Insomnia
defined as the inability to initiate or maintain adequate sleep
can lead to daytime somnolence, work absenteeism, motor vehicle accidents, poor general health, functional impairment, and impaired quality of life.
History
past and current symptoms of sleep apnea, restless legs syndrome, hypothyroidism, arthritis, cardiopulmonary disease, neurologic disease, and depression
history of medication and other substance use, including caffeine and other stimulants, alcohol, and over-the-counter medications, and a detailed description of sleep behavior and sleep environment is essential
Management
Nonpharmacologic Therapy
In a 2016 clinical practice guideline, the ACP strongly recommends cognitive-behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia
Pharmacologic Therapy
OTC meds
Melatonin
Diphenhydramine
In the elderly generally not recommended
contraindicated in patients with glaucoma and men with benign prostatic hyperplasia
Prescription Medications
Approved only for short-term (1-month) continuous use
1.Benzodiazepines, which are nonselective γ-aminobutyric acid (GABA)-receptor agonists 2. Nonbenzodiazepines (are more selective GABA-receptor agonists)
Avoid Benzos in elderly
Non-benzodiazepines are better initial choices
Doxepin, in low doses, is the only antidepressant approved for the treatment of insomnia. Doxepin, trazodone, and mirtazapine can be useful if a sedating antidepressant is indicated
Dopaminergic agonists have been effective in reducing involuntary leg movement and, hence, improving sleep. Pramipexole or ropinirole are the drugs of choice.
which consists of educational interventions (such as sleep hygiene), cognitive therapy, and behavioral interventions (such as sleep restriction therapy, stimulus-control therapy, and relaxation techniques)