INSOMNIA (Management (Long term insomnia -Refer to psychological services…
Manage identifiable cause where possible. Not to drive if feeling sleepy but no need to inform DVLA.
Long term insomnia -Refer to psychological services IAPT (Improving Access to Psychological Therapies) for a cognitive or behavioural intervention.
Refer to a sleep clinic or a specialist with expertise in sleep medicine if insomnia persists despite primary care management.
Hypnotics as per short term management. For people over 55 years of age with persistent insomnia, consider treatment with a modified-release melatonin.
The recommended initial duration of treatment is 3 weeks. If there is a response to treatment, it can be continued for a further 10 weeks.
Consider a short course of a hypnotic drug only if daytime impairment is severe.
Use the lowest effective dose for the shortest period possible. The exact duration will depend on the underlying cause but should not continue for longer than 2 weeks. Up to 4 weeks' use may occasionally be required, but continued use should always be re-assessed after 2 weeks.
Review after 2 weeks and consider referral for cognitive behavioural therapy if symptoms persist
Diazepam is not generally recommended, but it can be useful if insomnia is associated with daytime anxiety
Non-benzodiazepines (the 'z-drugs') — zopiclone, zolpidem, and zaleplon (all are short acting).
Short-acting benzodiazepines — temazepam, loprazolam, lormetazepam.
Short term insomnia -Good sleep hygiene: fixed bed time routine, relax. Avoid - caffeine, nicotine & alcohol 6hrs before bed. Avoid day time napping, avoid heavy meal late at night.
Secondary causes - sleep apnoea, circadian rhythm disorder, parasomnias, nacrolepsy, stress, anxiety or depression,. Physical cuases - COPD, congestive HF, GI reflux.
Duration of symptoms - short term <4weeks, long term >4 weeks. Sleepdiary for 2 weeks if underlying cause not clear.
Assess - person's beliefs about normal sleep & impact of insomnia : quality of life, employment, mood, relationships & ability to drive.
Long-term (or persistent) if insomnia lasts for 4 weeks or longer.
Short-term if insomnia lasts between 1 and 4 weeks.
Insomnia can be categorized according to duration or likely duration.
Definitions of duration of insomnia vary widely in the literature; for the purpose of this topic, insomnia is categorized as:
Comorbid (or secondary) insomnia is when insomnia occurs as a symptom of, or is associated with, other conditions, including medical or psychiatric illness, or drug or substance misuse.
Primary insomnia accounts for about 15–20% of long-term insomnia.
Typically, primary insomnia has a duration of at least 1 month.
Primary insomnia is insomnia that occurs when no comorbidity is identified.
Commonly, the person has conditioned or learned sleep difficulties, with or without heightened arousal in bed.
Insomnia can be classified according to cause:
Dfficulty in getting to sleep, difficulty staying asleep, early wakening, or non-restorative sleep despite adequate time and opportunity to sleep, resulting in impaired daytime functioning, such as poor concentration, mood disturbance, and daytime tiredness.