Trouble sleeping (insomnia)
Sleep
Different people need different amounts of sleep. On average, adults need 7 to 9 hours each night.
A sleep cycle lasts about 90 to 120 minutes. It is normal to wake up briefly at the end of each cycle. We naturally sleep less deeply and wake more often as we get older.
What is insomnia?
Insomnia means having trouble getting to sleep or staying asleep, or waking up still feeling tired.
There are many reasons why people affected by cancer might have trouble sleeping.
Sleeping less does not always mean you have insomnia. For example, you may:
- naturally sleep less on some nights than others
- sleep less at night because you are doing less during the day
- sleep less at night but not feel tired during the day
- sleep less at night because you have a nap during the day
- work shifts or have young children, but you are able to sleep when you have the chance.
You may have insomnia if you:
- find it difficult to fall asleep
- wake up often in the night, or lie awake for long periods
- wake up very early and cannot get back to sleep
- feel tired when you wake and get up
- feel tired and irritable or find it hard to concentrate during the day because of lack of sleep.
Insomnia can be described as:
- short term – when it lasts for less than 3 months
- long term (chronic) – when it lasts for 3 months or more.
Anxiety and sleep
Worry and anxiety are normal reactions when you are diagnosed with cancer. These feelings can come and go, depending on what is happening at the time. But managing worry and anxiety can be difficult. They can affect your daily life, including your sleep. There are things you can do to help:
- Talk to someone – this may be a friend, partner, family member, doctor or nurse, or a professional counsellor or psychologist.
- Focus on your breathing – breathe in slowly and deeply through your nose and breathe out slowly through your mouth.
- Practise mindfulness – paid apps such as Headspace and Calm and free apps such as Healthy Minds Program can help.
- Close your eyes and listen to your surroundings, or to music.
- Move more during the day, especially outdoors – even a short walk can help.
- Try complementary therapies, such as yoga, meditation, massage or reflexology.
- Keep a diary or journal – this can help you recognise things that trigger your anxiety. Writing down your worries at night may help you sleep better, as you can work through them during the day.
Sleepio offers a 6-week sleep improvement programme to help you sleep better if you have increased worries. You can sign up for free.
If you feel your anxiety is getting worse, speak to a member of your healthcare team. They can help you find ways of coping. Speaking to your healthcare team is the best way to get the help you need.
You can also visit our Online Community forum to talk with people who have been affected by sleep problems, share your experience, and ask an expert your questions.
Relaxation techniques
Simple breathing and relaxation exercises may be very useful in reducing anxiety and stress. They can also reduce muscle tension. Almost anyone can learn relaxation techniques. You can learn them at home using CDs, apps or podcasts. Or you may prefer to join a group.
The following organisations offer relaxation resources:
- Penny Brohn – you can book to attend an online relaxation session.
- the Pain Relief Foundation – you can buy a relaxation CD.
- Mind - provides relaxation tips and techniques you can try.
Some hospitals and support groups offer relaxation sessions. You can ask if they are provided at your hospital.
You may find it helpful to contact Anxiety UK. You may also find that it helps to join a support group. We have more information about talking therapies.
Causes of insomnia
Many things can cause sleep problems and insomnia. Some can affect anyone, such as worry and anxiety. But others might be because of cancer or cancer treatment.
Things that may affect your sleep include:
- worry, anxiety, depression or other emotions
- being uncomfortable, having pain or feeling unwell
- your bedroom feeling too hot or cold
- noise or light
- sleeping during the day or not being active during the day
- having different sleep routines from other people at home
- smoking, or drinking alcohol or caffeine
- taking medicines that affect sleep, such as steroids.
Things you can do that might help
You might find having a bedtime routine helps you to fall asleep. You could try:
- having a caffeine-free hot drink
- taking a warm bath
- reading in bed for a while.
We have included other suggestions on this page that might help you sleep. These changes are often called sleep hygiene. Sleep hygiene is an awareness of how your activities and environment can affect your sleep.
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Sleep for a set amount of time
Most adults need 7 to 9 hours of sleep each night. But you may be fine with less sleep if you feel refreshed when you wake. A regular sleep routine can help with sleep problems. Some people find their sleep is better when they go to bed and get up at a similar time every day. Go to bed when you feel sleepy and avoid going too early.
Some people find that taking a nap in the day can help them sleep at night. But this is not the case for everyone. If you take naps, shorter naps earlier in the day are less likely to affect sleep at night.
Some people find getting out of bed for a 10-minute break helps when they find they are awake for long periods at night. It is best to avoid screens such as phones and tablets in bed, as these devices can stimulate your brain. If watching or listening to a relaxing programme makes you feel sleepy, try setting a timer so you do not stay up too long.
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Physical activity
Physical activity can help with sleep. Being active might feel hard if you are coping with symptoms or treatment side effects. But even something small can help. Try regular, short walks or a little gentle gardening. Have some time to relax before bed, though.
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Keep your bedroom comfortable, relaxing and just for sleep
Keeping your bedroom quiet and dark can help with sleep problems. Having light in the room can affect your body clock (circadian rhythm). Your body clock responds to more light in the daytime and less light at night. Curtains or blinds with blackout lining can help with this. Ear plugs may also help stop noise from keeping you awake.
Temperature can affect sleep. If your room is too warm, your body does not feel as ready for sleep. Being too cold can also affect sleep. Try to keep your room at a comfortable temperature.
It is good to associate your bedroom with sleep. It can help to go to another room if you feel wide awake during the night. You can then go back to your bedroom when you feel sleepy. If you nap during the day, it can help to go to your bedroom to do this.
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Avoid screens
Screens, such as mobile phones, laptops and tablets, emit a blue light that can affect falling asleep. Using these devices can make your brain more active, which may delay sleep.
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Eating and drinking
Eating and drinking before bed can disturb your sleep. But so can going to bed hungry. You could try having a light snack, warm milk or other hot drink before going to bed. But avoid large amounts of food or lots of fluid.
Some food and drinks affect sleep. Try to avoid anything that contains caffeine or sugar, such as coffee, tea, cola and chocolate. Caffeine and sugar are stimulants, which means they can make you feel awake. Smoking is also a stimulant and best avoided close to bedtime. It may seem like alcohol is helping you fall asleep, but it causes interrupted sleep, so it is best to avoid it.
Medicines that can cause insomnia
Some cancer treatments can cause sleep problems. Your cancer team can give you advice about these. Steroids can make you feel alert, so your cancer team may suggest taking them in the morning.
Sometimes treatment side effects can affect your sleep. For example, hormonal therapy for breast or prostate cancer can cause hot flushes and sweats. These may keep you awake. Your cancer team can give you advice about coping with hot flushes.
Some cancer treatments can make you feel drowsy. It may be helpful to take these at bedtime. But it is important to check with a member of your healthcare team before making any changes to your medicines.
Treating insomnia with sleeping tablets
If sleep problems are making your life difficult, you may be able to take a short course of sleeping tablets. Sleeping tablets are usually only prescribed for a few days or weeks.
If you think sleeping tablets may help, talk to your doctor. They can advise whether they might be suitable for you.
Sleeping tablets come in different types called benzodiazepines and non-benzodiazepines. They work in different ways. Benzodiazepines may be used if anxiety is causing your sleep problems or making them worse.
Benzodiazepines include:
- diazepam
- lorazepam.
Non-benzodiazepines include:
- zolpidem
- zopiclone.
Side effects of sleeping tablets
Some people still feel effects from the sleeping tablets when they wake in the morning. These effects usually pass quickly.
Some of the most common side effects of sleeping tablets are:
- being clumsy or having poor co-ordination
- feeling light-headed, dizzy or sleepy
- difficulty concentrating or thinking clearly.
Sleeping tablets may increase the risk of having a fall if you get up during the night.
You should not drive if you feel sleepy, dizzy or unable to concentrate.
Tolerance and dependence on sleeping tablets
Doctors are careful when prescribing sleeping tablets. This is because sleeping tablets can cause problems with tolerance and dependence.
Drug tolerance means that as you continue to take a drug, it begins to feel as though it is no longer helping. You may need a higher dose to get the same effect. In time, the higher dose will also begin to feel as though it has no effect, while side effects may get worse.
Drug dependence means that you may get withdrawal symptoms if the drug is suddenly stopped. Withdrawal symptoms can include:
- feeling anxious
- feeling restless
- difficulty sleeping.
For some people, withdrawal can feel similar to the symptoms of insomnia.
Tolerance and dependence may sound worrying. But most people do not have these problems if they are only taking sleeping tablets for a short period of time. Talk to your doctor if you are worried about tolerance or dependence.
Melatonin
Melatonin is a natural hormone that you can take as a tablet. It is used to treat insomnia as well as some other conditions. In the UK, melatonin is only licensed as a short-term treatment for insomnia to people over the age of 55. So far, research has shown that melatonin causes fewer problems with tolerance and dependence. But for most people, it only reduces the time it takes to get to sleep by about 30 minutes.
Melatonin can cause drowsiness. You should not drive if you feel sleepy.
Over-the-counter medicines
Sleeping tablets do not always need to be prescribed by a doctor. You can buy them over the counter in a pharmacy. Over-the-counter sleeping tablets can be useful in the short term. But many people find if they take them for long periods, they develop a tolerance to these drugs. Sometimes these medicines are herbal. But other types often contain anti-allergy medication (antihistamines).
Over-the-counter medicines are not suitable for everyone. They may not be recommended if you are taking other treatments. If you are thinking of trying an over-the-counter medicine, speak to your doctor, specialist nurse or pharmacist first. Some medicines should not be taken together because they might affect how your cancer treatment works or cause you to have side effects.
Treating insomnia with behavioural therapy
Behavioural therapy helps to change the way you think, feel and behave when it comes to sleeping. The main types of behavioural therapy used for improving sleep are sleep restriction, stimulus control, mindfulness and cognitive behavioural therapy for insomnia (CBT-I).
Sleep restriction
For some people, spending too much time in bed means they wake up too early. Sleep restriction aims to help you go to bed at certain times, usually later than you normally would. This helps you get regular amounts of good-quality sleep.
Stimulus control
People who regularly have difficulty sleeping can have a strong mental link between their bed and not sleeping. Stimulus control therapy aims to break that link by encouraging people to use the bed only for sleeping. If possible, you should do other activities such as watching television, using a laptop or eating in a different room. If you worry while lying in bed, this therapy recommends you go to another room and try to distract yourself until you feel tired. This aims to break the mental link between your bed and worrying.
Mindfulness
Some people have trouble getting to sleep because their mind becomes active at bedtime. Mindfulness can help with this.
Mindfulness is being aware of your thoughts and feelings in the present moment. It uses techniques such as meditation, breathing exercises and yoga to help you focus on what is happening at that time. It can help you change the way you think about things. This can also help reduce stress and anxiety. You can search for mindfulness apps online.
Mindfulness classes are available from:
- the NHS – ask your doctor about what is available in your area or at your hospital
- Every Mind Matters – has a free Mind Plan, along with tips to help deal with stress and anxiety
- Mind – offers courses that are available throughout England and Wales
- Buddhist centres – offer courses that are available in England, Scotland and Wales
- Aware – the national depression charity for Northern Ireland, which runs courses in mindfulness
- private practitioners – search for a certified mindfulness teacher at Be Mindful.
The Mental Health Foundation has guides you can download called How to look after your mental health using mindfulness and How to sleep better.
Cognitive behavioural therapy for insomnia (CBT-I)
Cognitive behavioural therapy (CBT) is a talking therapy. It can help you manage your problems better by changing the way you think and behave, which can have a powerful effect on how you feel. Anxiety can often cause unhelpful patterns of thinking and behaviour. These can lead to the problem getting worse and other effects such as sleep problems.
CBT helps you change these negative patterns, including negative thoughts about sleep. It can also help you deal with worries about not getting enough sleep and the effect this can have on your day-to-day routine.
The therapist will help you recognise the negative thoughts and help you find ways to change them. Understanding the reasons for your sleep problems can be reassuring.
Cognitive behavioural therapy for insomnia (CBT-I) is a programme that combines:
- sleep hygiene – things you can do to help you get a good night’s sleep
- sleep restriction
- stimulus control
- mindfulness.
CBT-I is available through some psychology services. The therapist may do sessions online or face to face. They may work with 1 person at a time or groups.
Healthcare professionals in the NHS also recommend a CBT-I-based app called Sleepio. Sleepio offers a 6-week sleep improvement programme to help you sleep better if you have increased worries.
You can ask your cancer doctor, specialist nurse or GP about any local support services that are available to you. You can also search for therapists on the British Association of Behavioural and Cognitive Psychotherapies (BABCP) website.
About our information
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer.
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References
Below is a sample of the sources used in our ulcerating cancer wounds information. If you would like more information about the sources we use, please contact us at informationproductionteam@macmillan.org.uk
Wilson, S., Anderson, K., Baldwin, D., et al. (2019) British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. Journal of Psychopharmacology 33(8), 923-947. www.bap.org.uk/pdfs/BAP_Guidelines-Sleep.pdf (accessed October 2023)
NICE (2022) Sleepio to treat insomnia and insomnia symptoms. Medical technologies guidance (MTG70). National Institute for Health and Care Excellence. www.nice.org.uk/guidance/mtg70 (accessed October 2023)
NICE. Insomnia | Health topics A to Z | CKS | NICE (accessed October 2023)
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