Insomnia resident survival guide

Insomnia Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
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: Sleep difficulty, primary insomnia

Overview

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.

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 leg 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 a complete history Physical examination, especially Vital signs, Body Mass Index

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 quality of sleep : ❑ Tell me about the quality of your sleep? ❑ Do you feel refreshed in the morning or tired?

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

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 the 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 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.

Have you experienced any of the following : ❑ Restless sleep ❑ Leg or body twitching ❑ Leg jerking ❑ Sleepwalking or talking ❑ Sleep terror

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.

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

Treatment

The treatment of insomnia is below:

Non-pharmacological treatment of insomnia

Stimulus control therapy

Includes: ❑ Go to bed only when you feel sleepy ❑ Use bed only for sleep and sex ❑ If unable to fall asleep, get out of the bed and return after 15–20 mins when sleepy again ❑ Maintaining a regular time to wake up in the morning regardless of sleep duration the previous night ❑ Avoid daytime naps

Sleep restriction

Includes: ❑ Restricting the time spent in bed in order 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 to keep a sleep diary for 2 weeks. ❑ Discuss sleep hygiene ❑ Encourage the patient to give up behaviors incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bed on these occasions.

Non-pharmacological treatment

Relaxation therapies

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

Cognitive therapy

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

Sleep hygiene education

Includes: ❑ Good healthy lifestyle practices such as a 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 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

The following table is a summary of first and second line treatments of insomnia::

First line pharmacotherapy
Medication	Recommended dosage	Side effects
Zopiclone	3.75–7.5 mg	Drowsiness Dizziness Anterograde amnesia Nightmares Blurred vision Palpitation
Zaleplon	5–10 mg	Headache Dizziness Somnolence Nausea
Temazepam/quazepam	10–30 mg	Dependence and hangover
Second line pharmacotherapy
Antidepressants: • Amitriptyline • Trazodone	• 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

To read more about the treatment of insomnia, Click Here.

Dos

• 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.

Don'ts

• 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