Insomnia

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 49:1185-9
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 164:1888-96
6. Management: Sedative-Hypnotic Drugs
   1. Precautions
      1. Exercise caution in the elderly due to Delirium, falls, Fractures and MVA risks (on Beers List)
         1. (2013) Presc Lett 20(6): 33
      2. On average, Sedative-Hypnotics extend sleep time by only 30 minutes per night
      3. Even infrequent use of Sedative-Hypnotics increases mortality risk three-fold over baseline
         1. http://bmjopen.bmj.com/content/2/1/e000850
   2. Indications: Short term Insomnia treatment
      1. Avoid use more than 3 weeks
      2. Start with lowest effective dose
      3. Taper slowly if longer use
   3. Adverse Effects
      1. Daytime somnolence
      2. Amnesia
      3. Early morning Insomnia
      4. Daytime anxiety & confusion
      5. Ataxia and falls in elderly
   4. Preparations: Nonbenzodiazepine hypnotic agents
      1. Short-acting agents
         1. Zolpidem (Ambien)
            1. Used for initiating sleep and sleep maintenance
         2. Zaleplon (Sonata)
            1. Helpful in early night awakening (4 hour duration)
      2. Longer-acting agents (better sleep maintenance)
         1. Eszopiclone (Lunesta)
         2. Zolpidem CR (Ambien CR)
            1. Unlikely to offer significant benefit over standard Zolpidem in sleep maintenance
   5. 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. Resources: Non-medical Books
    1. Bishop (2000) Hello Midnight: Insomniac's ... Companion
       1. Paid link to Amazon.com (ISBN 0684848341)
12. References
    1. Holbrook (2000) CMAJ 162: 216-20
    2. Kupfer (1997) N Engl J Med 336:341-6
    3. Ramakrishnan (2007) Am Fam Physician 76(4):517-28
    4. Sateia (2004) Med Clin North Am 88:567-96