Sleep and insomnia

Almost a third of a person's life is spent in sleep, the physiological significance of which is to rest the body, strengthen motor functions, memory, and consolidate skills. Sleep disorders lead to fatigue, weakness, excitability, inhibition of motor functions, emotional and cognitive disorders.

Sleep disorders bother about 28-45% of the world's population, being a problem for half of them that requires special diagnosis and treatment.

In many ways, the development of these disorders is influenced by the "age factor". So, complaints about poor sleep in people over 60 years old are 3-4 times more common than in middle-aged people. Sleep disorders are one of the most common problems in elderly and senile patients, and their prevalence is increasing every decade.

Currently, sleep disorders are one of the most acute medical problems that doctors around the world are working on. The matter is complicated by the fact that there is no universal medicine that would help all people, as there is no single cause of sleep disorders.

Physiological sleepSleep is a natural physiological state of a person characterized by cyclicity, periodicity, a relative decrease in physical and mental activity, lack of consciousness and a decrease in response to external stimuli.

The sleep-wake center is located in the hypothalamus of the brain, which produces sleep hormones (melatonin) and wakefulness (cortisol). The existence of two stages of sleep has been proven − sleep with rapid eye movement (REM) and sleep with slow eye movement (MDG), which, in turn, is divided into 4 phases.

Before proceeding to the description of these phases, we note that when awake (at rest and relaxed), the so-called alpha rhythm is recorded on the electroencephalogram (EEG) – potential fluctuations with a certain frequency and amplitude, usually modulated into spindles. When falling asleep, the eyelids close, the muscles relax, and the 1st stage begins, which is called the phase of falling asleep. When the amplitude of the EEG decreases, the alpha rhythm disappears and slow rotational eye movements are observed.

During the second stage, or the phase of superficial sleep, the EEG records bursts of waves – the "sleep spindle" − and individual complexes of high amplitude. The 3rd and 4th stages correspond to the phases of deep sleep. During the 3rd stage, slow waves with separate "sleepy spindles" are observed, in the 4th, slow activity of θ-waves prevails. These 4 stages are also called the stages of synchronous, or restful sleep – MDG sleep.

The 5th stage corresponds to the rapid sleep stage, which is called the desynchronized sleep phase, or REM sleep. In this phase, the skeletal muscles are relaxed, and the muscles that ensure the movement of the eyeball are activated, and rapid eye movements occur behind closed eyelids. At the same time, EEG waves are desynchronized, low-voltage high-frequency waves with rare bursts of alpha waves are observed. Dreams usually appear at this stage.

The stages of sleep are characterized by certain cycles. Young and middle-aged people consistently go through the first 4 stages of sleep (MDG sleep), after 70-100 min. the 5th stage (REM sleep) follows, before which a person usually tosses in a dream, moves. These successive stages of MDG and REM sleep are repeated 4-7 times during the night, depending on the duration of sleep. Approximately 20-25% of the total duration of sleep is occupied by the stages of rem sleep (REM sleep), 3-5% - the 1st stage, 50-60% – the 2nd, 10-20% - the 3rd and 4th. With age, the 3rd and 4th stages are shortened, after 70 years, the 4th phase is practically absent, and the 3rd is reduced to a minimum.

In the REM sleep phase, it is easy to wake a person, at the 3rd and 4th stages it is difficult: awakening completely occurs within 5 minutes and longer, while a person may be confused, disoriented after that.

During sleep cycles, various changes in physiological processes occur. Motor activity is significantly reduced, however, at all stages of sleep approximately every 15 minutes. spontaneous muscle contractions (mainly tonic) occur, as much as possible during the transition from MDG to REM sleep. During the 5th stage of sleep (REM sleep), rapid coordinated movements of the eyeballs in all directions are carried out behind the closed eyelids. In the period between the phases, the musculature becomes sluggish or atonic; mainly the muscles of the respiratory tract, abdominal press, intercostal muscles relax, which can lead to increased breathing at the stage of rem sleep.

During sleep (mostly slow), the body temperature decreases slightly. The rhythm of cardiac activity and breathing in the REM sleep phase are accelerated, their irregularity is noted. But in the deep sleep phase, they slow down and become regular again. Cerebral blood supply and oxygen consumption during MDG sleep decreases, during REM sleep increases. At different phases, the activity of the autonomic nervous system, glucose metabolism, the level of a number of hormones, and urine excretion change.

The rhythm of sleep and its stages are regulated by nervous mechanisms implemented through the neurotransmitter systems of the brain. The latter include acetylcholine and two biogenic amines – serotonin and norepinephrine. During wakefulness, the activity of aminergic (inhibitory) neurons is high, while cholinergic, on the contrary, is low. During MDG sleep, aminergic activity gradually decreases, and cholinergic activity gradually increases. During REM sleep, these changes are completely completed.

The Dream MissionNormal physiological sleep in the human body performs the following main functions:

• provides rest for the body;
• it plays an important role in the processes of metabolism. During slow sleep, growth hormone is released; during rem sleep, the plasticity of neurons is restored, their oxygen enrichment, protein and RNA biosynthesis of neurons;
• promotes the processing and storage of information. Sleep (especially slow sleep) facilitates the consolidation of the studied material, fast sleep implements subconscious models of expected events;
• adapts the body to changes in illumination (day-night);
• restores immunity.

Sleep durationThe normal duration of sleep varies greatly from 4-5 hours to 10-12 hours for different people. Healthy people are divided into short–sleepers and long-sleepers.

The main indicator of the norm of sleep is the feeling of rest after it. If this feeling does not exist, we can talk about a violation of the sleep-wake cycle.

In children, the duration of sleep depends on age: the smaller the child, the more he should sleep. However, the duration of sleep is individual for everyone and often depends on temperament, psychophysiological state. The daily norms of sleep duration for children of the first years of life are as follows:

• 1-2 months – 18 hours;
• 3-4 months – 17-18 hours;
• 5-6 months – 16 hours;
• 7-9 months - 15 hours;
• 10 months -2 years – 13 hours;
• 2-3 years – 12 hours .

With age, due to an increase in the efficiency of the child's brain, the duration of periods of wakefulness increases. Some children, due to individual characteristics, require less sleep than their peers; if the child sleeps a little less, but feels and behaves well, parents should not worry.

Sleep and old ageThe physiological processes inherent in an aging organism lead to a change in the architectonics of sleep stages and rhythms.

In old age, the phases of "slow waves" of sleep undergo the greatest changes in the form of a decrease in their amplitude and a reduction in their overall duration. The duration of the REM sleep phase is also significantly reduced, and its quality deteriorates. Finally, during the entire sleep, there are frequent violations of the sequence of phase changes and a general decrease in the number of cycles. Sleep becomes shallow with frequent awakenings in the middle of the night, its total duration is reduced, morning awakening comes earlier. An age-related increase in waking time in the middle of the night and a deterioration in the quality of night sleep cause, respectively, daytime drowsiness and the need for sleep during the daytime. Old age is characterized by a shift in sleep time to earlier falling asleep and earlier waking up. However, all of the above changes in sleep are normal for late age and do not require special treatment.

Sleep disorders and insomniaSleep disorders are diverse.

According to the International Classification of Diseases , they are classified as follows:

• sleep disorders and sleep duration (insomnia);
• excessive sleep duration (hypersomnia);
• sleep-wake cycle disorders;
• sleep apnea;
• narcolepsy and cataplexy;
• other sleep disorders;
• sleep disorders are unspecified.

The intense rhythm of life, constant nervous stress, inadequate rest − all this leads to violations of the psychophysical state of a person, chronic fatigue. Especially often people who are engaged in mental work suffer from sleep disorders. Many of them, in order to constantly be in good shape, drink strong tea or coffee in large quantities, which may be the cause of sleep disorders. Weakened by lack of sleep, the body can no longer independently fight even minor disorders. Over time, psychological distress develops – fatigue, nervousness. Against the background of "lack of sleep", diseases such as hypertension, obesity and even diabetes can worsen or develop.

Insomnia is a concept that unites different states. It means the inability to sleep, despite the circumstances conducive to sleep. First of all, insomnia consists of a violation of the sense of sleep duration, changes in the depth of sleep and the feeling of not falling asleep. In addition, sleep can be shallow, fragile, with frequent recurring awakenings during the night. There may also be difficulties with falling asleep, and sometimes sleep does not come at all. Finally, with insomnia, there may be disorders associated with waking up too early and not being able to fall asleep again. A combination of these symptoms is often observed.

Depending on the nature of the disorders , the following types of insomnia are distinguished:

• short-term, which is observed for one or several nights, but no longer than a few weeks;
• intermittent, appearing periodically, at times;
• chronic, observed for many nights (usually longer than 3 weeks).

Background of primary and secondary insomniaBased on the etiopathogenetic nature, primary and secondary insomnia (insomnia) are distinguished.

Primary insomnia is a prolonged disturbance of night sleep, for which there are no specific reasons (psychosomatic or organic). There are people for whom 3-4 hours of sleep is quite enough, but for most people this mode of existence becomes a problem. Usually, the 4th stage of sleep is significantly reduced, which also decreases with physiological aging.

In turn, secondary insomnia is often situational in nature. It can be associated with somatic pathologies, organic diseases of the central nervous system, affective, associative and adaptive disorders (depression, anxiety syndrome), mental disorders, drug abuse, pain of various nature and other sensitivity disorders.

The most frequent among the listed causes of insomnia are psychological disorders: problems at work and at home, anxiety in everyday situations, physical and mental fatigue, etc. In these cases, insomnia most often goes away when the situation changes and improves.

With depression, along with depressed mood, daytime drowsiness, apathy, unwillingness to do anything, early morning awakening is often noted, and sometimes difficulties with falling asleep.

Among mental illnesses and conditions accompanied by insomnia, it should be mentioned, first of all, mania, arousal attacks, in which the phase of rem sleep disappears.

It is especially important for a pharmaceutical specialist to know about the "chemical factors" of insomnia development, which, in particular, include the intake of intoxicating substances and pharmacological agents. Chronic alcohol intoxication reduces the phase of rem sleep, as well as the 3rd and 4th stages of slow sleep, as a result of which the total duration of sleep decreases. After stopping alcohol intake, sleep is restored, but difficulties with falling asleep, frequent night awakenings remain.

Sleep disorders are also promoted by caffeine, steroids, thyroxine, some bronchodilators and anti-asthmatic drugs, antihypertensive adrenergic blockers of central action, antiarrhythmic drugs, psychostimulants, stimulating antidepressants, levodopa, neuroleptics, tobacco. The use of these substances can cause permanent or periodic short-term sleep disorders.

Neurological diseases can also change the overall duration of sleep and its rhythm. For a long time (for many months and even years), sleep disorders can persist in patients after traumatic brain injuries.

Another classificationDepending on which segment of sleep is disturbed, insomnia can be of several types:

• presomnicheskaya – in case of violation of the process of falling asleep;
• postsomnia – when the awakening process is disrupted;
• intrasomnic – the change in the sleep period between falling asleep and waking up.

Falling asleep disorders are usually associated with anxiety and increased emotional excitability. The emerging desire to sleep disappears as soon as the patients are in bed, painful thoughts and memories arise, motor activity increases and the desire to find a comfortable position. It is possible to increase the itching or pain that bothered during the day. An obsessive fear associated with the onset of sleep is often formed. If a healthy person falls asleep within 3-10 minutes, then in patients it is delayed up to 30-40 minutes, or even longer.

Postsomnia insomnia is characterized by early awakening. As a rule, they are associated with anxiety appearing in the early morning hours and are found in neurosis and depression. Sleep does not bring a sense of rest, and awakening, despite unmotivated anxiety, is accompanied by a "sleepy" state, which is manifested by the inability to quickly engage in active activity, apathy and a reduced mood.\

Intrasomnic disorders are manifested by a feeling of insufficient depth of sleep, frequent awakenings and difficulties falling asleep after them. In the morning, sleep seems insufficient, and sometimes there is even a feeling of complete insomnia at night, although objectively the sleep time may be 6-7 hours. Waking up in the middle of the night is caused by both external (primarily sounds) and internal factors (night terrors, vegetative shifts in the form of respiratory disorders, tachycardia or urge to urinate during sleep). All these factors can also awaken healthy people, but in patients with insomnia, awakening is much easier, and the process of falling asleep after such an episode of awakening is difficult.

A lot of attention has always been paid to the search for effective means to combat insomnia. The main range of drugs that are currently used for the treatment of insomnia is considered by us in the heading "Algorithm for choosing and offering drugs". In this article we would like to touch upon the rationality of pharmacotherapy of insomnia.

Despite the extensive experience of using sleeping pills, it is necessary to remember that they should be used with caution. Prescribe most sleeping pills should be short-term, no longer than 3-4 weeks., and cancel gradually. It is advisable to use the medicine not every day, but with breaks – 2-4 times a week.

Choosing a medicine, it is rational to give preference to short-term drugs, starting with the minimum effective dose. If it is necessary to use sleeping pills for longer than one month, you should change the drug group – prescribe another drug. We must not forget that all hypnotics are characterized by the phenomena of addiction and withdrawal, that these drugs potentiate the effect of alcohol and other drugs with a depressing central effect and can cause side effects, a depressed state, deepening depression. Benzodiazepines, among other things, can provoke headaches that depend on the use of medications.

Usually, doctors recommend that a patient with insomnia adhere to a number of simple rules that help normalize sleep, and if the use of a sleeping pill is unavoidable, reduce the therapeutic dose. These rules are as follows:

• going to bed at the same time. The patient is recommended to adhere to certain hours for sleep, even on weekends;
• performing the same actions before going to bed. With their help, the patient lets his body know that it's time to sleep;
• walking in the fresh air before going to bed;
• taking a warm relaxing shower or bath before going to bed. Streams of water seem to wash away the emotional and physical fatigue accumulated during the day;
• the use of warm foot baths (it is possible with extracts of relaxing herbs), which allow to remove the effects of daytime loads on the lower extremities. Foot massage is also useful in this regard;
• taking a cup of soothing tea an hour before bedtime. Especially beneficial are teas with valerian root, hops, motherwort, dodging peony, lavender flowers, orange, lemon balm leaves, mint;
• a comfortable bed. A mattress that is too small, too soft, too stiff or too old can "scare off" a healthy sleep. You should get rid of a pillow that is too high. Sleepwear should be light and loose;
• isolation of noise impacts. If it is impossible to eliminate the noise source, you can use "earplugs";
• creating and maintaining an optimal microclimate in the bedroom. In summer, when it is hot and humid, air conditioning is used, in winter they resort to using an air humidifier. The room temperature should be between 18-22 °C. Regular cleaning of the bedroom, getting rid of dust is necessary;
• you only need to sleep in a bed. Reading books, watching TV, the patient should take a different place;
• "forgetting problems." The patient should plan the coming day in the early evening, solve complex problems long before going to bed;
• concentration of attention on something abstract, for example, on your own breathing, the process of relaxation. For example, a patient may imagine that a huge glass hood protects him from all sleep disturbances;
• if the patient has a well–developed ability to perceive visual images, you can fix your gaze on a shiny object or familiar soothing plants whose flowers are colored in cold tones - blue, light blue.

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10.02.2009