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