Insomnia:Difficulty in getting to sleep, difficulty maintaining sleep, early wakening, or non-restorative sleep which occurs despite adequate opportunity for sleep and results in impaired daytime functioning.
Causes
Short term insomnia- Insomnia symptoms occurring for less than 3 months duration (typically a few days or weeks).
Comorbid (or secondary) insomnia: insomnia due to a comorbid condition
Primary insomnia-insomnia not attributable to an underlying cause
Long term insomnia
Assessment
Management
Differential Diagnosis
Restless legs syndrome
Narcolepsy — may present with falling asleep in the daytime without warning and collapse or muscle weakness triggered by emotion
Circadian rhythm disorders
Obstructive sleep apnoea
Parasomnias — may present with unusual or unpleasant experiences or behaviours associated with sleep that are troublesome or dangerous.
Short term insomnia
Long term insomnia
where sleep hygiene measures fail, daytime impairment is severe causing significant distress and
Stressful events such as bereavement, illness, changes in employment, exams, pending deadlines or financial difficulties.
Changes in sleeping patterns due to the birth of a child or environmental disturbance such as excess noise or light or extremes of temperature.
Insomnia symptoms occurring on at least 3 nights per week for three months or more.
Psychiatric disorders such as anxiety and depression.
Medical disorders such as COPD, heart failure, neurodegenerative diseases, malignancy, musculoskeletal conditions and chronic pain.
Substance misuse such as alcohol and illicit drugs.
possible triggers and behaviours during sleep
PMhx- pain, physical and psychological conditions
History of symptoms- duration and frequency, sleep schedule, sleep environment
Drug Hx and substance abuse, caffine
Impact of insomnia- QOL, ability to drive, employment, behaviour, mood, relations
Examination of comorbid conditions
sleep diary
Normal sleep pattern
Insomnia is likely to resolve soon (for example due to a short-term stressor):
A short course (3-7 days) of a non-benzodiazepine hypnotic medication (z-drug) may be considered, these should be avoided in older people.
Insomnia is not likely to resolve soon:
CBT-I should be offered as the first-line treatment.
Adjunctive treatment with a short-term hypnotic medication (a z-drug or prolonged released melatonin if over 55 years of age) may be appropriate.
CBT-I should be offered as the first-line treatment in adults of any age.
Pharmacological therapy should be avoided in the long-term management of insomnia, however, adjunctive treatment with a short-term hypnotic medication (a z-drug or prolonged released melatonin if over 55 years of age) may be appropriate for some people with severe symptoms or an acute exacerbation.
Referral to sleep clinic or neurolgy
another sleep disorder is suspected
doubt regarding the diagnosis
long-term insomnia has not responded to management in primary care.