insomnia

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
  • nocturnal dyspnea
    • asthma, COPD, congestive heart failure (CHF)
    • obstructive sleep apnea (snoring, choking, xerostomia, daytime sleepiness)
    • gastroesophageal reflux (GERD)
    • obesity
  • nocturia
    • urinary tract infection, benign prostatic hypertrophy, hyperglycemia, diuretics, obstructive sleep apnea
  • abdominal pain/discomfort
    • peptic ulcer disease, gastritis, gall bladder disease, intestinal ischemia
  • cardiac angina
  • limb pain/discomfort
    • nocturnal leg cramps, degenerative arthritis, peripheral vascular disease
  • chronic pain syndromes & somatization disorders
  • menopausal symptoms
  • affective disorder
    • depression, mania (see depression in the elderly)
  • anxiety (most common cause)
    • anxiety disorder
      • generalized anxiety disorder, pain disorder, obsessive-compulsive disorder, post-traumatic stress disorder
    • metabolic causes of anxiety
      • hypothyroidism, alcohol abuse, stimulant abuse, drug abstinence
  • cognitive disorder
  • poor sleep habits
  • pharmaceutical agents
    • hypnotic-dependent sleep disorder
    • see common prescription drugs associated with insomnia
  • high glycemic index diet
  • environmental sleep disorder
  • shift work, jet lag
• primary insomnia (much less common than secondary insomnia)
  • central sleep apnea
  • restless legs syndrome
  • periodic limb movement disorder
  • rapid eye movement (REM) sleep disorder
    • actually a parasomnia
    • active, sometimes violent movements
    • often more disturbing to partner than to patient
    • more common in men over 50
  • sleep phase asynchrony
    • 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
  • not associated with a sense of choking on waking
• sleep state misperception
  • objectively normal sleep perceived as abnormal by patient

Epidemiology

• tends to increase with age
  • may be as high as 30-50% in adults > 65 years of 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 socioeconomic status correlates with insomnia
• in 2020, 6.3% of adults took sleep medication every day in the last 30 days
  • sleep medication use higher in women than men & more frequent with older age

History

• onset of problem
• frequency of occurences
• course of change over time
• sleep patterns
  • time to sleep
  • duration of sleep
  • awakenings - etiology of awakenings
    • nocturia
  • total sleep/hours in bed
• daytime sleepiness/naps
• medications, alcohol, tobacco, caffeine
• cardiac/respiratory
  • cough, dyspnea, palpitations, chest pain
• neurologic
  • pain, paresthesias, parkinsonism, restless legs, seizure, stroke
• psychiatric history
  • adjustment disorders, anxiety, bereavement, depression, PTSD
  • nightmares
• social history
• history from partner
  • restless movements, loud snoring, periods of apnea, changes in mood, alcohol, caffeine, drugs

Clinical manifestations

• difficulty falling asleep, staying asleep, or waking up too early
• daytime sleepiness
• mood disorders may result from insomnia
• manifestations of underlying disorder:
  • obstructive sleep apnea (snoring, apnea)
  • heart failure (orthopnea)
  • pulmonary disease (dyspnea, wheezing*)
  • restless legs or periodic limb movement
  • anxiety disorder
  • substance abuse

* not all that wheezes is asthma

Laboratory

• urine toxicology
• abnormal liver function tests suggests alcoholism

Diagnostic procedures

• diagnostic testing generally unnecessary
• polysomnography
  • obstructive sleep apnea (OSA)
  • restless legs syndrome
  • periodic limb movement disorder
• continuous overnight pulse oximetry
  • has not been validated as a screening tool for OSA

Complications

• mood disorders, including major depression, anxiety
• increased risk of automobile accidents
• pain
• rebound insomnia after discontinuation of medication
• independent risk factor for cardiovascular disease
• sleep deprivation
  • increased risk of cognitive impairment
  • daytime sleepiness
• increased 10 year risk of stroke

• disease interaction(s) of osteoarthritis with insomnia
• disease interaction(s) of depression with insomnia
• disease interaction(s) of obstructive sleep apnea (OSA) with insomnia

Management

general measures

• sleep diary
• sleep hygiene
  • sleep hygiene education alone has a minimal impact on chronic insomnia
  • consistent awakening time
  • exercise
    • aerobic fitness
    • exercise may enhance sleep improve quality of life
  • regular dietary habits
  • comfortable sleeping place
  • develop a sleep ritual
  • avoid daytime naps
  • avoid caffeine, alcohol & CNS-active agents before bedtime
  • avoid large meals before bedtime
  • avoid difficult emotional or physical activity immediately before bedtime
  • avoid use of electronic devices befor sleep
• stimulus control therapy (sleep restriction) if sleep hygiene unsuccessful
  • a component of cognitive behavioral therapy (CBT)
    • alone, not best initial therapy; CBT is best initial therapy
  • 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
  • gradual increase in total sleep time
  • avoid daytime napping
• relaxation
  • progressive muscle relaxation
  • self hypnosis
  • yoga beneficial after 6 months of practice
  • biofeedback
• cognitive behavioral therapy (CBT) 1st line
  • most appropriate management of chronic insomnia in the elderly
  • especially useful if associated with affective or anxiety disorder
  • combine with CBT for pain if pain is a factor in the insomnia
    • combined behavioral therapy for pain & insomnia
  • 1st line for menopausal women with hot flashes
  • effective in patients with obstructive sleep apnea
  • time management, appropriate self expectations, problem-solving skills
  • 19-minute reduction in sleep onset latency relative to control groups
  • shorter time awake after sleep onset
  • 10% greater sleep efficiency
  • best outcomes when used alone for maintenance therapy
  • in combination with sedative/hypnotic
  • improves markers of inflammation in older adults
  • number need to treat to benefit 1 patient = 2-3
  • internet-base programs effective
• brief behavioral therapy (behavioral activation) when CBT is not an option
  • focuses on sleep restriction, stimulus control, & some sleep hygiene
  • delivered in person in an individual or group setting
• cognitive refocusing therapy
  • focusing on personally engaging but nonarousing thoughts instead (song lyrics, TV program plots, recipes)
• mindfulness meditation
• intensive sleep retraining (done in sleep lab)
• light therapy
  • bright light exposure during the day

management of specific disorders

• transient psychophysiologic insomnia
  • maintenance of sleep hygiene
  • avoid stimulants
  • brief course of benzodiazepines
• COPD: therapeutic trial of oxygen
• obstructive sleep apnea: therapeutic trial of continuous positive airway pressure (CPAP)
• sleep phase asynchronies
• treat depression
• treat restless legs syndrome
• hemodialysis: no difference in effectiveness between trazodone, cognitive behavioral therapy, & placebo
  • trazodone associated with higher risk of cardiovascular events

pharmacologic agents (also see sleeping pill)

• general principles
  • use in patients refractory to non-pharmaceutical measures
  • 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
  • all increase the risk of falls in the elderly
  • overprescribing may be driven by the availability of pharmaceuticals rather medical necessity
  • choice based on patient profile, preferences, prior response, & consideration of adverse effects
  • all recommendations weak, based on low-quality evidence k ) long-term sleep medication use not supported by data
• sedative/hypnotics
  • limit therapy to 1 month
  • benzodiazepines*
    • usual effective dose
      • flurazepam 30 mg PO QHS
      • temazepam 30 mg PO QHS
      • triazolam 0.25-0.5 mg PO QHS
      • quazepam 15 mg QHS
      • estazolam 2 mg QHS
    • somewhat effective, but not a cure
    • increases risk of falls (see footnote below)*
    • see discontinuation of chronic benzodiazepine use
  • zolpidem (Ambien) or triazolam (Halcion)
    • agents of choice in patients with problems initiating sleep
    • may impair driving performance after a single nighttime dose
  • eszopiclone (Lunesta) 2-3 mg QHS, 1-2 mg QHS (elderly)
    • only sleeping pill NOT labeled for short-term use
    • useful for sleep maintenance
    • may not increase risk of falls in the elderly
      • associated with same risk of falls as benzodiazepines (GRS11)
  • lemborexant (orexin antagonist)
    • lemborexant and eszopiclone showed the best efficacy, acceptability, & tolerability for acute & long-term insomnia treatment
  • suvorexant 5-20 mg QD (orexin antagonist)
    • FDA-approved, but efficacy in question
    • effective for improving sleep onset & continuity
    • for short-term use
  • daridorexant another orexin antagonist of benefit in clinical trial
    • may be effective in elderly but not yet FDA approved (July 2020)
  • zaleplon 5-10 mg QHS
    • short 1/2life; not approved for sleep maintenance
  • modestly effective for reducing sleep latency
    • mean reduction in sleep latency
      • 22 minutes by polymonography
      • 7 minutes subjectively
  • adverse effects twice as likely as benefit in elderly
  • not first line agents in the elderly
• antidepressants
  • use only if depression coexists
  • tolerability & safety uncertain
  • trazodone, doxepin & mirtazapine have sedative effects
  • low dose doxepin (only FDA-approved antidepressant)
    • may be small improvement in sleep quality with short-term use
    • doxepin at lower doses than needed for antidepressant effects is only antidepressant FDA approved for treatment of insomnia
  • low-dose trazodone may be of benefit in elderly
    • may be small improvement in sleep quality with short-term use
    • not much data to support use
  • selective serotonin reuptake inhibitors (SSRI)
    • sertraline is the most sedating
    • citalopram may be of benefit in posmenopausal women
    • benefit uncertain, insufficient evidence [53
  • tricyclic antidepressants
    • depressed patients
    • may decrease alpha wave intrusion into non-REM sleep
    • adverse anticholinergic effects & daytime sedation
    • amitriptyline 10-15 mg QHS
      • nortriptyline 25-50 mg QHS
      • full doses if insomnia is secondary to depression
      • no evidence for benefit of amytriptyline
  • associated with increased risk of falls
• atypical antipsychotics
  • depressed patients
  • mirtazapine (Remeron)
  • do NOT use quetiapine, risk outweighs benefit
• antihistamines
  • do not use for sleep despite efficacy
    • diphenhydramine 25-50 mg PO QHS
      • anticholinergic side effects marked
      • use with caution in elderly & patients with obstructive uropathy
      • do not use for insomnia in elderly
      • NOT helpful for young children
• melatonin 2 mg QHS may be of benefit in some patients, including the elderly
  • used mainly for circadian rhythm disorders or jet lag
  • some studies have shown improvement, others have not
  • melatonin (5 mg), zinc (11.25 mg), & magnesium (225 mg) QHS may be of benefit
  • American Academy of Sleep recommends against use for insomnia
  • ramelteon 8 mg QHS (melatonin receptor agonist) FDA-approved
  • tasimelteon is an investigational melatonin receptor agonist used for transient insomnia due to shift work or jet lag
• insomnia related to delirium
  • olanzapine 2.5-5 mg QHS
  • haloperidol 0.5-2 mg QHS
  • quetiapine 25-50 mg QHS
• agents whose use should be discouraged
  • chloral hydrate
    • affectiveness disappears in 2 weeks
    • physical dependence remains
  • L-tryptophan
    • was used with some success until appearance of eosinophilic-myalgia syndrome
    • believed to be due to a contaminant in manufacturing
    • may be useful agent in future
  • barbiturates
    • risk of abuse
    • induction of cytochrome P450
    • narrow therapeutic:toxic ratio
  • alcohol may suppress REM temporarily with REM rebound disrupting sleep
• higher health care resource use & costs associated with falls in the elderly among older Medicare recipients with medication use to treat insomnia

unproven measures

• insufficient data to support use of acupuncture
• American Academy of Medicine recommends against
  • trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, valerian due to lack of evidence for their effectiveness

More general terms

• sleep disorder

Additional terms

• common prescription drugs associated with insomnia
• sleep
• sleep apnea

Patient information

insomnia patient information