Insomnia

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Contents

Introduction

  • The perception by patients that their sleep is inadequate or abnormal. The term may also be used by patients in reference to fatigue, daytime sleepiness or mood disturbances.

Etiology

  • psychophysiologic insomnia
  • transient psychophysiologic insomnia
  • < 3 weeks duration
  • generally secondary to stressful event
  • chronic psychophysiologic insomnia
  • > 3 weeks duration, commonly > 3 months duration
  • may be secondary to inadequate management of transient insomnia
  • secondary insomnia
  • primary insomnia (much less common than secondary insomnia)
  • actually a parasomnia
  • active, sometimes violent movements
  • often more disturbing to partner than to patient
  • more common in men over 50
  • mismatch of the biological sleep clock with the environment
  • may result from time zone changes ( jet lag), altered sleep schedules (shift work), or idiopathic
  • adolescents tend to have a delayed sleep phase
  • elderly tend to fall asleep & awake too early
  • childhood onset insomnia
  • rare disorder
  • though to be related to a developmental defect in the sleep cycle neuronal circuitry
  • most children who sleep poorly suffer environmental stress or dysfunctional parenting
  • delayed sleep onset may be associated with sedentary lifestyle [15]
  • sleep state misperception [2]
  • objectively normal sleep perceived as abnormal by patient

Epidemiology

  • tends to increase with age
  • more prevalent among women; however, laboratory studies show that older men have more disrupted sleep
  • more common among divorced, widowed, separated than married
  • lower correlates with insomnia

History

  • onset of problem
  • frequency of occurences
  • course of change over time
  • sleep patterns
  • time to sleep
  • duration of sleep
  • awakenings - etiology of awakenings
  • total sleep/hours in bed

Clinical-manifestations

Laboratory

Diagnostic-procedures

Complications

Management

  • general measures
  • lie down to sleep only when sleepy
  • use bed only for sleep or sexual activity
  • if unable to fall asleep after 10-20 minutes, get up & leave the bedroom; repeat as necessary
  • get up at the same time every morning
  • avoid daytime napping
  • relaxation
  • especially useful if associated with affective or anxiety disorder
  • time management, appropriate self expectations, problem-solving skills
  • in combination with sedative/hypnotic [14]
  • best outcomes when used alone for maintenance therapy [14]
  • number need to treat to benefit 1 patient = 2-3 [19]
  • management of specific disorders
  • transient psychophysiologic insomnia
  • use lowest effective dose, for the shortest time
  • doses should be reduced in the elderly & patients with renal or hepatic insufficiency
  • used with caution in patients with pulmonary disease
  • all start to work in about 30 minutes [8]
  • all increase the risk of falls in the elderly [24]
  • overprescribing may be driven by the availability of pharmaceuticals rather medical necessity [21]
  • agents of choice in patients with problems initiating sleep
  • may impair driving performance after a single nighttime dose [22]
  • selective serotonin reuptake inhibitors ( SSRI)
  • do not use for sleep [2] despite efficacy
  • do not use for insomnia in elderly [24]
  • NOT helpful for young children [12]
  • melatonin 2 mg QHS may be of benefit in some patients, including the elderly [5]
  • alcohol may suppress REM temporarily with REM rebound disrupting sleep

More General Terms

Additional Terms

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1087-90
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
  3. Kupfer DJ & Reynolds CF III Management of insomnia. N Eng J Med 336(5):341, 1997 PMID: [1]
  4. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
  5. Leger D et al, Am J Med 116:91, 2004 PMID: [2]
    - Buscemi N et al, Efficiency and safety of exogenous melatonin for secondary sleep disorders and sleep disorders accompanying sleep restriction: Meta-analysis. BMJ 2006; 332:385 PMID: [3]
    - Herxheimer A, Does melatonin help people sleep? It's a misapplied but probably safe miracle drug. BMJ 2006; 332372 PMID: [4]
  6. Prescriber's Letter 12(3): 2005 Detail-Document#: [5] (subscription needed) [6]
  7. Journal Watch 25(5):40-41, 2005 Suvanto-Luukkonen E, Koivunen R, Sundstrom H, Bloigu R, Karjalainen E, Haiva-Mallinen L, Tapanainen JS. Citalopram and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized, 9-month, placebo- controlled, double-blind study. Menopause. 2005 Jan-Feb;12(1):18-26. PMID: [7]
  8. Prescriber's Letter 12(9): 2005 Comparison of Insomnia Treatments Detail-Document#: [8] (subscription needed) [9]
  9. Prescriber's Letter 12(9): 2005 Comparison of Insomnia Treatments Detail-Document#: [10] (subscription needed) [11]
  10. Glass J et al Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits BMJ 2005; 331:1169 PMID: [12]
  11. Sivertsen B et al, Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized, controlled trial. JAMA 2006; 295:2851 PMID: [13]
  12. Merenstein D, Diener-West M, Halbower AC, Krist A, Rubin HR. The trial of infant response to diphenhydramine: the TIRED study--a randomized, controlled, patient-oriented trial. Arch Pediatr Adolesc Med. 2006 Jul;160(7):707-12. PMID: [14]
    - Prescriber's Letter 13(9): 2006 Diphenhydramine for Sleep in Infants Detail-Document#: [15] (subscription needed) [16]
  13. Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep. 2007 Mar 1;30(3):274-80. PMID: [17]
    - Ozminkowski RJ, Wang S, Walsh JK. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep. 2007 Mar 1;30(3):263-73. PMID: [18]
  14. Morin CM et al Cognitive Behavioral Therapy, Singly and Combined With Medication, for Persistent Insomnia. A Randomized Controlled Trial JAMA. 2009;301(19):2005-2015. <PubMed> PMID: [19] <Internet> [20]
  15. Nixon GM et al Falling asleep: the determinants of sleep latency. Archives of Diseases of Childhood July 24, 2009 <PubMed> PMID: [21] <Internet> [22]
  16. Prescriber's Letter 16(8): 2009 What's the best way to treat insomnia in the elderly? Detail-Document#: [23] (subscription needed) [24]
    - Prescriber's Letter 16(8): 2009 Insomnia in the Elderly Detail-Document#: [25] (subscription needed) [26]
  17. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008 Oct 15;4(5):487-504 PMID: [27]
  18. Prescriber's Letter 17(10): 2010 COMMENTARY: Oleptro (Trazodone) and Silenor (Doxepin) CHART: Comparison of Insomnia Treatments Detail-Document#: [28] (subscription needed) [29]
  19. Buysse DJ et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med 2011 Jan 24 PMID: [30]
  20. Rondanelli M et al. The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: A double-blind, placebo-controlled clinical trial. J Am Geriatr Soc 2011 Jan; 59:82 PMID: [31]
  21. Moloney ME et al. The medicalization of sleeplessness: A public health concern. Am J Public Health 2011 Aug; 101:1429. PMID: [32]
  22. Bocca ML, Marie S, Lelong-Boulouard V, et al. Zolpidem and zopiclone impair similarly monotonous driving performance after a single nighttime intake in aged subjects. Psychopharmacology (Berl) 2011; 214(3):699-706. PMID: [33]
  23. Harris J et al. A randomized controlled trial of intensive sleep retraining (ISR): A brief conditioning treatment for chronic insomnia. Sleep 2012 Jan 1; 35:49. PMID: [34]
    - Spielman AJ and Glovinsky PB. What a difference a day makes. Sleep 2012 Jan 1; 35:11. PMID: [35]
  24. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  25. Prescriber's Letter 19(4): 2012 COMMENTARY: Medications for Insomnia: A Wake-Up Call PATIENT EDUCATION HANDOUT: Strategies for a Good NightÂ’s Sleep Detail-Document#: [36] (subscription needed) [37]
  26. Prescriber's Letter 19(5): 2012 Comparison of Insomnia Treatments Detail-Document#: [38] (subscription needed) [39]
  27. Facts About Insomnia [40]
  28. National Guideline Clearinghouse
    - Practice parameters for the nonpharmacologic treatment of chronic primary insomnia in the elderly. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program ngc-guideline: [41]
    - Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. ngc-guideline: [42]
    - Clinical guideline for the evaluation and management of chronic insomnia in adults. American Academy of Sleep Medicine ngc-guideline: [43]

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