drugs. Some but not all of the nonbenzodiazepines are selective for the α₁ subunit on GABA_A receptors which is responsible for inducing sleep and may therefore have a cleaner side effect profile than the older benzodiazepines. Zopiclone and eszopiclone like benzodiazepine drugs bind unselectively to α₁, α₂, α₃ and α₅ GABA_A benzodiazepine receptors. Zolpidem is more selective and zaleplon is highly selective for the α₁ subunit, thus giving them an advantage over benzodiazepines in terms of sleep architecture and a reduction in side effects. However, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence though less than traditional benzodiazepines and can also cause the same memory and cognitive disturbances along with morning sedation.

Alcohol

Alcohol is often used as a form of self-treatment of insomnia to induce sleep. However, alcohol use to induce sleep can be a cause of insomnia. Long-term use of alcohol is associated with a decrease in NREM stage 3 and 4 sleep as well as suppression of REM sleep and REM sleep fragmentation. Frequent moving between sleep stages occurs, with awakenings due to headaches, polyuria, dehydration and diaphoresis. Glutamine rebound also plays a role as when someone is drinking, alcohol inhibits glutamine, one of the body’s natural stimulants. When the person stops drinking, the body tries to make up for lost time by producing more glutamine than it needs. The increase in glutamine levels stimulates the brain while the drinker is trying to sleep, keeping them from reaching the deepest levels of sleep. Stopping chronic alcohol use can also lead to severe insomnia with vivid dreams. During withdrawal REM sleep is typically exaggerated as part of a rebound effect.

Opioids

Opioid medications such as hydrocodone, oxycodone, and morphine are used for insomnia which is associated with pain due to their analgesic properties and hypnotic effects. Opioids can fragment sleep and decrease REM and stage 2 sleep. By producing analgesia and sedation, opioids may be appropriate in carefully selected patients with pain-associated insomnia.

Antidepressants

Some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can often have a very strong sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have properties which can lead to many side effects, for example; amitriptyline and doxepin both have antihistaminergic, anticholinergic and antiadrenergic properties which contribute to their side effect profile, while mirtazapines side effects are primarily antihistaminergic, and trazadones side effects are primarily antiadrenergic. Some also alter sleep architecture. As with benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to withdrawal effects; withdrawal may induce rebound insomnia.

Mirtazapine is known to decrease sleep latency, promoting sleep efficiency and increasing the total amount of sleeping time in patients suffering from both depression and insomnia.

Melatonin and melatonin agonists

The hormone and supplement melatonin is effective in several types of insomnia. Melatonin has demonstrated effectiveness equivalent to the prescription sleeping tablet zopiclone in inducing sleep and regulating the sleep/waking cycle. One particular benefit of melatonin is that it can treat insomnia without altering the sleep pattern which is altered by many prescription sleeping tablets. Another benefit is it does not impair performance related skills.

Melatonin agonists, including ramelteon (Rozerem) and tasimelteon, seem to lack the potential for misuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. While these drugs show good effects for the treatment of insomnia due to jet lag, the results for other forms of insomnia are less promising.

Natural substances such as 5-HTP and L-Tryptophan have been said to fortify the serotonin-melatonin pathway and aid people with various sleep disorders including insomnia.

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids such as Benadryl. The antihistamine doxylamine is used in nonprescription sleep aids such as Unisom (USA) and Unisom 2 (Canada). In some countries, including Australia, it is marketed under the names Restavit and Dozile. It is the most effective over-the-counter sedative currently available in the United States, and is more sedating than some prescription hypnotics.

While the two drugs mentioned above are available over the counter in most countries, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Anticholinergic side effects may also be a draw back of these particular drugs. Dependence does not seem to be an issue with this class of drugs.

Cyproheptadine is a useful alternative to benzodiazepine hypnotics in the treatment of insomnia. Cyproheptadine may be superior to benzodiazepines in the treatment of insomnia because cyproheptadine enhances sleep quality and quantity whereas benzodiazepines tend to decrease sleep quality.

Atypical antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine, olanzapine and risperidone are also prescribed for their sedative effect but the danger of neurological, metabolic and cognitive side effects make these drugs a poor choice to treat insomnia. Over time, quetiapine may lose its effectiveness as a sedative. The ability of quetiapine to produce sedation is determined by the dosage. Higher doses (300 mg – 900 mg) are usually taken for its use as an antipsychotic, while lower doses (25 mg – 200 mg) have a marked sedative effect, e.g. if a patient takes 300 mg, he/she will more likely benefit from the drug’s antipsychotic effects, but if the dose is brought down to 100 mg, it will leave the patient feeling more sedated than at 300 mg, because it primarily works as a sedative at lower doses.

Eplivanserin is an investigational drug with a mechanism similar to these antipsychotics, but probably with less side effects.

Other substances

Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.

Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven. A healthy diet containing magnesium can help to improve sleep in individuals without an adequate intake of magnesium.

Drugs rating:

	Title	Votes	Rating
1	Excedrin PM (Acetaminophen And Diphenhydramine)	2		(10.0/10)
2	Somnote (Chloral hydrate)	1		(10.0/10)
3	Luminal (Phenobarbital)	16		(8.3/10)
4	Halcion (Triazolam)	60		(8.0/10)
5	Ativan (Lorazepam)	987		(7.7/10)
6	Percogesic (Acetaminophen And Phenyltoloxamine)	14		(7.7/10)
7	Dalmane (Flurazepam)	53		(7.6/10)
8	Unisom (Doxylamine)	49		(7.6/10)
9	Tylenol PM (Acetaminophen And Diphenhydramine)	38		(7.5/10)
10	Midazolam	4		(7.5/10)
11	Edluar (Zolpidem)	2		(7.5/10)
12	Ambien (Zolpidem)	1214		(7.3/10)
13	Zolpidem	223		(7.2/10)
14	Prosom (Estazolam)	5		(7.2/10)
15	Benadryl (Diphenhydramine)	222		(7.0/10)
16	Ambien CR (Zolpidem)	180		(7.0/10)
17	Lunesta (Eszopiclone)	462		(6.7/10)
18	Restoril (Temazepam)	207		(6.7/10)
19	Diphenhydramine	34		(6.6/10)
20	Sonata (Zaleplon)	143		(4.6/10)
21	Rozerem (Ramelteon)	211		(4.5/10)
22	Seconal (Secobarbital)	0		(0/10)
23	Nembutal (Pentobarbital)	0		(0/10)
24	Q-Dryl (Diphenhydramine)	0		(0/10)
25	Zolpimist (Zolpidem)	0		(0/10)
26	Percogesic Extra Strength (Acetaminophen And Diphenhydramine)	0		(0/10)
27	Butisol (Butabarbital)	0		(0/10)
28	Solfoton (Phenobarbital)	0		(0/10)
29	Doral (Quazepam)	0		(0/10)

Epidemiology

The National Sleep Foundation’s 2002 Sleep in America poll showed that 58% of adults in the U.S. experienced symptoms of insomnia a few nights a week or more. Although insomnia was the most common sleep problem among about one half of older adults (48%), they were less likely to experience frequent symptoms of insomnia than their younger counterparts (45% vs. 62%), and their symptoms were more likely to be associated with medical conditions, according to the 2003 poll of adults between the ages of 55 and 84.