Insomnia– Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Difficulty initiating or maintaining sleep, early morning awakening, nonrestful sleep, nonrestorative sleep, leading to daytime tiredness, low energy, irritability, or difficulty in concentrating
  • Primary: Sleeplessness not caused by another sleep, medical, or psychiatric disorder; or by medications, substances of abuse, or environmental factors
  • Secondary: Sleeplessness due to any of the above factors
  • Transient (<1 week): Secondary to life crises, bereavement, change in environment, or concomitant illness
  • Chronic (>1 month): Associated with medical and psychiatric conditions, drug intake, and maladaptive behavioral patterns

Geriatric Considerations

  • Caution when prescribing benzodiazepines or other sedative-hypnotics to the elderly; use short-acting nonbenzodiazepine benzodiazepine agonists or melatonin agonists if absolutely necessary for short-term treatment of sleep-onset insomnia
  • Increased risk of falls and confusion

Pregnancy Considerations

Transient insomnia occurs secondary to change of sleep position, nocturia, gastritis, back pain, anxiety

Epidemiology

  • Predominant age: Increases with age
  • Predominant sex: Female > Male (1.5:1)

Prevalence

  • Insomnia (transient and chronic): 15–20% of the population
  • Chronic insomnia: 10% middle-aged adults; 1/3 of people >65 years

Risk Factors

  • Age
  • Female gender
  • Chronic illness
  • Obesity
  • Depression/anxiety
  • Polypharmacy
  • Major stressor
  • Shift work

General Prevention

  • Avoid or treat known etiologies.
  • Practice consistent sleep hygiene:
    • Establish regular sleep–wake schedule on weekdays; use same on weekends
    • Sleep in cool, dark, quiet environment
    • No activities or stimuli in bedroom associated with anything but sleep or sex
    • 30-minute wind-down time before sleep
    • If >30 minutes is spent in bed worrying about sleep, move to another environment and engage in quiet activity until sleepiness sets in.
  • Limit caffeine intake to mornings.
  • Do not use alcohol as a sleep aid.
  • No excessive alcohol or smoking in evenings

Etiology

  • Transient/intermittent:
    • Stress/excitement/bereavement
    • Shift work
    • Medical illness
    • High altitude
  • Chronic:
    • Medical: Gastroesophageal reflux disease, chronic obstructive pulmonary disease, asthma, fibromyalgia
    • Psychiatric: Mood and anxiety disorders
    • Primary sleep disorder: Idiopathic (primary), breathing-related, restless leg syndrome, sleep state misperception, parasomnias
    • Circadian rhythm disorder: Irregular pattern, jet lag, delayed/advanced sleep phase, shift work
    • Environmental: Light (LCD clocks), noise (snoring, household, traffic), movements (partner/young children/pets)
    • Neurologic: Dementia, stroke, Parkinson disease and other extrapyramidal disorders, epilepsy, headache/pain, myotonic dystrophy, traumatic brain injury
    • Behavioral: Poor sleep hygiene, psychophysiologic, adjustment sleep disorder
    • Substance-induced

Commonly Associated Conditions

  • Psychiatric disorders
  • Drug or alcohol addiction/dependence
  • Obstructive sleep apnea
  • Restless leg syndrome

Sleep disorder, Sleep hygiene, Circadian rhythm sleep disorder, sedative hypnotics, daytime tiredness, depression anxiety, psychiatric conditions, psychiatric disorder,

Diagnosis

History

  • Perceived reduction in sleep time
  • Initial insomnia: Difficulty in initiating sleep at usual time
  • Middle insomnia: Wakefulness during the usual sleep cycle, tossing and turning
  • Terminal insomnia: Early awakening
  • Daytime sleepiness and napping
  • Unintended sleep episodes (driving, working)
  • Tiredness
  • Anticipatory anxiety
  • Insomnia history:
    • Duration, time of problem
    • Sleep latency, difficulty in maintaining sleep (repeated awakening), early morning awakening, nonrestorative sleep, or patterns (weekday vs weekend, with or without bed partner, home vs away)
  • Sleep hygiene:
    • Bedtime/wakening time
    • Physical environment of sleep area: LED clocks, TV, room lighting, ambient noise
    • Activity: Nighttime eating, exercise, sexual activity
    • Intake: Caffeine, alcohol, herbal supplements, diet pills, illicit drugs, prescriptions, over-the-counter (OTC) sleep aids
  • Related: Medical conditions such as pain, stressors, mood issues, medications/timing of administration
  • Sleep questionnaire: Pittsburgh Sleep Quality Index (1)
  • Sleep diary: Sleep log for 7 consecutive days

Diagnostic Tests & Interpretation

  • Polysomnography for evaluation of sleep apnea, restless legs, parasomnia, or when sleep history does not provide diagnosis
  • Primary insomnia:
    • Symptoms for at least 1 month: Difficulty in initiating/maintaining sleep, or nonrestorative sleep
    • Impairment in social, occupational, or other important areas of functioning
    • Does not occur exclusively during narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or parasomnia
    • Does not occur exclusively during major depressive disorder, generalized anxiety disorder, delirium, etc.
    • Is not secondary to physiologic effects of substance or general medical condition
    • Sleep disturbance (or resultant daytime fatigue) causes clinically significant distress.
  • Secondary insomnia:
    • Due to substance abuse, medication-induced (diuretics, stimulants, etc.), primary depressive disorder, generalized anxiety disorder or phobias, acute situational stress, post-traumatic stress disorder, pain, etc.

Lab

Initial lab tests

Testing to consider based on history and physical exam:

  • Thyroid-stimulating hormone
  • Urine toxicology

Differential Diagnosis

  • Sleep-disordered breathing, such as obstructive sleep apnea:
    • History from partner/family: Snoring, irregular breathing, sleep movements, length of sleep, mood/performance changes
  • Hypersomnia history: Daytime naps, drowsiness, situation/location of daytime sleep; Epworth Sleepiness Scale (1)
  • Central nervous system hypersomnias:
    • Narcolepsy:
      • Excessive daytime sleepiness, cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis
  • Circadian rhythm sleep disturbances
  • Parasomnias:
    • REM sleep behavior disorder
  • Sleep-related movement disorders:
    • Restless leg syndrome (2)
  • Transient stress
  • Substance abuse
  • Pain
  • Insomnia due to medical or neurological disorder
  • Mood and anxiety disorders such as depression or anxiety

Treatment

  • Transient insomnia (<4 weeks)
    • May use medications for short-term use only; benzodiazepines favored
    • Self-medicating with alcohol can increase awakenings and sleep-stage changes.
  • Chronic insomnia:
    • Rule out secondary causes (major depressive disorder, generalized anxiety disorder, medications, substance abuse, etc.).
    • Thorough sleep history, drug/caffeine intake, diet, and exercise pattern may uncover correctable causes.
    • Cognitive behavioral therapy is 1st-line treatment for chronic insomnia, especially in >60 population, especially when sedatives are not going to be advantageous (3)[A].
    • Behavioral therapy can be an effective treatment for insomnia and a potentially more effective long-term treatment than pharmacotherapy (4)[B].
    • Address underlying causes (e.g., pain, drugs/alcohol, depression).
    • Avoid daytime napping; develop bedtime rituals conducive to sleep.
    • Refrain from using bed for anything besides sleeping or sex (no eating, reading, TV)
    • Ramelteon only agent without abuse potential
  • Remove large or bright clocks from bedroom to prevent focusing on how little sleep is accomplished, as well as light stimulus.

Medication

  • Reserved for transient insomnia, such as with jet lag, stress reactions, transient medical condition
  • Nonbenzodiazepine benzodiazepine receptor agonists:
    • Zaleplon (Sonata), 5–20 mg; half-life 1–1.5 hours
    • Zolpidem (Ambien), 2.5–10 mg; half-life 1.5–4 hours
    • Zolpidem ER, 1–3 mg; half-life 5–7 hours
    • Eszopiclone (Lunesta), 1–3 mg; half-life 5–7 hours
  • Benzodiazepine hypnotics:
    • Intermediate-acting:
      • Temazepam, 7.5–30 mg; half-life 8–12 hours
      • Oxazepam, 10–30 mg; half-life 5–15 hours
    • Long-acting:
      • Alprazolam, 0.25–1 mg; half-life 12–20 hours
      • Lorazepam, 0.5–2 mg; half-life 10–22 hours
      • Clonazepam, 0.5–2 mg; half-life 22–38 hours
      • Diazepam, 2.5–10 mg; half-life 20–50 hours
  • Contraindications/precautions:
    • Not indicated for long-term treatment of chronic insomnia due to risks of tolerance, dependency, daytime attention and concentration compromise, incoordination, rebound insomnia
    • Avoid in elderly, pregnant, breast-feeding, substance abusers, patients with suicidal or parasuicidal behaviors
    • Avoid in patients with untreated obstructive apnea and chronic pulmonary disease.
    • Consider risk of falls and cognitive impairment when using sedative hypnotics in those >60 (5)[B].
    • No good evidence to suggest using benzodiazepines for the treatment of insomnia in patients undergoing palliative care (6)[A]
    • Nonbenzodiazepine benzodiazepine receptor agonists may occasionally induce parasomnias (sleep walking, sleep eating, etc.).
  • Ramelteon, 8 mg; half-life 1–2.6 hours
    • Proven to be the one agent without potential to be abused and effective to reduce sleep time onset for short- and long-term use in adults (7)[B]
  • Serotonergic antidepressants:
    • Trazodone, 25–200 mg; half-life 3–9 hours
    • Doxepin, 25–150 mg; half-life 6–8 hours
    • Amitriptyline, 25–150 mg; half-life 10–50 hours
    • Mirtazapine, 15–60 mg; half-life 20–40 hours
  • γ-hydroxy butyrate:
    • Sodium oxybate, 4.5–9 mg; half-life 40 minutes (only for insomnia due to narcolepsy)

Additional Treatment

Insomnia is highly associated with hypertension, congestive heart failure, anxiety and depression, and obesity. Therefore, prevention and optimal management of these chronic conditions will help with incidence and symptoms of insomnia.

Complementary and Alternative Medicine

  • Biologically based practices:
    • Melatonin can decrease sleep latency when taken 30–120 minutes prior to bedtime, but there is no class A evidence for efficacy in insomnia, and long-term effects are unknown (8).
    • Valerian: There is no clear evidence supporting its efficacy in treating insomnia.
  • Although acupuncture has often been reported to help with insomnia, adequately controlled randomized trials supporting its efficacy are lacking (9)[B].
  • Psychotherapy:
    • Cognitive behavioral therapy (including relaxation therapy) is effective and considered more useful than medication treatment for chronic insomnia.

Ongoing Care

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Follow-Up Recommendations

  • Daily exercise improves quality of sleep and may be more effective than medication.
  • Avoid exercise within 3 hours of bedtime.

Patient Monitoring

  • Reassess need for medications periodically; avoid standing prescriptions.
  • Caution patients that nonbenzodiazepine benzodiazepine agonists (zolpidem, zaleplon, eszopiclone), as well as benzodiazepines, can be habit-forming.

Diet

  • Avoid caffeine or reserve for morning only.
  • Avoid heavy late-night snacks (light snack at bedtime may help).
  • Avoid alcohol within 6 hours of bedtime.

Patient Education

Describe limitations and side effects of drugs used for insomnia.

Prognosis

  • Situational insomnia should resolve with time.
  • Treatment of underlying etiology and consistent sleep hygiene are the mainstays of treatment.

Complications

  • Transient insomnia can become chronic.
  • Daytime sleepiness, cognitive dysfunction
  • Pulmonary hypertension (HTN) if chronic sleep apnea left untreated
  • Sleep apnea may lead to HTN, stroke, or cardiac ischemia.

References

1. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213.

2. Panossian LA, Avidan AY. Review of sleep disorders. Med Clin North Am. 2009;93:407–25, ix.

3. Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2003;CD003161.

4. Ebben MR, Spielman AJ. Non-pharmacological treatments for insomnia. J Behav Med. 2009.

5. Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005;331:1169.

6. Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev. 2002;CD003346.

7. Reynoldson JN, Elliott ES, Nelson LA. Ramelteon: A Novel Approach in the Treatment of Insomnia (CE) (September). Ann Pharmacother. 2008.

8. Verster GC. Melatonin and its agonists, circadian rhythms and psychiatry. Afr J Psychiatry (Johannesbg). 2009;12:42–6.

9. Huang W, Kutner N, Bliwise DL. A systematic review of the effects of acupuncture in treating insomnia. Sleep Med Rev. 2009;13:73–104.

Additional Reading

See Also (Topic, Algorithm, Electronic Media Element)

Anxiety; Depression; Fibromyalgia; Sleep Apnea, Obstructive

Algorithms: Insomnia, Chronic; Restless Leg Syndrome (RLS); Anxiety

Codes

ICD9

  • 307.41 Transient disorder of initiating or maintaining sleep
  • 307.42 Persistent disorder of initiating or maintaining sleep
  • 780.52 Insomnia, unspecified
  • 307.49 Other specific disorders of sleep of nonorganic origin

Snomed

  • 193462001 Insomnia (disorder)
  • 3972004 primary insomnia (disorder)
  • 191997003 persistent insomnia (disorder)
  • 192454004 nonorganic insomnia (disorder)
  • 268652009 transient insomnia (disorder)

Clinical Pearls

  • Treatment of underlying etiology of the insomnia and consistent sleep hygiene are key.
  • Most medications used to treat insomnia are indicated for short-term use only. Eszopiclone is the only medication for insomnia to have been tested for daily use over a 6-month period.
  • Weigh the risks and benefits of pharmacological treatment and consider short-term vs long-term goals when planning your treatment regimen.
  • Patients with chronic insomnia may benefit from cognitive behavioral therapy.

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