Insomnia resident survival guide

Insomnia Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

Insomnia means inability to sleep or a total lack of sleep. The word 'insomnia' originates from the Latin "in" (no) and "somnus" (sleep). It is critical to find out if the patient is really suffering from insomnia, if there is a problem in falling asleep or it is difficult to remain asleep or returning back to sleep after awakening from sleep. Finding out the underlying cause of insomnia is also important. It can be due to stress, anxiety, depression, substance use, sleep disorders or due to any chronic disorder. Insomnia can be divided into mild, moderate, and severe form. Mild insomnia means complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode almost every night and 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 and accompanied by mild or moderate impairment of social or occupational functioning. Severe insomnia presents with severe impairment of social or occupational functioning. Severe insomnia is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.Insomnia can be treated with non pharmacological therapy for example, sleep hygiene education, cognitive behavioral therapy,sleep restriction. Additionally, it can be treated with medications like benzodiazepines and other second-line therapy.

Causes

Common Causes

• Primary insomnia
• Circadian rhythm disorder, such as:
  • Delayed sleep phase disorder
  • Advanced sleep phase syndrome
  • Jet lag
  • Shift work sleep disorder
  • Non-24-hour sleep-wake syndrome
• Depression
• Anxiety
• Obstructive sleep apnea
• Poor sleep hygiene:
  • Alcohol abuse or other substance abuse
  • Caffeine
  • Inappropriate sleep environment (light, noise, improper temperature and mattress)
• Restless legs syndrome
• Bruxism
• General health problems:
  • Chronic pain
  • Cancer
  • Heart failure
  • Diabetes
  • Asthma
  • Arthritis
  • Rhinitis
  • Renal disorders
  • Gastroesophageal reflux disease (GERD)
  • Hyperthyroidism and other endocrine problems
  • Parkinson's disease
  • Alzheimer's disease
  • Prostate hypertrophy
• Medication induced insomnia:
  • Corticosteroids
  • Stimulants
  • Antidepressants
  • Medications for asthma (such as long-acting β2-agonists)
• Age related insomnia

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Insomnia

Abbreviations: EEG: Electroencephalogram; EOG: Electrooculography; ECG: Electrocardiograph; BMI: Body Mass Index: TSH: Thyroid stimulating hormone

Patient with insomnia

Take complete history

Ask the following questions: ❑ Tell me more about your main concern? Are you having difficulty in falling asleep or getting up from bed too early? ❑ Do you have difficulty going back to sleep if you wake during the night? ❑ Do you take any sleeping-pills or any other medications to help you sleep? ❑Tell me about any disturbances at your home that may have affected your sleep for example lights, temperature,loud noise?

Ask the following questions about pattern of sleep  : ❑ Can you describe the pattern of your sleep? ❑when do you go to bed usually? ❑ How much time is generally required to fall asleep ❑ Can you tell me the number and duration of awakenings per night? ❑ How many hours do you sleep on a regular basis? ❑When do you wake up in the morning? ❑ How many nights have you suffered from the same problem each week? ❑Do you have same schedule in the weekends or during holidays?

Ask the following questions about quality of sleep : ❑ Tell me about the quality of your sleep? ❑ Do you feel fresh in the morning or tired?

Ask the following questions about impact on daily activity : ❑Does it hamper your function the next day? ❑ Do you feel unrefreshed/tired in the morning?Have you noticed having difficulty to concentrate or irritability recently

Ask when did the problem start : ❑Tell me when and how did it start? ❑ For how many days/months are you having this sleeping problem? ❑Do you remember any particular event/stress going on that that time? ❑Has there been any changes in your sleep patterns since then? ❑Is there any factors that increases the problem? ❑Is there any factors that decrease the problem? ❑Tell me more about the impact of the problem in your life

Ask the following questions about past history : ❑ Did you used to have a good sleep previously? ❑ Tell me more about your sleep pattern in your early life? ❑Tell me more about your sleep pattern in adulthood? ❑Did you have similar episodes previously? If yes, how did you get over the problem? Have you taken any medication or therapy for it in the past?

Ask the following questions about General Health : ❑ Do you have any chronic diseases? If yes, what medications do you take for it?

Ask the following questions about Mental and psychological health : ❑Can you cope up well with stressfull situations?

Do initial screening for depression with 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? ❑Have you been feeling down, depressed, or hopeless ❑ Did you have trouble falling or staying asleep, or sleeping too much ❑ 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 ❑Was there any trouble concentrating on things, such as reading the newspaper or watching television ❑Moving or speaking so slowly that other people could have noticed? Have you been fidgety or restless that you have been moving around a lot more than usual ❑Have you ever had thoughts that you would be better off dead or of hurting yourself in some way

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 as Eye-opener?

2 If yes, Do further evaluation for alcoholism

Do you take day time nap? If yes, tell me about frequency, timing, and duration

Longer naps may cause difficulty in falling asleep at night

Where are you sleeping when you have the problem? Does the problem persists throughout the weeks and months or when you sleep elsewhere

If the patient sleeps better when on holiday or at weekends, 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

Consider obstructive sleep apnea

Have you experienced any of the following : ❑Restless sleep ❑Leg or body twitching ❑ Leg jerking ❑Sleep walking or talking ❑Sleep terror ❑Unusual night time behaviours

Do physical examination

Physical examination is needed to rule out other diseases such as chronic obstructive pulmonary disease (COPD), asthma, or restless leg syndrome

Record the vitals and do following investigations: ❑ Blood pressure ❑ Weight ❑ Body Mass Index:High body mass index (≥30) and neck circumference of 40 cm or more increase the risk of obstructive sleep apnoea ❑Temperature ❑Heart rate ❑Respiratory rate ❑TSH, serum T3, serum T4 ❑Ferritin levels:Low level is seen in restless leg syndrome ❑Complete blood count to rule out anemia

Perform Polysomnography :to confirm sleep apnoea and limb movement disorders or restless legs syndrome.It measures brain and muscle activity and assesses oxygen saturation the whole night during sleep

Do the following investigations if needed: ❑ Electroencephalogram(EEG) ❑ Electrooculography (EOG) ❑ Electrocardiograph(ECG) ❑Pulse oximetry ❑Actigraphy

Treatment

The treatment of insomnia is given below:

Non-pharmacological treatment of insomnia

Stimulus control therapy

Includes: ❑ Going to bed only when feeling sleepy ❑ Using bed only for sleep and sex ❑ Getting out of bed and going into another room if unable to fall asleep or returning to sleep within 15–20 minutes and returning to bed only when sleepy again ❑ Maintaining a regular time to wake up in the morning regardless of sleep duration the previous night ❑ Avoid day time napping

Sleep restriction

Includes: ❑ Restricting the time spent in bed to nearly match the amount of time spent sleeping ❑To prevent excessive daytime sleepiness, time spent in bed should not be less than 5 hours per night

Behavioral intervention

Includes: ❑ Tell the patient keep a sleep diary for 2 weeks ❑ Discuss sleep hygiene ❑Encourage the patient to eliminate behavior incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bedroom at these time

Non-pharmacological treatment

Relaxation therapies

Includes: ❑ Progressive muscle relaxation ❑ Biofeedback techniques ❑ Imagery training and thought stopping ❑ Abdominal breathing ❑ Meditation, hypnosis

Cognitive therapy

Includes: ❑ Alter faulty beliefs and attitudes about sleep. ❑ Reduce insomnia, emotional distress, dysfunctional thoughts and further sleep disturbances

Sleep hygiene education

Includes: ❑ Good health practices for example healthy diet, moderate exercise, and reduce substance use ❑ Check environmental factors for example light, noise, temperature, and mattress

Paradoxical intention

Includes: ❑ Convince the patient to engage in his or her most feared behavior, for example staying awake. If a patient stops trying to sleep and instead tries to stay awake, performance anxiety will be reduced and sleep may come more easily

Pharmacological treatment of insomnia:

First line pharmacotherapy
Medication	Recommended dosage	Side effects
Zopiclone	3.75–7.5 mg	Drowsiness Dizziness Anterograde amnesia Nightmares Blurred vision Palpitations
Zaleplon	5–10 mg	Headache Dizziness Somnolence Nausea
Temazepam/quazepam	10–30 mg	Dependence and hang over
Second line pharmacotherapy
Anti depressant: • Amitriptyline •Trazodone	• 10–50 mg	• At low doses, anticholinergic effects 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 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

To read more about the treatment of insomnia Click Here.

Do's

• Patient should keep their bedtime and wake time consistent from day to day, including weekends.
• Patient should stay active and do regular exercise. Regular activity helps promote good sleep.
• Patient should check his/her 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 causes problems during sleep, the patient should use a sleeping mask.
• If sound causes the problem, the patient should cover up sounds by trying earplugs, a fan, white noise machine.
• Always create a relaxing bedtime ritual, such as taking a warm bath, reading, or listening to soft music.
• If the patient can't fall asleep and is not sleepy, he/she should get up and do something calming, like reading until you feel sleepy
• Patient should follow a routine to relax before bed. Read a book, listen to music, or take a bath.

Don'ts

• Advise patients to not take naps during the day, because naps make people less sleepy at night.
• Patient should not use phones before bed, the light can make it harder to fall asleep.
• Advise patients to avoid caffeine, nicotine, and alcohol before going to bed. Caffeine and nicotine are stimulants and prevent from falling asleep
• Encourage patients to avoid eating a heavy meal late in the day.
• Tell patients to avoid using the bed for anything other than sleep and sex