Sleep Problems: Common Causes and What Helps

Types of sleep problems

Common causes of sleep problems

Lifestyle and environment

• Caffeine: from coffee, tea, cola, energy drinks and some medicines. Its effects can last 6 hours or more.
• Alcohol: helps you fall asleep but disrupts sleep in the second half of the night.
• Nicotine, a stimulant.
• Screens and light: bright light in the evening delays the body clock.
• Irregular schedules: shift work, jet lag, late weekends.
• Late heavy meals and exercise close to bedtime.
• A bedroom that is too warm, noisy or bright.

Mental health

• Anxiety and stress: racing thoughts make it hard to fall asleep.
• Depression: often causes early-morning waking, or sometimes oversleeping.
• PTSD: nightmares and hypervigilance.
• Bipolar disorder: reduced need for sleep during mania.

Medical conditions

• Pain: arthritis, back pain, headaches, fibromyalgia.
• Acid reflux, worse lying down. See GERD.
• Needing to urinate at night (nocturia) from an enlarged prostate, overactive bladder, diabetes or heart failure.
• Breathing problems: asthma, COPD, nasal congestion.
• Menopause: hot flashes and night sweats disrupt sleep.
• Overactive thyroid, heart failure, Parkinson's disease, dementia.
• Pregnancy, especially in the third trimester.

Medicines

Some antidepressants, steroids, decongestants, beta blockers, stimulants for ADHD, diuretics taken late in the day, and some asthma medicines can disrupt sleep. Sleeping pills and alcohol can cause rebound insomnia when stopped.

Sleep problems in different groups

• Older adults: sleep becomes lighter and more broken, and the body clock shifts earlier. Pain, nocturia and medicines contribute. Total sleep need does not drop much.
• Teenagers: a natural shift toward later sleep and wake times, colliding with early school starts, causes chronic sleep loss.
• Women: periods, pregnancy and menopause all affect sleep. Insomnia is more common in women.
• Children: bedtime resistance, night waking, night terrors and snoring from enlarged tonsils and adenoids.

How sleep problems are diagnosed

A doctor will ask about your sleep schedule, how long it takes to fall asleep, night waking, snoring, leg symptoms, mood, caffeine, alcohol and medicines, and how you feel during the day. A bed partner's description helps. You may be asked to keep a sleep diary for 1 to 2 weeks.

Tests include:

• Questionnaires such as the Epworth Sleepiness Scale or the Insomnia Severity Index
• Home sleep apnea test, worn overnight to measure breathing and oxygen
• Polysomnography: an overnight study in a sleep lab measuring brain waves, breathing, oxygen, heart rate and leg movements
• Multiple sleep latency test for narcolepsy
• Actigraphy: a wrist device worn for 1 to 2 weeks to track sleep-wake patterns
• Blood tests for iron (ferritin, important in restless legs), thyroid function and other conditions

Treatment for sleep problems

Cognitive behavioral therapy for insomnia (CBT-I)

CBT-I is recommended as the first treatment for chronic insomnia by major medical bodies, ahead of sleeping pills. It is usually delivered over 4 to 8 sessions, in person or through digital programs, and includes:

• Stimulus control: use the bed only for sleep and sex. If you cannot sleep within about 20 minutes, get up and do something calm in dim light until sleepy.
• Sleep restriction: temporarily limiting time in bed to match actual sleep time, to build sleep drive, then gradually extending it.
• Changing unhelpful thoughts about sleep.
• Relaxation techniques and sleep hygiene.

Medicines

Sleeping pills can help short term but carry risks, including next-day drowsiness, falls in older adults and dependence. Options a doctor may consider include short-acting hypnotics, low-dose doxepin, melatonin receptor agonists and orexin receptor antagonists. Over-the-counter antihistamine sleep aids (diphenhydramine, doxylamine) are not recommended for long-term use, especially in older adults, because of confusion and falls. Melatonin is most useful for body clock problems such as jet lag and delayed sleep phase.

Treating specific disorders

• Sleep apnea: CPAP, oral appliances, weight loss and positional therapy
• Restless legs: iron replacement if ferritin is low, avoiding triggers, and prescription medicines
• Narcolepsy: wake-promoting medicines and scheduled naps
• Circadian disorders: timed light exposure and melatonin

Tips to sleep better

• Keep the same wake-up time every day, including weekends.
• Get bright light, ideally daylight, in the morning.
• Avoid caffeine after midday and limit alcohol, especially within 3 hours of bed.
• Stop screens 30 to 60 minutes before bed and keep phones out of the bedroom.
• Keep the bedroom cool, dark and quiet.
• Exercise regularly, but finish vigorous exercise at least a few hours before bed.
• Avoid long naps. If you nap, keep it under 30 minutes and before mid-afternoon.
• Wind down with a regular routine such as reading, a warm shower or relaxation exercises.
• Do not lie in bed awake watching the clock.

Frequently asked questions

What causes sleep problems in adults?

Common causes are stress, anxiety and depression, caffeine and alcohol, irregular schedules, screens late at night, pain, acid reflux, needing to urinate at night, menopause and some medicines. Sleep disorders such as insomnia, sleep apnea and restless legs syndrome are also common and treatable.

Why do I keep waking up at night?

Waking at night is often caused by needing to urinate, alcohol, stress, pain, reflux, hot flashes, a noisy or warm bedroom, or sleep apnea. Early-morning waking that you cannot get back to sleep from can be a sign of depression. A sleep diary can help identify the pattern.

What are the types of sleep problems?

The main types are insomnia, sleep-related breathing disorders such as sleep apnea, movement disorders such as restless legs syndrome, circadian rhythm disorders, conditions causing excessive sleepiness such as narcolepsy, and parasomnias such as sleepwalking and nightmares.

When should I see a doctor about sleep problems?

See a doctor if poor sleep happens 3 or more nights a week for more than 3 months, affects your mood, work or driving, or comes with loud snoring, breathing pauses, leg discomfort, sudden daytime sleep attacks or unusual behaviors during sleep.

Is melatonin good for sleep problems?

Melatonin is most helpful for jet lag and body clock problems such as delayed sleep phase. Evidence for chronic insomnia is modest. Use a low dose, taken 1 to 2 hours before bedtime, for short periods, and check with a doctor if you are pregnant, take other medicines or are giving it to a child.