Insomnia

para>Transient insomnia occurs secondary to change of sleep position, nocturia, gastritis, back pain, anxiety.

RISK FACTORS

Age
Female gender
Medical comorbidities
Unemployment
Psychiatric illness
Impaired social relationships
Lower socioeconomic status
Shift work
Separation from spouse or partner
Drug and substance abuse

GENERAL PREVENTION

Practice consistent sleep hygiene:
- Fixed wake-up times and bedtimes regardless of amount of sleep obtained (weekdays and weekends)
- Go to bed only when sleepy.
- Avoid naps.
- Sleep in a cool, dark, quiet environment.
- No activities or stimuli in bedroom associated with anything but sleep or sex.
- 30-minute wind-down time before sleep
- If unable to sleep within 20 minutes, move to another environment and engage in quiet activity until sleepy.
Limit caffeine intake to mornings.
No alcohol after 4 pm.
Fixed eating times
Avoid medications that interfere with sleep.
Regular moderate exercise

COMMONLY ASSOCIATED CONDITIONS

Psychiatric disorders
Painful musculoskeletal conditions
Obstructive sleep apnea
Restless leg syndrome
Drug or alcohol addiction/dependence

DIAGNOSIS

HISTORY

Daytime sleepiness and napping
Unintended sleep episodes (driving, working)
Insomnia history
- Duration, time of problem
- Sleep latency, difficulty in maintaining sleep (repeated awakening), early morning awakening, nonrestorative sleep, or patterns (weekday vs. weekend, with or without bed partner, home vs. away)
Sleep hygiene
- Bedtime/wakening time
- Physical environment of sleep area: LED clocks, TV, room lighting, ambient noise
- Activity: nighttime eating, exercise, sexual activity
- Intake: caffeine, alcohol, herbal supplements, diet pills, illicit drugs, prescriptions, over-the-counter (OTC) sleep aids
Symptoms or history of depression, anxiety, obsessive-compulsive disorder, or other major psychological symptomatology
Symptoms of restless leg syndrome and periodic limb movement disorder
Symptoms of heightened arousal
Snoring and other symptoms of sleep apnea
Symptoms or history of drug or alcohol abuse
Current medication use
Chronic medical conditions
Acute change or stressors such as travel or shift work
Sleep diary: sleep log for 7 consecutive days

DIFFERENTIAL DIAGNOSIS

Sleep-disordered breathing such as obstructive sleep apnea
CNS hypersomnias (e.g., narcolepsy)
Circadian rhythm sleep disturbances
Sleep-related movement disorders (e.g., restless leg syndrome)
Substance abuse
Insomnia due to medical or neurologic disorder
Mood and anxiety disorders such as depression or anxiety

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic testing usually not required; consider polysomnography if sleep apnea or periodic limb movement disorder is suspected (1)[C].
Primary insomnia
- Symptoms for at least 1 month: difficulty in initiating/maintaining sleep or nonrestorative sleep
- Impairment in social, occupational, or other important areas of functioning
- Does not occur exclusively during narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or parasomnia
- Does not occur exclusively during major depressive disorder, generalized anxiety disorder, delirium
- Is not secondary to physiologic effects of substance or general medical condition
- Sleep disturbance (or resultant daytime fatigue) causes clinically significant distress.
Secondary insomnia
- Due to substance abuse, medication induced (diuretics, stimulants, etc.), primary depressive disorder, generalized anxiety disorder or phobias, acute situational stress, posttraumatic stress disorder, pain

Initial Tests (lab, imaging)
Testing to consider based on history and physical exam:

Thyroid-stimulating hormone
Urine toxicology

Diagnostic Procedures/Other
Polysomnography or multiple sleep latency test not routinely indicated but may be considered if

Initial diagnosis is uncertain.
Treatment interventions have proven unsuccessful.

TREATMENT

Transient insomnia
- May use medications for short-term use only; benzodiazepines favored
- Self-medicating with alcohol can increase awakenings and sleep-stage changes.
Chronic insomnia
- Treatment of underlying condition (major depressive disorder, generalized anxiety disorder, medications, pain, substance abuse)
- Advise good sleep hygiene.
- Cognitive-behavioral therapy is first-line treatment for chronic insomnia, especially in >60 years population, especially when sedatives are not advantageous. (2)[A]
- Behavioral therapy is an effective treatment for insomnia and a potentially more effective long-term treatment than pharmacotherapy (3)[B].
- Ramelteon is the only agent without abuse potential (4)[B].

MEDICATION

Reserved for transient insomnia such as with jet lag, stress reactions, transient medical condition
Nonbenzodiazepine hypnotics
- Act on benzodiazepine receptor so have abuse potential
  - Zaleplon (Sonata) 5 to 20 mg; half-life 1 hour
  - Zolpidem (Ambien) 5 to 10 mg (males); 5 mg (females); half-life 2.5 to 3 hours
  - Zolpidem (Ambien CR) 6.25 to 12.5 mg (males); 6.25 mg (females); half-life 2.5 to 3 hours
  - Eszopiclone (Lunesta) 1 to 3 mg; half-life 6 hours
Benzodiazepine hypnotics
- Short acting
  - Triazolam (Halcion) 0.25 mg; half-life 1.5 to 5.5 hours
- Intermediate acting
  - Temazepam (Restoril) 7.5 to 30 mg; half-life 8.8 hours long-acting:
    - Lorazepam (Ativan) 1 to 4 mg; half-life 14 hours
    - Diazepam (Valium) 5 to 10 mg; half-life 30 to 60 hours
    - Estazolam (Prosom) 1 to 2 mg; half-life 10 to 24 hours
Contraindications/precautions are as follows:
- Not indicated for long-term treatment due to risks of tolerance, dependency, daytime attention and concentration compromise, incoordination, rebound insomnia
- Long-acting benzodiazepines associated with higher incidence of daytime sedation and motor impairment
- Avoid in elderly, pregnant, breastfeeding, substance abusers, and patients with suicidal or parasuicidal behaviors.
- Avoid in patients with untreated obstructive apnea and chronic pulmonary disease.
- No good evidence for benzodiazepines for patients undergoing palliative care. (5)[A]
- Nonbenzodiazepine receptor agonists may occasionally induce parasomnias (sleepwalking, sleep eating, sleep driving).
Melatonin receptor agonist
- Ramelteon 8 mg; half-life 1 to 2.6 hours
  - Effective to reduce sleep time onset for short- and long-term use in adults, without abuse potential; no comparative studies with older agents have been completed. Onset of effect may take up to 3 weeks. (4)[B]
Serotonergic antidepressants
- Trazodone 25 to 200 mg; half-life 3 to 9 hours
- Doxepin 10 to 50 mg; half-life 15 hours
  - New formulation of medication is available at dosage 3 to 6 mg QHS.
- Amitriptyline 25 to 50 mg; half-life 10 to 26 hours
- Mirtazapine 7.5 to 15 mg; half-life 20 to 40 hours
Sedating antihistamines are not recommended and should be used conservatively for insomnia due to insufficient evidence of efficacy and significant concerns about risks of these medications.

Geriatric Considerations

Caution (risk of falls and confusion) when prescribing benzodiazepines or other sedative hypnotics; if absolutely necessary, use short-acting nonbenzodiazepine agonists at half the dosage or melatonin agonists for short-term treatment.

ADDITIONAL THERAPIES

Associated with hypertension, congestive heart failure, anxiety and depression, and obesity; management of these chronic conditions will help with incidence and symptoms of insomnia.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Melatonin: decreases sleep latency when taken 30 to 120 minutes prior to bedtime, but there is no good evidence for efficacy in insomnia, and long-term effects are unknown. (6)[B]
Valerian: Inconsistent evidence supporting efficacy and its slow onset of action (2 to 3 weeks) makes it unsuitable for the acute treatment of insomnia.
Acupuncture: insufficient evidence on effect of needle acupuncture and its variants (7)
Antihistamines: insufficient evidence; should not be recommended for use
Cognitive-behavioral therapy (including relaxation therapy): effective and considered more useful than medications; recommended initial treatment for patients with chronic insomnia
Mindfulness awareness practices: improved sleep quality and sleep-related daytime impairment for older adults per small randomized trial (8)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Daily exercise improves quality of sleep and may be more effective than medication.
Avoid exercise within 4 hours of bedtime.

Patient Monitoring

Reassess need for medications periodically; avoid standing prescriptions.
Caution patients that nonbenzodiazepine agonists (zolpidem, zaleplon, eszopiclone), as well as benzodiazepines, can be habit forming.
Studies suggest an association between receiving a hypnotic prescription and a >3-fold increase in hazards of death, even when prescribed <18 pills per year. (9)[B]

DIET

Avoid caffeine or reserve for morning only.
Avoid heavy late-night snacks (light snack at bedtime may help).
Avoid alcohol within 6 hours of bedtime.

PROGNOSIS

Situational insomnia should resolve with time.
Treatment of underlying etiology and consistent sleep hygiene are the mainstays of treatment.

COMPLICATIONS

Transient insomnia can become chronic.
Daytime sleepiness, cognitive dysfunction
Pulmonary hypertension if chronic sleep apnea left untreated
Sleep apnea may lead to hypertension, stroke, or cardiac ischemia.

REFERENCES

11 Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499-521.22 Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2003;(1):CD003161.33 Ebben MR, Spielman AJ. Non-pharmacological treatments for insomnia. J Behav Med. 2009;32(3):244-254.44 Reynoldson JN, Elliott ESr, Nelson LA. Ramelteon: a novel approach in the treatment of insomnia. Ann Pharmacother. 2008;42(9):1262-1271.55 Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev. 2002;(4):CD003346.66 Verster GC. Melatonin and its agonists, circadian rhythms, and psychiatry. Afr J Psychiatry (Johannesbg). 2009;12(1):42-46.77 Cheuk DK, Yeung WF, Chung KF, et al. Acupuncture for insomnia. Cochrane Database Syst Rev. 2012;(9):CD005472.88 Black DS, O'Reilly GA, Olmstead R, et al. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015;175(4):494-501.99 Kripke DF, Langer RD, Kline LE. Hypnotics' association with mortality or cancer: a matched cohort study. BMJ Open. 2012;2(1):e000850.

ADDITIONAL READING

Glass J, Lanct ´t KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005;331(7526):1169.

CODES

ICD10

G47.00 Insomnia, unspecified
F51.02 Adjustment insomnia
F51.01 Primary insomnia
F51.09 Oth insomnia not due to a substance or known physiol cond
G47.01 Insomnia due to medical condition
F51.03 Paradoxical insomnia
F51.05 Insomnia due to other mental disorder
F51.04 Psychophysiologic insomnia
G47.09 Other insomnia

ICD9

780.52 Insomnia, unspecified
307.41 Transient disorder of initiating or maintaining sleep
307.42 Persistent disorder of initiating or maintaining sleep
307.49 Other specific disorders of sleep of nonorganic origin
780.51 Insomnia with sleep apnea, unspecified

SNOMED

193462001 Insomnia (disorder)
268652009 Transient insomnia (disorder)
3972004 Primary insomnia
191997003 Persistent insomnia
192454004 Nonorganic insomnia

CLINICAL PEARLS

Treatment of underlying etiology of the insomnia and consistent sleep hygiene are key.
Most medications are indicated for short-term use only.
Sedative hypnotics are not recommended in the elderly because risks may outweigh benefits.
Patients with chronic insomnia benefit from cognitive-behavioral therapy.

Home

Erectile Dysfunction

Doctor123.org