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InsomniaAka: Disorder of Initiating and Maintaining Sleep, DIMS

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  1. Causes
    1. See Insomnia Causes
  2. Diagnosis
    1. Complaints consistent with insomnia (one or more)
      1. Difficulty initiating or maintaining sleep
      2. Poor quality sleep
      3. Early awakening
      4. Difficult sleep despite adequate conditions
    2. Daytime Impairment due to insomnia (one or more)
      1. Impaired memory, concentration, attention
      2. Excessive Worry about sleep
      3. Daytime somnolence, Fatigue, or malaise
      4. Depressed mood, irritability or poor motivation
      5. Accidents or errors while working or driving
      6. Poor work or school performance
      7. Tension Headaches or gastrointestinal upset
    3. Duration
      1. Acute insomnia: <30 days
      2. Chronic insomnia: 30 days or more
    4. Subtypes based on cause
      1. Primary insomnia (no cause): <20% of chronic cases
      2. Comorbid insomnia (insomnia secondary to other cause)
  3. Evaluation
    1. History
      1. Sleep habits and history of problems
      2. Substance use
      3. Limb Movement Disorders
      4. Sleep Apnea
      5. Psychiatric Illness (Depression, Bipolar Disorder)
      6. Substance use or abuse (e.g. caffeine, Alcohol)
    2. Sleep diary
      1. Keep 2 week sleep log
      2. Times: Bedtime, Awakening, Naps, Total sleep time
      3. Sleep onset latency
      4. Number of nighttime awakenings
      5. Well rested on awakening?
    3. Examination
      1. Thyroid examination
      2. Neurologic Examination
      3. Mini-Mental Status Exam (MMSE)
  4. Complications
    1. Cognitive decline in over age 65 years (especially men)
      1. Insomnia is an independent risk factor
      2. Cricco (2001) J Am Geriatr Soc 49:1185
  5. Management: Non-Pharmacologic
    1. See Sleep Hygiene
    2. Consider written sleep plan
    3. Regular Exercise (6 hours before bedtime)
    4. Sleep Stimulus Control therapy
    5. Sleep Restriction Therapy
    6. Relaxation
      1. Progressive muscle relaxation
      2. Mental imaging
      3. Meditation
    7. Cognitive behavior therapy
      1. Refocuses attention on positive factors
        1. Turns off cycle: worrying about not sleeping
      2. More effective for sleep than Ambien (Zolpidem)
      3. Jacobs (2004) Arch Intern Med 164:1888
  6. Management: Sedative-Hypnotic Drugs
    1. Indications: Short term Insomnia treatment
      1. Avoid use more than 3 weeks
      2. Start with lowest effective dose
      3. Taper slowly if longer use
    2. Adverse Effects
      1. Daytime somnolence
      2. Amnesia
      3. Early morning insomnia
      4. Daytime anxiety & confusion
      5. Ataxia and falls in elderly
    3. Preparations: Nonbenzodiazepine hypnotic agents
      1. Short-acting agents
        1. Zolpidem (Ambien)
        2. Zaleplon (Sonata)
          1. Helpful in early night awakening
      2. Longer-acting agents (better sleep maintenance)
        1. Zolpidem CR (Ambien CR)
        2. Eszopiclone (Lunesta)
    4. Preparations: Benzodiazepines
      1. Temazepam (Restoril) 7.5 to 30 mg, 15 min before bed
      2. Estazolam (Prosom) 1 to 2 mg, 15 min before bed
  7. Management: Tricyclic Antidepressants
    1. Indications: Insomnia with comorbidity
      1. Major Depression
      2. Bruxism
      3. Fibrositis
      4. Hyperactivity history
    2. Adverse effects
      1. Anticholinergic side effects are common
      2. Long half lives lead to hangover effect in AM
    3. Preparations
      1. Doxepin (Adapin, Sinequan)
      2. Trazodone (Desyrel) 50 to 150 mg at bedtime
      3. Amitriptyline (Elavil) 25 to 100 mg at bedtime
        1. Avoid Elavil in elderly (anticholinergic effects)
      4. Mirtazipine (Remeron) 15-45 mg daily
  8. Management: Antihistamines
    1. Indications: Insomnia
    2. Adverse effects
      1. Anticholinergic adverse effects
      2. Paradoxical CNS agitation may occur
      3. Exacerbates Restless Leg Syndrome
    3. Preparations
      1. Diphenhydramine (Benadryl) 25 to 50 mg at bedtime
      2. Doxylamine (Unisom) 12.5 to 25 mg at bedtime
      3. Hydroxyzine (Vistaril) 25 to 100 mg at bedtime
  9. Management: Herbals
    1. Melatonin
    2. Ramelteon (Rozerem)
      1. Melatonin receptor agonist
      2. May be more effective in shifted sleep phase
    3. Valerian Root
  10. Management: Bright Light Exposure
    1. Mechanism
      1. Bright lights reset circadian rhythm
      2. Bright light sources
        1. Outdoor light
        2. Light box
    2. Indications
      1. Delayed sleep phase
        1. Young adults who do not get sleepy until midnight
        2. Use bright light in early morning (6 to 7 am)
      2. Early Sleep phase
        1. Elderly have onset of tiredness at 6 pm
        2. Use bright light in late afternoon
  11. Books: Non-medical
    1. Bishop (2000) Hello Midnight: Insomniac's ... Companion
      1. Paid Link to Amazon.com (ISBN 0684848341)
  12. References
    1. Holbrook (2000) CMAJ 162:216
    2. Kupfer (1997) N Engl J Med 336:341
    3. Ramakrishnan (2007) Am Fam Physician 76(4):517
    4. Sateia (2004) Med Clin North Am 88:567

Sleeplessness (C0917801)

Definition (NCI)Difficulty in going to sleep or getting enough sleep.
ConceptsSign or Symptom (T184)
ICD9780.52
MSHD007319
BasqueLOAREN PERTURBAZIOA/LOGABETASUNA
DanishSovnforstyrrelser/sovnloshed
DutchSlapeloosheid/andere slaapstoornis
EnglishCannot sleep - insomnia, Disturbances of sleep/insomnia, Insomnia, INSOMNIA DIS, Insomnia Disorder, Insomnia Disorders, Insomnia symptom, Insomnias, Sleeplessness
FrenchTroubles du sommeil/insomnie
Germangestoerter Schlaf/Schlaflosigkeit
Hebrewhafraot beshena
Hungarianalvaszavar/insomnia
ItalianDisturbi del sonno/insonnia
NorwegianSOVNFORSTYRRELSER/SOVNLOSHET
PortuguesePerturbacao do sono/insonia
SpanishAlteracion del sueno/insomnio, desvelo, insomnio
SwedishSOMNRUBBNING/SOMNLOSHET
Parent ConceptsDyssomnias (C0700201), Brain Diseases (C0006111), Anxiety neurosis (finding) (C1279420), Sleep disturbances (C0037317), Symptoms and Complaints Component (C0497525), Psychiatric problem (C1306597), Sleep Disorders (C0851578), Sleep Initiation and Maintenance Disorders (C0021603), Sleeplessness (C0917801), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MEDLINEPLUS, MSH, MTH, NCI, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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