Insomina
characterized by
- Difficulty with sleep initiation:
- the time it takes to fall asleep, normally less than 30 minutes(called “sleep latency” in sleep studies)
- In children, this may manifest as difficulty initiating sleep without caregiver intervention
- Difficulty maintaining sleep:
- frequent awakenings
- problems returning to sleep after awakenings
- In children, this may manifest as difficulty returning to sleep without caregiver intervention
- Early-morning awakening with inability to return to sleep
- occurs despite adequate opportunity for sleep
- Timing:
- present for at least 3 months
- occurs at least 3 nights per week
- Although insomnia disorder is formally diagnosed when insomnia symptoms occur 3 or more times a week for at least 3 months, these guidelines take a pragmatic approach to categorise insomnia, because these periods of time do not reflect clinical practice.
- causes
- impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
- fatigue
- tiredness
- difficulty with memory
- concentration and attention
- worry about sleep
- mood disturbances
- irritability
- impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
- Although all forms of insomnia may be a symptom of depression, late (terminal) insomnia is especially indicative of depression
- Sleep history – ASK
- if they work night shifts—see Sleep–wake disturbances in shift workers
- if they have recently undertaken international air travel
- if they have restless limbs during sleep
- if they snore or have sleep-disordered breathing
- if they experience unusual behaviours during sleep
- about the duration of the sleep problem and if it was triggered by an event:
- acute insomnia is commonly triggered by short-term stress (eg emotional or financial stress, physical illness) and usually resolves once the acute period of stress passes
- chronic insomnia is an established pattern of troubled sleeping
- Estimated hours of sleep (“sleep quantity“):
| Age | Recommended sleep time (hours) | Not recommended sleep time (hours) |
| 18 to 25 years | 7 to 9 | less than 6 or more than 11 |
| 26 to 64 years | 7 to 9 | less than 6 or more than 10 |
| older than 65 years | 7 to 8 | less than 5 or more than 9 |
- about the nature of their insomnia (ie which portion[s] of the sleep cycle is affected):
| trouble falling asleep | either sleep-onset (initial) insomnia or delayed sleep–wake phase disorder |
| waking often or for prolonged periods (more than 30 minutes) before returning to sleep | sleep-maintenance (middle) insomnia |
| early morning awakening (more than 30 minutes before desired wake time) and not returning to sleep | late (terminal) insomnia or advanced sleep–wake phase disorder |
| multiple portions of the sleep cycle | coexisting sleep-onset and sleep-maintenance insomnia |
- to assist monitoring and assessment
- Sleep Diary
- time went to bed and got to sleep
- number of hours slept
- number, duration and reasons for night-time awakenings
- when woke and arose and whether felt refreshed
- lifestyle, environmental or medical factors that may impact sleep (eg drugs, caffeine and alcohol intake, exercise, meals)
- Organisations with sleep diaries, include:
- the American Academy of Sleep Medicine
- the National Sleep Foundation (US), see here.
- Sleep questionnaires for insomnia
- the Auckland Sleep Questionnaire : aims to identify common sleep disorders and comorbid conditions
- the Insomnia Severity Index : assesses sleep habits and disturbance, quality of sleep and impact of sleep problem
- the Pittsburgh Sleep Quality Inventory : assesses sleep habits and disturbance, quality of sleep and impact of sleep problems.
- Sleep Diary
Factors that can contribute to or cause insomnia
| Factor | Common examples |
| insomnia is a symptom of another disorder | anxiety bipolar disorder dementia depressive disorders – (Although all forms of insomnia may be a symptom of major depression, late (terminal) insomnia is especially indicative of major depression) hyperthyroidism Parkinson disease personality disorder psychosis |
| physical symptoms of a condition contribute to insomnia | dyspnoea gastro-oesophageal reflux menopause nocturia pain |
| drugs | – Alcohol – Alcohol makes sleep less refreshing and can shorten sleep duration, reduce rapid eye movement (REM) sleep and cause sleep-maintenance insomnia. – Amphetamines and other psychostimulants – Antiepileptics – aripiprazole – beta agonists – caffeine – corticosteroids – dopamine agonists – nicotine replacement therapy – selective serotonin reuptake inhibitors (SSRIs) – theophylline – tobacco – Alcohol makes sleep less refreshing and can shorten sleep duration, reduce rapid eye movement (REM) sleep and cause sleep-maintenance insomnia. |
| withdrawal states | alcohol withdrawal benzodiazepine withdrawal |
| poor sleep practices [NB5] | irregular bedtimes and wake times napping eating heavy meals before bed vigorously exercising before bed using electronic devices in bed poor sleep environment—bright light, pets or children in the bedroom, noise, feeling insecure or unsafe, uncomfortable bedding and extreme temperatures can make sleeping difficult |
Treatment
- multimodal approach to achieve these goals:
- address factors affecting sleep
- treat contributing disorders
- if a drug is thought to be causing insomnia, change the administration time, reduce the dose or change to another drug
- encourage good sleep practices
- use other psychological and behavioural interventions
- address factors affecting sleep
- Cognitive therapy
- Focuses on changing false beliefs and attitudes about sleep
- e.g., everyone needs at least 8 hours of sleep for good health
- This can lead to distorted beliefs about adverse consequences of sleep deprivation and sleep anxiety (a cycle in which worrying about not sleeping increases arousal at bedtime and contributes further to insomnia
- Focuses on changing false beliefs and attitudes about sleep
- Relaxation Techniques
- hypnosis
- meditation
- visualisation
- mindfulness
- deep breathing and progressive muscle relaxation
- Sleep hygiene education
- go to bed and arise at regular times (including on weekends)
- No pets in the bedroom
- No caffeine consumption after 4 p.m
- No electronic devices (eg phones, television) or a clock in the bedroom
- No nicotine use, especially in the evening
- No exercising within 2 to 3 hours before bedtime
- Keep bedroom cool and conducive to sleep
- avoid oversleeping
- avoid napping (if necessary, limit to an afternoon ‘powernap’ of 15 to 30 minutes).
- avoid exposure to bright light
- Blue wavelengths of light are emitted from computer, television and phone screens.
- Blue light inhibits melatonin release and may disrupt sleep.
- If screens cannot be avoided, blue-light filtering glasses or blue-light screen filters may reduce the effect of blue light.
- Sleep restriction
- aim to reduce time spent awake in bed by building natural sleep drive
- Time in bed can be reduced by estimating the actual total time that the patient is sleeping (€.g., if the patient is in bed for 8 hours but sleeps for 5.5 hours, time in bed could be reduced to 5.5 hours);
- time in bed usually should not be reduced to less than 5 hours After sleep efficiency (ratio of time sleeping to time in bed) reaches 90%, the time in bed can be increased by 15 minutes every week
- Stimulus control
- Go to bed only when sleepy
- Use the bedroom only for sleep and sex
- Go to another room if unable to fall asleep within 15 to 20 minutes
- Read or engage in other quiet activities((eg listening to music or an audiobook, meditating, drinking a cup of warm milk or noncaffeinated tea) and return to bed only when sleepy
- avoid stressful ruminations before or at bedtime; allocate time earlier in the evening to reflect and address worries
- Medications
Hypnotics
- Hypnotics are effective in inducing and maintaining sleep and increase total sleep time
- Risks
- risk of misuse
- increased tolerance
- likelihood of dependence
- Zopiclone and zolpidem may have less potential for dependence than benzodiazepines.
- side effects
- daytime hangover effects
- sedation
- cognitive impairment
- impaired driving
- Hypnotics with longer half-lives are more likely to cause daytime impairment.
- Temazepam, with a half-life of approximately 10 hours, is the only benzodiazepine recommended for insomnia in eTG
- Diazepam and Nitrazepam, for example, have much longer half-lives (more than 24 hours).
- can induce
- dangerous complex sleep-related behaviours
- paradoxical reactions (eg hallucinations, acute rage, agitation)
- Explain to the patient that broken sleep with vivid dreams may occur when the hypnotic is stopped and that it takes several days or weeks for a normal sleep rhythm to re-establish.
- This rebound insomnia does not indicate that further hypnotic use is needed.
- daytime hangover effects
Melatonin
- Melatonin is a hormone that regulates circadian rhythm and sleep.
- Clinical trial data show that melatonin may reduce sleep-onset time and improve sleep quality in adults with insomnia, but data are conflicting and the clinical significance of improvements is small.
- Melatonin is well tolerated
- does not appear to have abuse potential and reduces hypnotic use.
- Melatonin does not appear to cause daytime sedation, although high doses (eg 5 mg) may have hypnotic properties
Suvorexant
- is an orexin A and B receptor antagonist
- improves sleep-onset time
- reduces wakening after sleep onset
- improves sleep efficiency and total sleep time in adults
- should not be combined with other sedatives or alcohol—this increases the risk of adverse effects (eg abnormal dreams).
Other drugs commonly used for insomnia
- Do not use to treat insomnia:
- sedating antidepressants (in the absence of comorbid depression)
- sedating antihistamines
- antipsychotics
- gabapentin
- pregabalin
- Although these drugs are commonly used, there is insufficient evidence of benefit to support this practice and they can cause significant adverse effects:
- antidepressant adverse effects vary, depending on the antidepressant
- sedating antihistamine adverse effects include:
- daytime sedation
- impaired cognition
- delirium and paradoxical agitation
- tolerance to sedation can rapidly develop
- antipsychotic adverse effects
- ex: quetiapine is associated with abuse, problem use and overdose
- gabapentin and pregabalin
- associated with dependence and abuse.
| Medication | dose | Onset of action | half life | notes/se |
|---|---|---|---|---|
| temazepam | 10 to 20 mg orally | 30-60min | 8-15hrs | for sleep onset and maintenance insomnia s/e: somnolence, blurred vision, hypotension, rebound insomina |
zolpidem modified-release | 6.25 to 12.5 mg orally | 30min | 3-4.5hrs | for sleep onset and maintenance insomnia s/e: Somnolence, fatigue, drugged state, dizziness, sleeep walking/talking/eating, amnesia, increased fall risk rebound insomina |
| zolpidem immediate-release | 5 to 10 mg orally | 7-30mins | 2-3 hrs | Sleep onset insomina se: as above |
| zopiclone | 3.75 to 7.5 mg orally | |||
| melatonin modified-release | 2 mg orally | 60 to 120 minutes before bedtime for an initial period of 3 weeks then review. Melatonin may be continued for an additional 10 weeks | ||
| melatonin immediate-release | 0.5 to 3 mg orally | at bedtime for an initial period of 3 weeks then review. Melatonin may be continued for an additional 10 weeks | ||
| suvorexant | 20 mg orally (adult 65 years or older: 15 mg) | 30 minutes before bedtime and at least 7 hours before the patient plans to get up. Take for up to 3 months then review |