Click here for a PDF version of Special Focus: Insomnia
When patients complain of insomnia, the challenge for physicians stems from both the complexity of the diagnosis and the need to tailor treatment to each patient.
Although hypnotic sleeping pills are safe and effective for many patients in the short-term, chronic insomnia is best treated by matching the cure to the problem, said Robert D. Vorona, MD, associate professor of internal medicine and sleep medicine at Eastern Virginia Medical School in Norfolk, Va., and co-author (along with J. Catesby Ware, PhD) of ACP's PIER insomnia module.
“Many times insomnia is multifactorial,” Dr. Vorona explained. “If patients have abysmal sleep hygiene—watching TV in bed, drinking a gallon of tea a day and keeping chaotic bed- and wake-times—you have to get them to work on that." If, however, patients are depressed, you must treat the depression—or their inadequately controlled asthma or GERD, which can also be factors. The same is true for sleep disorders, such as sleep apnea or restless legs syndrome.
And for patients with psychophysiological insomnia, where there is no other apparent reason why they can't fall and stay asleep or have restorative sleep, “it is probably better to engage in behavioral interventions," he said. "Over the long haul, behavioral interventions are more efficacious than sleeping pills.” Behavioral interventions, he added, are certainly less apt to cause side effects than pharmacotherapy.
Affecting as many as 19% of the general population, insomnia is particularly prevalent among elderly patients.
To complicate decision making, the evidence about long-term use of sedatives is changing. Some sleep specialists now believe that some patients are best served by taking sleeping pills for months or even years.
“The dogma of sleeping pills and duration of use is changing,” he said, “but the majority of sleep specialists are not wavering from the idea that behavioral interventions are better over the long run.”
Although insomnia is a bigger problem than many people believe and is treatable, few physicians screen for it. One-third of adults report some difficulty sleeping, with 12% admitting to chronic insomnia for more than three months. About 85% of those with chronic insomnia never receive treatment.
Inadequate sleep is related to higher death rates from ischemic heart disease, cancer, stroke and all other causes. And people with insomnia are more likely to report their health as “poor” or “rather poor” than middle-aged adults who get enough sleep.
Insomnia, meanwhile, is particularly prevalent among the elderly, with about one- quarter to one-third of people older than age 65 complaining of significant insomnia. It is also more common among people living at lower socioeconomic and educational levels, regardless of their gender, age or ethnicity.
This edition of ACP Observer Special Focus is designed to help optimize your ability to diagnose, treat and manage patients with insomnia.
Making a diagnosis of insomnia is important for clinicians to establish a cause and plan a tailored treatment regimen.
A comprehensive sleep history includes questions about sleep initiation, maintenance, quality and waking. Ask about duration and progression of symptoms to see if they are stable, worsening or improving, and to determine if the patient has acute, short-term or chronic insomnia. (Patients have acute insomnia if it lasts a week or less; short-term, if it continues between one week and three months; and chronic, if it persists for more than three months.)
Several tools can help:
A standardized sleep questionnaire, such as the Pittsburgh Sleep Quality Index (PSQI), can help you assess sleep patterns.
The Epworth Sleepiness Scale can help identify the subgroup with complaints of daytime sleepiness. A score or more than 10 suggests excessive daytime sleepiness.
A sleep log can lead to a more accurate record of sleep habits than general questioning.
Look for any precipitating causes of insomnia, including acute stress; circadian rhythm stressors like jet lag; illicit and prescribed medication use; shift work; irregular sleep schedules; and medical or psychiatric illness. Ask about sedatives taken in the past; alcohol, caffeine and recreational drug consumption; and behavioral therapies previously used for insomnia.
In analyzing potential causes, keep in mind that many medications can affect sleep including beta-blockers, antiretroviral agents such as efavirenz and chronic nightly use of benzodiazepines.
A wide variety of medical disorders can also cause insomnia. Focus the physical examination and make judicious use of lab tests to confirm suspected concomitant diseases. The following diseases are associated with insomnia:
- obstructive sleep apnea
- thyroid dysfunction
- cardiopulmonary diseases
- neurologic disease
- restless legs syndrome (RLS)
- benign prostatic hyperplasia with nocturia
If you suspect obstructive sleep apnea, on your physical examination look for obesity, hypertension, an enlarged tongue, a high and narrow hard palate, an elongated soft palate and uvula, enlarged tonsils and micro- or retrognathia. In suspected RLS, look for iron deficiency.
Other sleep disorders include psychophysiologic insomnia, circadian rhythms disorders, sleep environmental and sleep hygiene problems, anxiety, depression and a variety of other psychiatric conditions. A National Institute of Mental Health study found that about 40% of people with insomnia have psychiatric pathology.
In general, you should resist ordering polysomnography, the multiple sleep latency test or both for insomnia. Reserve those tests to confirm the diagnosis of specific sleep disorders, including narcolepsy, or sleep apnea. Polysomnography is most useful for patients whose insomnia has been resistant to initial therapeutic measures.
Consider referring patients with insomnia to a sleep specialist if the diagnosis remains unclear, if polysomnography is warranted or if they request a consultation. Also, consult a specialist to confirm a diagnosis of sleep apnea, parasomnias, RLS, narcolepsy, excessive daytime sleepiness, circadian rhythm disturbances or psychophysiologic insomnia.
Psychiatric referral can help patients with insomnia who have concurrent depression or who take moderate to large doses of hypnotic medications.
To treat insomnia effectively, physicians must understand its cause (often several causes), whether medical, psychiatric, behavioral or environmental. For many patients, non-drug interventions—particularly improving sleep hygiene—can help.
Recommend these sleep hygiene rules, depending on specific patient needs:
- Maintain regular bed and rising times.
- Spend no more than eight hours in bed.
- Experience regular daytime light exposure and avoid bright light before bedtime.
- Maintain a dark, quiet bedroom.
- Maintain adequate nutrition and get regular exercise, but avoid exercise within two hours of bedtime.
- Avoid sleep-fragmenting substances such as caffeine, nicotine and alcohol.
- Adopt a 30-minute pre-bed relaxation period.
- Do not use alcohol to initiate sleep.
Teach patients to use their bed only for sleep and sex, and to get up out of bed, leaving the bedroom, when awake for more than 20 minutes.
When sleep hygiene maneuvers are unsuccessful, consider initiating a “sleep restriction” program to increase sleep consolidation. (See "Initiating 'sleep restriction' to treat insomnia.")
Cognitive behavior therapy can reduce dysfunctional beliefs about sleep, such as exaggerated patient concerns about the impact and consequences of insomnia, and mitigate normal changes in sleep that come with aging. It can also be more effective than drug therapy in the treatment of chronic sleep-onset insomnia.
Muscle relaxation and biofeedback conducted by a sleep disorders specialist or a knowledgeable therapist can reduce muscle and cognitive arousal that interferes with sleep. Most interventions that increase patients' expectation of falling asleep more quickly, including placebo, are effective.
Prescribe benzodiazepines and non-benzodiazepine GABA agonists as sedative hypnotics for short-term therapy for acute insomnia. In the short term, drug therapy is probably as effective as behavioral interventions, but using hypnotics along with behavioral therapy may lessen the efficacy of behavioral measures.
Some patients will need intermittent or long-term use of such medications, but consult a sleep specialist before starting patients on long-term sedative therapy. Some sleep disorders that can cause insomnia symptoms, such as sleep apnea, can be exacerbated by hypnotic sleeping pills.
Although most sleep specialists do not currently recommend long-term use of hypnotic medication, others disagree. Recent studies of several different drugs have noted safe and effective use for between six months and one year.
Be aware of medication side effects: daytime sleepiness, potential interactions with many other drugs and rebound insomnia after discontinuation. Use the lowest effective dose and, if possible, avoid medications with a long half-life, such as flurazepam and quazepam. Caution patients about how these drugs interact with alcohol and that they must use care when driving or using hazardous equipment.
Ramelteon is a melatonin (MT1 and MT2) agonist and thus has a different mechanism of action from the commonly-used GABA agonists, such as zolpidem. Ramelteon has modest hypnotic properties—and relatively few side effects, giving it an impressive benefit-risk ratio. Elderly patients, who can have low melatonin levels, are one group that might benefit from this drug.
Although commonly used, over-the-counter products containing diphenhydramine tend to be less effective and cause more side effects, including impaired mental status.
Reserve antidepressants for patients who need treatment for underlying depression as well as insomnia. Compared with GABA agonists, antidepressants tend to be less effective and cause more side effects. Sedating antidepressants include trazodone, doxepin, trimipramine and mirtazapine. Some antidepressants, such as fluoxetine, can exacerbate insomnia.
Some patients have RLS that significantly impairs sleep and daytime function, but they do not manifest iron deficiency or report increased caffeine intake. To alleviate symptoms in these patients, prescribe a low bedtime dose of a dopamine agonist agent, such as pramipexole or ropinirole. Alternatives include benzodiazepines, such as clonazepam; opiates, such as propoxyphene, hydrocodone or oxycodone; or antiepileptic drugs, such as gabapentin.
PATIENT EDUCATION AND FOLLOW-UP
Teach patients that mood disorders often occur with insomnia, and that insomnia may precede or be a cause of depression.
Because insomnia treatment is usually long-term and requires support, schedule frequent follow-up visits to monitor response to therapy and assess side effects, efficacy and need for continuing treatment.
See patients taking sedatives after one month, but encourage them to contact you sooner if concerns about side effects arise. If a particular hypnotic is not working, review the diagnosis and consider alternative treatments, such as behavioral therapy.
Patients with psychophysiologic insomnia, where there is not another medical cause of the insomnia, may need weekly visits to motivate them to carry out behavioral recommendations. Antidepressant treatment requires case-by-case follow-up to determine if the insomnia and depression are resolving.
Follow up on patients receiving dopamine agonists for RLS after one month--or sooner--to assess response, and at least annually thereafter. If patients are being treated with iron for iron deficiency and RLS, order a follow-up serum ferritin test in four to six weeks.
|This information comes from the PIER module "Insomnia."|
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Inadequate sleep is related to higher death rates from ischemic heart disease, cancer, stroke and all other causes.
One-third of adults report some difficulty sleeping.
Among adults, 12% admit to chronic insomnia for more than three months. About 85% of those never receive treatment.
People with insomnia are more likely to report their health as “poor” or “rather poor” than middle-aged adults who get enough sleep.
Insomnia is more prevalent among the elderly: One- quarter to one-third of people older than age 65 complaining of significant insomnia.
It is also more common among people living at lower socioeconomic and educational levels, regardless of their gender, age or ethnicity.
For some patients who suffer from insomnia but have no underlying medical or psychological disorder, “sleep restriction” can help improve total sleep time and other sleep parameters. Studies have shown effectiveness after eight weeks. Here is a strategy for starting sleep restriction therapy:
- Advise patients to keep a two-week sleep log to assess actual sleep time.
- Calculate mean sleep duration and then reduce the patient’s time in bed to match. For instance, if a patient sleeps five hours and needs to wake up at 7:30 a.m., strictly set the rising time at 7:30, but tell the patient he may not get into bed to go to sleep until 2:30 a.m.
- Advise maintaining a strict rising time, then back up the bedtime by 15-minute increments as long as sleep efficiency (total sleep time divided by total time in bed) exceeds 90%, as documented by a sleep log.
- Caution patients that sleep restriction therapy may lead to excessive daytime sleepiness and that they should be careful driving.
In May 2005, the Food and Drug Administration approved the first drug--ropinirole--specifically to treat a disease some sleep specialists consider an important cause of insomnia: restless legs syndrome (RLS). As many as 12 million people in the U.S. suffer from the disease.
At the same time, RLS has been cited by other researchers, including those at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, N.H., as a primary example of “disease mongering.” That's a term used to describe efforts by pharmaceutical companies to increase the market for their drugs by convincing people they are sick and need treatment.
According to internist and sleep medicine specialist Robert D. Vorona, MD, from Eastern Virginia Medical School in Norfolk, Va., RLS is a “not uncommon” and a real cause of insomnia among patients he sees.
RLS, he said, is frequently under-recognized, overlooked and disbelieved by general internists and family physicians. On the other hand, he said, many adults with RLS do not need drug treatment.
He advises physicians to keep RLS in mind when patients complain of insomnia. Patients with RLS say they have an urge to move, often a “creepy-crawly, antsy” feeling in their legs, which is worse at night and is relieved by movement, leading them to get out of bed and walk around. It is more common in women, in people older than age 50, in patients with end-stage renal disease and in pregnant women during their third trimester.
If you suspect RLS, order a serum ferritin level because some evidence supports an association between RLS and iron deficiency. For some patients, iron supplementation can help. For others, Dr. Vorona said, dopamine agonists, including ropinirole and pramipexole, can help control symptoms and allow patients to sleep. Excessive caffeine intake may make RLS worse, he said.
Dr. Vorona said RLS complaints need to be taken seriously because they may occasionally be a sign that something else is going on. For instance, he said, there have been several reports of patients with gastrointestinal malignancies who first presented with RLS.
“They were bleeding, so they became iron deficient,” he said. “Patients aren’t likely to come to you and say they can’t keep their legs still. They are going to come to you because they can’t fall asleep or stay asleep.”
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