Why can't I sleep properly any more?

Sleep problems come in distinguishable shapes, and the shape matters more than the total hours. Difficulty falling asleep points one way — an active mind, a delayed body clock, caffeine, screens. Waking in the middle of the night and staying awake points another — alcohol, reflux, hot flushes, anxiety, sleep apnoea, needing to pass urine. Waking too early and not getting back is associated with low mood. Sleeping through and still waking unrefreshed is the pattern most likely to be sleep apnoea.

Obstructive sleep apnoea, which is substantially under-diagnosed in India. The airway narrows repeatedly through the night, oxygen dips, and sleep fragments without the person being aware of it. The clues are loud snoring, pauses in breathing that someone else has noticed, waking with a dry mouth or headache, and daytime sleepiness. It matters beyond tiredness: untreated, it drives blood pressure, glucose and cardiac risk. South Asians develop it at lower body weights than most reference populations, and neck circumference often tells more than weight.

The perimenopausal transition. Night sweats and hot flushes wake many women repeatedly through the second half of the night, and falling oestrogen and progesterone change sleep architecture independently of flushes. This is one of the most common reasons sleep changes in the forties and fifties, and it is frequently attributed to stress instead.

Thyroid disease. An overactive thyroid produces difficulty falling asleep with palpitations, tremor and heat intolerance. An underactive thyroid contributes to unrefreshing sleep and daytime heaviness, and increases the likelihood of sleep apnoea.

Reflux. Acid reaching the food pipe when lying flat causes waking, sometimes with a burning sensation, sometimes with coughing or a sour taste, and sometimes with no symptom the person connects to the gut at all. A late, heavy dinner followed by lying down within the hour — a common Indian schedule — sets this up reliably.

Mood, stress and the loop that builds. Anxiety delays sleep onset; low mood characteristically causes early waking. Beyond that, insomnia develops its own momentum: after several bad nights the bed becomes associated with lying awake, and the anticipation itself keeps people up. That loop is treatable, and it responds better to behavioural approaches than to tablets.

The things that are easy to change once noticed. Caffeine has a half-life of around five to six hours, so an evening tea or coffee is still present at bedtime. Alcohol shortens sleep onset and wrecks the second half of the night. Screens late, irregular schedules, shift work and daytime naps all shift the body clock.

Physical causes worth naming. Restless legs syndrome — an urge to move the legs at rest, better with movement, worse at night — is strongly associated with iron deficiency and is easily missed. Nocturia from uncontrolled diabetes or prostate enlargement. Chronic pain. Medicines, including steroids, some antidepressants, decongestants and certain asthma treatments.

ⓘThis information is educational and not a diagnosis.

Some sleep problems carry risk beyond tiredness, and they need to be raised specifically.

Seek prompt assessment if someone has witnessed you stop breathing during sleep, particularly with loud snoring and daytime sleepiness. Falling asleep while driving, at work, or during a conversation needs urgent attention — that is a safety matter as well as a medical one.

Waking suddenly gasping or choking, or chest pain and breathlessness that come on when lying flat, warrant early medical review, since both the heart and the lungs can present this way.

Acting out dreams, sleepwalking, or repeated night-time confusion deserve assessment rather than reassurance. So does going several days with very little sleep while feeling energetic and restless, which is a different clinical picture and needs its own attention.

If you are having thoughts of harming yourself, or feel you cannot go on, please seek help today — from a doctor, a mental health professional, or someone you trust.

Beyond these, it is reasonable to see a doctor when poor sleep has continued for more than three months, when it is affecting work and mood, or when you have been relying on a sleeping tablet — prescribed or otherwise — for longer than a few weeks.

Keep a sleep diary for two weeks before changing anything. Record when you got into bed, roughly when you fell asleep, how many times you woke and for how long, when you finally got up, and how the next day felt. Add caffeine, alcohol, dinner time and any medicines. People are poor judges of their own sleep from memory, and two weeks of notes frequently makes the pattern obvious.

Ask whoever sleeps near you two questions: do I snore loudly, and have you seen me stop breathing. Those two answers redirect a large share of these consultations toward the right investigation.

Then change the things that are free. Keep a consistent wake time, including weekends — that anchors the body clock more effectively than a consistent bedtime. Get daylight within an hour of waking. Move caffeine to before mid-afternoon. Finish dinner three hours before lying down, which helps reflux and sleep together. If you have been awake for twenty minutes and are becoming frustrated, get up, sit somewhere dim and dull, and return when sleepy — protecting the association between bed and sleep is one of the more effective things you can do.

If sleep remains disrupted after six to eight weeks, the useful next step is an assessment rather than a stronger tablet. Cognitive behavioural therapy for insomnia outperforms medication over the long term. Where sleep apnoea is suspected, a sleep study answers the question directly. And thyroid function, iron studies where restless legs feature, and HbA1c are worth checking alongside, because sleep is often reporting on something else.