Insomnia

Question 1

What is insomnia?

Answer 1

• Difficulty initiating or maintaining sleep OR early morning awakening that leads to dissatisfaction with sleep quantity or quality
• This is despite adequate time and opportunity for sleep
• Results in impaired daytime functioning

Question 2

Acute vs chronic insomnia

Answer 2

• Acute → typically related to life event + resolves without treatment
• Chronic → trouble falling asleep or staying asleep for at least 3 nights/week for > 3 months

Question 3

What are clinical features in the history for insomnia?

Answer 3

• Decreased daytime functioning
• Decreased periods of sleep
• Increased accidents due to poor concentration
• Often partner’s rest will also suffer

Less common diagnostic factors → daytime napping, enlarged tonsils/tongue, micognathia, lateral narrowing of oropharynx

Question 4

What are key risk factors for insomnia?

Answer 4

• Female gender
• Increased age
• Lower educational attainment
• Unemployment
• Economic inactivity
• Widowed, divorced, or separated status

Question 5

Investigations for insomnia?

Answer 5

• Diagnosis primarily made through patient interview, looking for presence of risk factors
• Sleep diaries and actigraphy may aid diagnosis - actigraphy is non-invasive motor activity monitoring
• Polysomnography not routinely indicated - consider this in pts with suspected OSA or periodic limb movement diosrder, or when insomnia poorly responsive to conventional treamtent

Question 6

Short-term management for insomnia?

Answer 6

• Identify underlying (mental/physical) causes
• Sleep hygeine education → no screens before bed, limited caffeine, fixed bed times
• Advise person not to drive if sleepy
• Only consider use of hypnotics if daytime impairment severe

Question 7

There is good evidence for using hyponotics in short-term insomnia. What are the adverse effects?

Answer 7

• Daytime sedation
• Poor motor coordination
• Cognitive impairment
• Related concerns about accidents/injuries
• Tolerance within few days or weeks of regular use

Question 8

Which hypnotics are used for insomnia?

Answer 8

• Benzos or Z drugs
• Diazepam not recommended but useful for insomnia related to daytime anxiety
• Use lowest effective dose for shortest period possible
• No response w/ first hypnotic? Do NOT prescribe another
• Important to review after 2 weeks + consider referral for CBT