Special Populations

Women

The prevalence of insomnia appears to be higher in women than men, and whilst the reasons are not completely understood, clinicians should be aware that the clinical presentation of insomnia in women is different to men⁹⁷. Women are more likely to complain of insomnia, headache, irritability and fatigue than the ‘typical’ symptoms of loud snoring and breathing cessation in men⁸⁹. Hormones play an important role in sleep in women:

• Menopause. Insomnia increases as women approach and pass through the menopause often caused by hot flushes due to hormonal changes, psychiatric disorders and a rise in the incidence of sleep-disordered breathing⁸.
• Pregnancy. Many women complain of poor sleep during pregnancy. In the first trimester, nausea, backache and urinary frequency can cause sleep disturbance. The second trimester tends to be easier but foetal movements and heartburn may cause problems. By the third trimester, sleep is more disturbed with complaints again of urinary frequency and backache in addition to cramps, itching and unpleasant dreams. Most women fall asleep easily but wake more frequently. Snoring and sleep-disordered breathing, especially in obese subjects can also occur and affect sleep quality.

Older people

The nature of sleep changes with age. Older age is associated with poorer objectively measured sleep with shorter sleep time, diminished sleep efficiency, and more arousals. These changes may be more marked in men than in women, as reported in a large study of over 5,000 elderly people living at home in the USA⁹¹. In the same study the association of subjective reporting of poor sleep with older age was conversely stronger in women. The higher prevalence of chronic health conditions, including sleep apnoea, in older adults did not explain changes of sleep parameters with aging and age/sex differences in these relationships.

Special consideration should be given to the treatment of insomnia in older patients as the motor side effects of some sleep-promoting drugs can lead to an increased risk of falls.

Children

Sleep problems are commonly associated with certain genetic and neuro-developmental problems seen in childhood, including ADHD, autism, learning difficulties and epilepsy. The profound impact on the physical and mental health of a child and the distress for families and carers of children with long-term sleep disorders should not be underestimated³⁹. Training and awareness of paediatric sleep disorders is poor, and accurate diagnoses and hence appropriate treatments are often delayed⁹⁷. There is a growing body of evidence describing abnormal melatonin secretion in children with neuro-developmental disorders which has prompted its off-label use to treat sleep disorders in this population³⁹⁶⁵.