What causes early awakening?

From the Guidelines

Early awakening is primarily caused by disruptions to your circadian rhythm, which regulates your sleep-wake cycle, and can be triggered by various factors including depression, anxiety disorders, age-related sleep changes, certain medications, and environmental factors. Common causes of early awakening include:

• Depression and anxiety disorders, which can disrupt the body's natural sleep-wake cycle 1
• Age-related sleep changes, which can cause older adults to wake up earlier due to changes in their circadian rhythm 1
• Certain medications, such as SSRIs, stimulants, or corticosteroids, which can interfere with sleep patterns 1
• Environmental factors, such as noise, light, or uncomfortable sleeping conditions, which can disrupt sleep and cause early awakening 1
• Medical conditions, such as sleep apnea, acid reflux, chronic pain, and hyperthyroidism, which can also trigger early morning awakenings 1

To address early awakening, it is recommended to:

• Establish consistent sleep and wake times to regulate the body's internal clock
• Limit screen exposure before bed to reduce the disruption of sleep patterns
• Create a comfortable sleep environment, such as keeping the room cool, dark, and quiet
• Avoid caffeine and alcohol near bedtime, as they can interfere with sleep
• Consider relaxation techniques, such as meditation or deep breathing, to help reduce stress and promote sleep

If early awakening persists and affects daily functioning, it is recommended to consult a healthcare provider who may recommend cognitive behavioral therapy for insomnia (CBT-I) or, in some cases, short-term use of medications like low-dose doxepin (3-6mg) or ramelteon (8mg) to help regulate sleep patterns 1.

From the FDA Drug Label

In a 6-month double-blind, placebo-controlled study of nightly administration of eszopiclone 3 mg, rates of anxiety reported as an adverse event were 2.1% in the placebo arm and 3.7% in the eszopiclone arm. During nightly use for an extended period, pharmacodynamic tolerance or adaptation has been observed with other hypnotics. If a drug has a short elimination half-life, it is possible that a relative deficiency of the drug or its active metabolites (i.e., in relationship to the receptor site) may occur at some point in the interval between each night’s use. This is believed to be responsible for two clinical findings reported to occur after several weeks of nightly use of other rapidly eliminated hypnotics: increased wakefulness during the last quarter of the night and the appearance of increased signs of daytime anxiety

The cause of early awakening may be related to the development of pharmacodynamic tolerance or adaptation to the hypnotic medication, such as eszopiclone, particularly with short-acting hypnotics. This can lead to a relative deficiency of the drug or its active metabolites, resulting in increased wakefulness during the last quarter of the night 2.

From the Research

Causes of Early Awakening

• Age-related changes in circadian rhythm timing and behavior changes contribute to sustained poor sleep and early morning awakenings among older adults 3
• Insomnia, which includes premature wakening, can be a cause of early awakening, and it is often associated with comorbidities such as depression, pain, and illness 4
• Disordered sleep, including sleep apnea, and intrasleep architecture can also lead to spontaneous awakenings 5
• Circadian phase and time awake can influence awakening, and age is a powerful factor that may influence awakening 5

Factors Contributing to Early Awakening

• Lifestyle factors, such as sleep hygiene and environmental factors, can contribute to early awakening 4
• Medications, such as selective serotonin reuptake inhibitors (SSRIs), can disrupt sleep patterns and lead to early awakening 6
• Depression and other psychological factors can also contribute to early awakening 5
• The regulation of awakening is influenced by neurophysiological mechanisms, including the homeostatic and circadian factors 5

Treatment of Early Awakening

• Cognitive-behavioral therapy for insomnia (CBT-I) and circadian interventions, such as timed light exposure, can be effective in treating early morning awakenings 3, 7
• Brief bright-light therapy can phase delay the circadian rhythms of early-morning awakening insomniacs and improve sleep measures and daytime functioning 7
• Sleep hygiene and pharmacological and alternative modalities can also be used to treat early awakening 4