Insomnia

Introduction

Insomnia is a condition characterized by difficulty in falling asleep or staying asleep. It may be primary and unrelated to any physical or mental disorder
It may relate to a mental disorder, medical or physical conditions
It may be an adverse effect of medication (or psychoactive substances)
It is a common, often chronic problem; tends to increase with age.

History taking & assessment of patients with Insomnia

  • Characterization of the sleeping environment (couch/bed, light/dark, quiet/noisy, room temperature, alone/bed partner, TV on/off), patient’s state of mind (sleepy vs. wide awake, relaxed vs. anxious)
  • Identify perpetuating negative behaviours and cognitive processes
  • Assess Sleep-Wake Schedule with sleep dairy: time to fall asleep (sleep latency), number of awakenings, Wake time After Sleep Onset (WASO), sleep duration

Assess

  • Breathing-related sleep disorders (snoring, gasping, coughing)
  • Sleep related movement disorders (kicking, restlessness)
  • Parasomnias (behaviors or vocalization)
  • Co-morbid medical/neurological disorders (reflux, palpitations, seizures, headaches)
  • Other physical sensations and emotions associated with wakefulness (such as pain, restlessness, anxiety, frustration, sadness)

Assess Daytime Activities and Daytime Function:

  • Napping (frequency/day, times, voluntary/involuntary)
  • Work (work times, work type such as driving or with dangerous consequences, disabled, caretaker responsibilities)
  • Lifestyle (sedentary/active, homebound, light exposure, exercise)
  • Travel (especially across time zones)
  • Quality of life and exacerbation of co-morbid disorders

Clinical features

  • Early insomnia: difficulty in initiating sleep
  • Middle insomnia: difficulty in going back to sleep after waking up at night
  • Terminal insomnia: early awakening, commonly 2 hours or more before desiring to do so

Differential diagnoses

  • It is useful to consider possible aetiological factors: medical, mental, situational,
  • Pain is a common factor environmental

Complications

  • Deteriorating physical and/or mental health
  • Decline in overall well being and quality of life

Investigations

Mainly of the presumed underlying cause(s)

Treatment objectives

  • To improve sleep, especially sleep
    satisfaction
  • To remove underlying/associated factors

Non-drug treatment

  • Sleep hygiene
  • Behavioural modifications to enhance
  • Avoid habits and lifestyles that promote insomnia
  • Improve environmental/sleeping conditions relaxation

Drug treatment

General principles

  • Treat underlying cause(s)
  • Avoid sedatives: use for only short periods when indicated

1st Line Treatment
Evidence Rating: [C]
Lorazepam, oral,
Adults: 1-4 mg at bedtime
Children: Not recommended

Or

Triazolam, oral,
Adults:

  • Elderly; 125-250 microgram at bedtime
  • < 60 years; 125-500 microgram at bedtime

Children: Not recommended
2nd Line Treatment
Evidence Rating: [B]
Melatonin, oral, (particularly for children)
Adults: 3-5 mg daily, 1-2 hours before bedtime (max. 10 mg)
Children

  •  1 month-18 years; 2-3 mg at bedtime. Increase if necessary after 1-2 weeks to 4-6 mg daily (max. 10 mg)

Or

Evidence Rating: [B]
Amitriptyline, oral,
Adult: 25-50 mg at night for two weeks
Children: Not recommended

Supportive measures

  • Relaxation therapy: a useful adjunct for the most common forms of insomnia

Notable adverse drug reactions

  • Benzodiazepines: dependence and rebound insomnia

Prevention

  • Reduced stress exposure
  • Caution with alcohol and psychoactive substances, such as coffee, kolanut
  • Discourage misuse of “sleeping pills” e.g. Bromazepam, diazepam