Insomnia

Introduction

Insomnia is a common problem presenting to general practice. It is defined as the inability to initiate or maintain sleep, despite adequate opportunity for sleep.

It can involve:

• Difficulty getting to sleep
• Frequent waking in the night
• Early morning waking, with inability to get back to sleep
• A combination of the above

Many patients under-estimate the amount of sleep they have actually achieved when they have had disturbed sleep. Part of managing the insomnia patient is managing their expectations about how much sleep and the quality of the sleep they should expect to achieve.

There may be an associated or underlying disorder, such as depression, drug use or pain.

• There is an association between chronic insomnia and depression

There are often associated daytime symptoms such as irritability, fatigue, impaired concentration and impaired memory. However, usually patients do not fall asleep easily during the day. 

• If they do, consider sleep apnoea
• About 30% of the general population complain of disrupted sleep
• About 10% of the general population have the associated symptoms of day time disruption required for a diagnosis of insomnia

Many patients present requesting a medication option to “get me to sleep”. In reality, insomnia can be a lengthy and tricky consultation to explore the underlying issues, although very satisfying if successfully resolved.

The European Sleep Research Society, American Academy of Sleep Medicine and Australasian Sleep Association all recommend cognitive behavioural therapy as the first line management of insomnia. In reality, this is often not used as the first line treatment.

History

• Sleep
  • Bed time routine
  • Time they go to bed
  • Time they go to sleep
  • Waking in the night
  • Time the wake up
  • Time they get up
• Lifestyle factors
  • Diet
  • Time that they eat evening meal
  • Caffeine intake
  • Exercise
  • Sexual issues
• Psychiatric history
• Painful conditions
• Drug use (and abuse)
• Alcohol intake
  • Patients often use alcohol as a way of getting to sleep
• Sleep diary
  • Consider a sleep diary with periods of sleep and wakefulness recorded, as well as the effect on daytime functioning
• Ask about underlying disorders (below)

Underlying disorders

There are many underlying disorders than can disturb sleep. Treat these before treating insomnia as a primary issue:

• Drugs
• Alcohol
• Depression
• Restless leg syndrome
• Pain
• Sleep apnoea
• CCF
• Asthma
• GORD
• Thyroid disorders – especially hyperthyroidism
• Menopause
• Urinary frequency
  • e.g. BPH
• Snoring partner!

Management

The ultimate goal is to aim for a restful sleep without the use of medication.

Cognitive behavioural therapy is the recommended first-line intervention by most recognised sleep medicine organisations.

Basic interventions

• Ensure you have excluded any underlying problems
• Explain and reassure that it is not likely indicative of a more serious cause
• Explain that most people with insomnia get more sleep than they realise, and that lack of sleep is not associated with significant physical health problems
• Sleep Hygeine
  • This is a term used to describe methods of providing optimal conditions for a good night’s sleep
  • Establish a bedtime routine, including a regular bed time
  • Try to identify things that help to induce sleep for the patient (e.g. a warm bath, listening to music)
  • Regular time for getting up in the morning
    • Avoid oversleeping
    • Advise exposure to bright light soon after getting up in the morning
  • Regular exercise
    • BUT – avoid strenuous exercise within 3 hours of bed time
  • Avoid long periods of lying in bed worrying about sleeping
    • Instead – encourage patients to get up and do something fairly sedentary, until they feel tired
  • Avoid daytime naps
    • If necessary – limit to 10-15 minutes of a “power nap”
  • Avoid the use of screens in the last hour before going to bed
  • Avoid alcohol and caffeine in the evening
  • Avoid eating within 2-3 hours of going to bed
  • Avoid bright lights in the bedroom around bed time
  • Avoid pets in the bedroom
  • Avoid brightly lit clocks or other items in the bedroom
  • Avoid watching TV, using laptop or tablet or phone whilst in bed
  • Avoid ruminating about worrying issues whilst in bed – if must do this – allocate time earlier in the evening
  • Avoid tobacco – especially in the evening
• Consider mindfulness and meditation exercises as a way of reducing stress
• Inducing sleep
  • Try a warm bath before bed
  • A light snack or warm milk before bed
  • Ensure comfortable temperature for sleep
  • Ensure maximal darkness

Cognitive behavioural therapy (CBT)

• Typically delivered over several sessions by a trained medical practitioner (usually a psychologist)
• Proven to:
  • Reduce sleep latency (time taken to get to sleep)
  • Reduce number of night-time arousals
  • Improve sleep efficiency (amount of time spent asleep vs amount of time spent in bed)
• Is proven to be as effective as medication, without the side effects
  • Effects last at least three years after cessation of CBT
• CBT targets maladaptive beliefs about sleep
  • In particular, patients often worry about not sleeping which leads to a vicious cycle of insomnia

Sleep restriction

Sleep restriction can be an effective technique to induce longer periods of restful sleeping

• Ask the patient to keep a sleep diary
• Using the sleep diary estimate – get the patient to only sleep for this amount of time per night
  • For example – if they estimate only 4 hours of sleep between 10pm and 8am in bed, then get them to only be in bed for four hours each night – e.g. from 2am to 6am
• This will usually result in some sleep deprivation
• Most patients will find within a few days they are sleeping solidly for this 4 hour period
• You can then gradually begin to increase the amount of time in bed by 30 minutes, until the patient is solidly sleeping through for the increased amount of time. Then increase again, in 30 minute increments, until 7-8 hours of good quality sleep is achieved

Pharmacological

Should typically only be used short term, whilst any lifestyle measures are addressed and CBT is arranged.

They may also be used in chronic insomnia where the above methods have not been effective.

Options include:

• Temazepam 10mg PO about an hour before bedtime
  • A benzodiazepine
  • Warn about the risks of addiction and tolerance
• Zolpidem 5mg OD at bed time
  • Warn about possible risks of hallucinations, agitation
  • Avoid use in combination with alcohol
• Zopiclone 3.75mg PO at bed time
  • Zolpidem and zopiclone both potentiate the inhibitory effects of GABAThey are known as hypnotics
  • They have less risk of addiction than benzodiazepines
  • When coming off benzodiazepines and hypnotics – reduce doses slowly
• Melatonin 5mg (or 2mg extended release) PO OD an hour before bedtime
  • An endogenous hormone that promotes sleep
  • Relatively new to the market
  • Not a lot of evince, especially in patients under 55, or for use longer than 3 weeks
  • Many patients complain its effects are too subtle
  • Also used by many doctors to help ‘reset the body clock’ for shift work!Is available over the counter in the US, but requires prescription in Australia
    • Proven to reduce jet-lag when time difference between locations is >5 hours
• Tricyclic antidepressants
  • Especially amitriptyline – often used, but evidence is limited, and should be avoided unless also treating depression
• Anti-psychotics
  • Particularly haloperidol and quetiapine – should NOT be used for insomnia. Risk of significant side effects

References

• Insomnia Management – AJGP
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

Read more about our sources

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