Insomnia resident survival guide

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

Overview

Insomnia means inability to sleep or a total lack of sleep. It is a common problem that people present with in regular primary care.The word 'insomnia' originates from the Latin "in" (no) and "somnus" (sleep).It can be due to stress, anxiety, depression, substance use, sleep disorders or due to any chronic disorder. It is important to find out if the patient is really suffering from insomnia and is there a problem falling asleep or difficulty to remain asleep or difficulty in returning back to sleep after awakening from sleep.It is important to find out the underlying cause of insomnia.Insomnia can be mild, moderate and severe. 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 treated with medications like benzodiazepines and other second line therapy.

Causes

Common Causes

• Primary insomnia
• Delayed sleep phase disorder
• Depression
• Anxiety
• Obstructive sleep apnoea
• Restless legs
• Alcohol problem
• Other substance problem
• Bruxism
• Sleep walking
• General health problems :
  • Chronic pain
  • Cancer
  • Diabetes
  • Heart disease
  • Asthma
  • Gastroesophageal reflux disease (GERD)
  • Overactive thyroid
  • Parkinson's disease
  • Alzheimer's disease.
• Sleep walking
• Stress
• Environmental factors like noise, light, or temperature
• Jet lag
• Work shift insomnia
• Medication induced insomnia:
  • Medications for cold
  • Allergies
  • Medications fordepression
  • Medications for high blood pressure
  • Medications for asthma
• Caffeine
• Hyperthyroidism and other endocrine problems
• Age related insomnia

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Insomnia

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

Patient with insomnia

Take complete history

Do initial screening

Ask the following questions about the complaint : ❑ Do you have difficulty primarily in  falling asleep  staying asleep  waking too early? ❑ Do you have trouble going back to sleep if you wake during the night? ❑ Do you take any medications to help you sleep? ❑ Is there anything in your home that disturbs your sleep such as loud TV, pets, infants, noise, lights, etc.?

Ask the following questions about sleep pattern : ❑ Can you describe to me the pattern of your sleep? ❑ What time do you go to bed? ❑ How much time do you take to fall asleep ❑ Can you tell me the number and duration of awakenings per night? ❑ How many hours do you sleep? ❑When do you wake up in the morning? ❑ How many nights per week have you suffered from the same problem? ❑How is your routine different at the weekends or during holidays? Do you have the same bedtime?

Ask the following questions about sleep quality : ❑ How do you feel about the quality of your sleep? ❑ Do you feel refreshed in the morning or restless?

Ask the following questions about effects on regular daily activity : ❑Does it interfere with your function the next day? ❑ Do you feel unrefreshed in the morning, fatigued, have poor concentration or irritability

Ask the following questions about onset of the complaint : ❑ Do you remember how did it start? ❑ For how long are you having this sleeping problem? ❑Was there any particular event going on that that time? ❑Has there been any variation in your sleep patterns since then? ❑Is there any exacerbating factors? ❑Is there any alleviating factors? ❑Tell me more about the impact or intrusiveness

Ask the following questions about past history : ❑ Were you a good sleeper previously? ❑ Tell me more about your sleep pattern in childhood? ❑Tell me more about your sleep pattern in adulthood? ❑Has there been any similar episode previously? If yes, how did you overcome it? Have you taken any medication or therapy for it in the past?

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

Ask the following questions about Psychological functioning : ❑Are you the kind of person who copes 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 you needed to cut down on your drinking? ❑Have people annoyed you by criticizing your drinking? ❑ Have you ever felt guilty about drinking? ❑Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

2 yes answers indicate that there is a possibility of alcoholism, so should be investigated further

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 still sleepy after waking up? ❑Any symptoms such as headaches or dry mouth? ❑Ask about daytime sleepiness—falling asleep in waiting rooms, as a passenger in a car, or during lectures ❑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 ❑Waking up in 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 greater 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 overnight

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

Treatment

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 the vicious cycle of 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 attempts 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 being evaluated
l-Tryptophan	0.5–2 g	Experimental drugs still being evaluated
Indiplon	10–20 mg	Experimental drugs still being evaluated

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