Insomnia resident survival guide
|Insomnia Resident Survival Guide Microchapters|
Synonyms and keywords: Sleep difficulty, primary insomnia
Insomnia means the inability to sleep or a total lack of sleep. The word 'insomnia' comes from the Latin word "in" which means no and "somnus" which means sleep. It is critical to find out if the patient is really suffering from insomnia and if there is a problem in falling asleep or if it is difficult to remain asleep or return to sleep after awakening. Finding out the underlying cause of insomnia is also important. Insomnia can be idiopathic or could be due to circadian rhythm sleep disorder, depression, stress, anxiety, substance use, obstructive sleep apnea, poor sleep hygiene, restless leg syndrome or due to medications or general health disorders. Insomnia can be divided into mild, moderate, and severe. In mild insomnia patients complain of an insufficient amount of sleep or not feeling rested after the habitual sleep episode almost every night which is accompanied by little or no evidence of impairment of social or occupational functioning. Moderate insomnia means an insufficient amount of sleep or not feeling rested after the habitual sleep episode every night which is accompanied by mild or moderate impairment of social or occupational functioning. Severe insomnia presents with severe impairment of social or occupational functioning and is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness. In the approach to treating insomnia, a thorough history review is critical. Patients should be asked about their sleep routines, sleep quality and the duration of the complaint, daytime naps, medications they take and past medical and mental histories. If depression or alcohol abuse is suspected, further questions should be asked. Laboratory investigations to rule out anemia and thyroid disorders could be required for selected patients. Non-pharmacological and pharmacological treatments are two certain treatment approaches for insomnia.
- Primary insomnia
- Circadian rhythm disorder, such as:
- Obstructive sleep apnea
- Poor sleep hygiene:
- Restless leg syndrome
- General health problems:
- Medication induced insomnia:
- Age related insomnia
Abbreviations: EEG: Electroencephalogram; EOG: Electrooculography; ECG: Electrocardiograph; BMI: Body Mass Index: TSH: Thyroid Stimulating Hormone
|Patient with insomnia|
Ask the following questions:
❑ Do you have trouble in falling asleep? Or do you wake up too early?
❑ Do you struggle going back to sleep if you wake up during the night?
❑ Do you take any sleeping-pills or any other medications to help you sleep?
❑ How often does your insomnia occur? How many nights have you suffered from the same problem each week? Do you notice any association between your symptom and seasonal changes or menstrual cycle (if applicable)?
❑Tell me about any disturbances at home that may have affected your sleep, such as lights, temperature, loud noise or any other environmental factors.
Ask the following questions about sleep routine:
❑ When do you go to bed usually?
❑ How much time is generally required to fall asleep?
❑ When do you wake up in the morning?
❑ Do you wake up throughout the night? If yes, please tell me the number and duration of your awakenings per night.
❑How many hours do you sleep regularly at night?
❑ Do you usually take a nap during the day?
❑ Do you have a specific work schedule that may affect your sleep?
❑ Do you have the same schedule on the weekends or during holidays?
Ask the following questions about insomnia time span:
❑ Tell me when and how did it start?
❑ How many days/months have you had sleep problems?
❑ Do you remember any particular event/stress going on that time?
❑ Have there been any changes in your sleep patterns since then?
❑ Are there any factors that further augment the problem?
❑ Are there any factors that decrease the problem?
Ask the following questions about past history :
❑ Did you sleep well previously?
❑ Tell me more about your sleep pattern in your early life.
❑ Tell me more about your sleep pattern in your adulthood.
❑ Did you have similar episodes previously? If yes, how did they subside? Have you taken any medication or therapy for your problem in the past?
Ask the following questions about mental and psychological health:
❑ Can you cope well with stressful/unexpected situations?
|Do initial screening for depression with the patient health questionnaire (PHQ)-9|
PHQ-9 questionnaire: Over the last 2 weeks, how often have you been bothered by any of the following problems?
❑ Have you felt little interest or pleasure in doing things that you used to enjoy previously?
❑ Have you been feeling down, depressed, or hopeless?
❑ Did you have trouble falling or staying asleep, or sleeping a lot?
❑ Have you had a feeling of being tired or having little energy?
❑ Did you have a poor appetite or habit of overeating?
❑ Have you felt bad about yourself or that you are a failure or have let yourself or your family down?
❑ Do you notice any trouble with concentrating on things, such as reading a newspaper or watching television?
❑ Did you ever move or speak so slowly that other people could have noticed? Have you been fidgety or restless/moving around much more than usual?
❑ Have you ever had thoughts of hurting yourself or committing suicide?
|Do initial screening for alcohol abuse with CAGE questionnaire|
Ask the following CAGE questionnaire :
❑ Have you ever felt that you need to cut down on your drinking?
❑Have people annoyed you by telling you to stop drinking?
❑ Have you ever felt guilty about drinking?
❑ Have you ever felt you needed a drink first thing in the morning (Eye-opener)?
|If two answers are yes, do further evaluation for alcoholism.|
|Do you take a daytime nap? If yes, tell me about frequency, timing, and duration||Longer naps may cause difficulty in falling asleep at night|
|How often do you experience difficulty in falling asleep? Does it change on holidays or weekends?||If the patient sleeps better when on holiday or on the weekend, think of delayed sleep phase disorder|
|How do you feel on awakening?|
❑ Do you feel unrefreshed and sleepy after getting up from bed?
❑Have you suffered from a headache or dry mouth?
❑Ask about daytime sleepiness.
❑ Do you snore, ask partners if possible, about heavy snoring, pauses in breathing, and gasping
|Run more evaluation for obstructive sleep apnea if the patient has high body mass index (≥30) or neck circumference of 40 cm or more, or if feels unrefreshed and sleepy through the day or snores at nights.|
The following physical examination and laboratory investigations are needed to rule out other diseases such as chronic obstructive pulmonary disease (COPD), thyroid disease, REM sleep disorders, asthma, or restless leg syndrome:
❑ TSH, serum T3, serum T4
❑ Respiratory examination
❑ Ferritin levels: Low level has been associated to [restless leg syndrome]]
❑ Complete blood count to rule out anemia
|Perform polysomnography: to confirm sleep apnea and limb movement disorders or restless legs syndrome. It measures brain and muscle activity and assesses oxygen saturation throughout the night when patient is asleep.|
|Patient with insomnia|
|Non-pharmacological treatment||Pharmacological treatment|
|• Stimulus control therapy
• Sleep restriction
• Relaxation therapies
• Cognitive therapy
• Paradoxical intention
• Sleep hygiene education
• Behavioral intervention
Non-pharmacological treatment of insomnia
|Stimulus control therapy |
|Non-pharmacological treatment||Relaxation therapies|
|Sleep hygiene education|
Pharmacological treatment of insomnia
|First line pharmacotherapy|
|Medication||Recommended dosage||Side effects|
|Temazepam/quazepam||10–30 mg||Dependence and hangover|
|Second line pharmacotherapy|
|• 10–50 mg||• At low doses, anticholinergic effects are rare|
• Trazodone has risk of priapism
|Antihistamines||OTC drugs||Sedation and tolerance|
|Medications with variable and insufficient effects|
|Medications||Dose||Uses and side effects|
|Valerian||May cause headache and daytime sedation|
|Ramelteon||8 mg||Approved for chronic insomnia in the elderly|
|Melatonin||1–5 mg||Experimental drugs still under evaluation|
|l-Tryptophan||0.5–2 g||Experimental drugs still under evaluation|
|Indiplon||10–20 mg||Experimental drugs still under evaluation|
- Patient should keep consistent sleep and wake time everyday, including weekends.
- Patient should stay active and do regular exercise. Regular activity promotes good sleep.
- Check all of the patient's medications to see if they may contribute to insomnia.
- Make the bedroom comfortable for sleep. The room should be dark, quiet, and the temperature should be comfortable, not too warm or too cold.
- If light cannot be modified during sleep, the patient should use a sleeping mask.
- If sound cannot be eliminated, the patient should cover up sounds by trying earplugs, a fan or a white noise machine.
- Create a relaxing bedtime ritual and do it every night, such as taking a warm bath, reading, or listening to light music.
- If the patient can't fall asleep and is not sleepy, he/she should get up and do something calming, like reading until feel sleepy.
- Advise the patient to avoid daytime naps, because naps make them less sleepy at night.
- Patient should not use phones or other screens before bed, the light can make it harder to fall asleep.
- Advise the patient to avoid caffeine, nicotine, and alcohol before bed. Caffeine and nicotine are stimulants and prevent them from falling asleep.
- Encourage the patient to avoid eating a heavy meal before bed.
- Patients should avoid using the bed for anything other than sleep and sex
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