Insomnia

Question 1

Patient presents with insomnia.

Impression/DDx/Goals

Answer 1

Impression.
Likely insomnia, altho need to consider other associated ddx as is often multifactorial, so consider psychiatric (GAD, depression, stress), cardiovascular (OSA), medication related (B blockers, stimulants, steroids).

Goals:

• take full sleep history, identify factors for optimisation
• delineate any other underlying conditions relating to the presentation of insomnia
• initiate appropriate patient-centred management plan

Question 2

Insomnia - History

Answer 2

History:

• Characterise insomnia: early vs late. difficulty getting to sleep vs staying asleep, feel refreshed, etc
• sleep hygiene: ask about activities surrounding sleep, what to do when waking up, no interruptions
• issues during sleep: OSA, restless legs
• effect on life, degree of concern
• PMHx, FamHx, medications, SNAP

Question 3

Insomnia - Examination

Answer 3

Exam:

• EOBOG, general inspection
• Vitals: baseline obs
• Cardiorespiratory examination
• Mental state exam

Question 4

Insomnia - Investigations

Answer 4

Investigations:
Largely a clinical diagnosis, only require further investigation if underlying cause not detected

• Bedside: vital signs
• Bloods: TSH, BSL, Hba1C, lipid panel, other opportunistic (FBC, UEC)
• Imaging: Nil
• Other: Sleep diary, Pittsburgh sleep quality index, polysomnography, actigraphy (restless legs suspected)

Question 5

Insomnia - Management

Answer 5

Management:
non-pharm
- sleep diary: to work out triggers.
- address acute stressors in patient’s life
- patient education: improve sleep hygiene baesd on history findings
- relaxation techniques (visualisations, deep breathing, progressive muscle relaxation, medications)
- Sleep restriction
- Stimulus control (lights, food, exercse, caffeine, alcohol, etc)
- consider CBT - self-administered of face to face, exercise

Pharm

• melatonin, 2 - 5 mg
• hypnotics (temazepam): only use for short term, and in specific scenarios if benefit outweighs risk
• antidepressants/anxiolytics

Review
- 2 weeks after sleep diary and initiation of non-pharm activities

Referral:
- sleep specialist if diagnosis unclear or refractory symptoms

Opportunistic

• immunisations
• screening
• other chronic disease management