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Insomnia
Susanne Wild, MD
image BASICS
DESCRIPTION
  • Difficulty initiating or maintaining sleep or nonrestorative sleep despite adequate opportunity and circumstances for sleep
  • Causes at least one of the following forms of daytime impairment related to nighttime sleep difficulty:
    • Fatigue or malaise
    • Attention, concentration, or memory impairment
    • Social or vocational dysfunction or poor school performance
    • Mood disturbance or irritability
    • Daytime sleepiness
    • Motivation, energy, or initiative reduction
    • Proneness for errors or accidents at work or while driving
    • Tension, headaches, or GI symptoms in response to sleep loss
    • Concerns or worries about sleep
EPIDEMIOLOGY
  • Predominant age: increases with age
  • Predominant sex: female > male (5:1)
Prevalence
  • Insomnia (transient and chronic): 5-35% of the population; 10-15% associated with daytime impairment
  • Chronic insomnia: 10% middle-aged adults; 1/3 of people >65 years
ETIOLOGY AND PATHOPHYSIOLOGY
  • Transient/intermittent (<30 days)
    • Stress/excitement/bereavement
    • Shift work
    • Medical illness
    • High altitude
  • Chronic (>30 days)
    • Medical: gastroesophageal reflux disease, sleep apnea, chronic pain, congestive heart failure, Alzheimer disease, Parkinson disease, chronic fatigue syndrome, irritable bowel syndrome
    • Psychiatric: mood, anxiety, psychotic disorders
    • Primary sleep disorder: idiopathic, psychophysiologic (heightened arousal and learned sleeppreventing associations), paradoxical (sleep state misperception)
    • Circadian rhythm disorder: irregular pattern, jet lag, delayed/advanced sleep phase, shift work
    • Environmental: light (liquid crystal display [LCD] clocks), noise (snoring, household, traffic), movements (partner/young children/pets)
    • Behavioral: poor sleep hygiene, adjustment sleep disorder
    • Substance induced
    • Medications: antihypertensives, antidepressants, corticosteroids, levodopa-carbidopa, phenytoin, quinidine, theophylline, thyroid hormones
Pregnancy Considerations
Transient insomnia occurs secondary to change of sleep position, nocturia, gastritis, back pain, anxiety.
RISK FACTORS
  • Age
  • Female gender
  • Medical comorbidities
  • Unemployment
  • Psychiatric illness
  • Impaired social relationships
  • Lower socioeconomic status
  • Shift work
  • Separation from spouse or partner
  • Drug and substance abuse
GENERAL PREVENTION
  • Practice consistent sleep hygiene:
    • Fixed wake-up times and bedtimes regardless of amount of sleep obtained (weekdays and weekends)
    • Go to bed only when sleepy.
    • Avoid naps.
    • Sleep in a cool, dark, quiet environment.
    • No activities or stimuli in bedroom associated with anything but sleep or sex.
    • 30-minute wind-down time before sleep
    • If unable to sleep within 20 minutes, move to another environment and engage in quiet activity until sleepy.
  • Limit caffeine intake to mornings.
  • No alcohol after 4 PM.
  • Fixed eating times
  • Avoid medications that interfere with sleep.
  • Regular moderate exercise
COMMONLY ASSOCIATED CONDITIONS
  • Psychiatric disorders
  • Painful musculoskeletal conditions
  • Obstructive sleep apnea
  • Restless leg syndrome
  • Drug or alcohol addiction/dependence
image DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
  • Sleep-disordered breathing such as obstructive sleep apnea
  • CNS hypersomnias (e.g., narcolepsy)
  • Circadian rhythm sleep disturbances
  • Sleep-related movement disorders (e.g., restless leg syndrome)
  • Substance abuse
  • Insomnia due to medical or neurologic disorder
  • Mood and anxiety disorders such as depression or anxiety
DIAGNOSTIC TESTS & INTERPRETATION
  • Diagnostic testing usually not required; consider polysomnography if sleep apnea or periodic limb movement disorder is suspected (1)[C].
  • Primary insomnia
    • Symptoms for at least 1 month: difficulty in initiating/maintaining sleep or nonrestorative sleep
    • Impairment in social, occupational, or other important areas of functioning
    • Does not occur exclusively during narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or parasomnia
    • Does not occur exclusively during major depressive disorder, generalized anxiety disorder, delirium
    • Is not secondary to physiologic effects of substance or general medical condition
    • Sleep disturbance (or resultant daytime fatigue) causes clinically significant distress.
  • Secondary insomnia
    • Due to substance abuse, medication induced (diuretics, stimulants, etc.), primary depressive disorder, generalized anxiety disorder or phobias, acute situational stress, posttraumatic stress disorder, pain
Initial Tests (lab, imaging)
Testing to consider based on history and physical exam:
  • Thyroid-stimulating hormone
  • Urine toxicology
Diagnostic Procedures/Other
Polysomnography or multiple sleep latency test not routinely indicated but may be considered if
  • Initial diagnosis is uncertain.
  • Treatment interventions have proven unsuccessful.
image TREATMENT
  • Transient insomnia
    • May use medications for short-term use only; benzodiazepines favored
    • Self-medicating with alcohol can increase awakenings and sleep-stage changes.
  • Chronic insomnia
    • Treatment of underlying condition (major depressive disorder, generalized anxiety disorder, medications, pain, substance abuse)
    • Advise good sleep hygiene.
    • Cognitive-behavioral therapy is the first-line treatment for chronic insomnia, especially in >60 years population, especially when sedatives are not advantageous (2)[A].
    • Behavioral therapy is an effective treatment for insomnia and a potentially more effective long-term treatment than pharmacotherapy (3)[B].
    • Ramelteon is the only agent without abuse potential (4)[B].
P.565

MEDICATION
  • Reserved for transient insomnia such as with jet lag, stress reactions, transient medical condition
  • Nonbenzodiazepine hypnotics
    • Act on benzodiazepine receptor so have abuse potential
      • Zaleplon (Sonata) 5 to 20 mg; half-life 1 hour
      • Zolpidem (Ambien) 5 to 10 mg (males); 5 mg (females); half-life 2.5 to 3 hours
      • Zolpidem (Ambien CR) 6.25 to 12.5 mg (males); 6.25 mg (females); half-life 2.5 to 3 hours
      • Eszopiclone (Lunesta) 1 to 3 mg; half-life 6 hours
  • Benzodiazepine hypnotics
    • Short acting
      • Triazolam (Halcion) 0.25 mg; half-life 1.5 to 5.5 hours
    • Intermediate acting
      • Temazepam (Restoril) 7.5 to 30 mg; half-life 8.8 hours long-acting:
        • Lorazepam (Ativan) 1 to 4 mg; half-life 14 hours
        • Diazepam (Valium) 5 to 10 mg; half-life 30 to 60 hours
        • Estazolam (Prosom) 1 to 2 mg; half-life 10 to 24 hours
  • Contraindications/precautions:
    • Not indicated for long-term treatment due to risks of tolerance, dependency, daytime attention and concentration compromise, incoordination, rebound insomnia
    • Long-acting benzodiazepines associated with higher incidence of daytime sedation and motor impairment
    • Avoid in elderly, pregnant, breastfeeding, substance abusers, and patients with suicidal or parasuicidal behaviors.
    • Avoid in patients with untreated obstructive apnea and chronic pulmonary disease.
    • No good evidence for benzodiazepines for patients undergoing palliative care (5)[A]
    • Nonbenzodiazepine receptor agonists may occasionally induce parasomnias (sleepwalking, sleep eating, sleep driving).
  • Melatonin receptor agonist
    • Ramelteon 8 mg; half-life 1 to 2.6 hours Effective to reduce sleep time onset for shortand long-term use in adults, without abuse potential; no comparative studies with older agents have been completed. Onset of effect may take up to 3 weeks (4)[B].
  • Serotonergic antidepressants
    • Trazodone 25 to 200 mg; half-life 3 to 9 hours
    • Doxepin 10 to 50 mg; half-life 15 hours
      • New formulation of medication is available at dosage 3 to 6 mg QHS.
    • Amitriptyline 25 to 50 mg; half-life 10 to 26 hours
    • Mirtazapine 7.5 to 15 mg; half-life 20 to 40 hours
  • Sedating antihistamines are not recommended and should be used conservatively for insomnia due to insufficient evidence of efficacy and significant concerns about risks of these medications.
Geriatric Considerations
Caution (risk of falls and confusion) when prescribing benzodiazepines or other sedative hypnotics; if absolutely necessary, use short-acting nonbenzodiazepine agonists at half the dosage or melatonin agonists for short-term treatment.
ADDITIONAL THERAPIES
Associated with hypertension, congestive heart failure, anxiety and depression, and obesity; management of these chronic conditions will help with incidence and symptoms of insomnia.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Melatonin: decreases sleep latency when taken 30 to 120 minutes prior to bedtime, but there is no good evidence for efficacy in insomnia, and longterm effects are unknown (6)[B]
  • Valerian: Inconsistent evidence supporting efficacy and its slow onset of action (2 to 3 weeks) makes it unsuitable for the acute treatment of insomnia.
  • Acupuncture: insufficient evidence on effect of needle acupuncture and its variants (7)
  • Antihistamines: insufficient evidence; should not be recommended for use
  • Cognitive-behavioral therapy (including relaxation therapy): effective and considered more useful than medications; recommended initial treatment for patients with chronic insomnia
  • Mindfulness awareness practices: improved sleep quality and sleep-related daytime impairment for older adults per small randomized trial (8)
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Daily exercise improves quality of sleep and may be more effective than medication.
  • Avoid exercise within 4 hours of bedtime.
Patient Monitoring
  • Reassess need for medications periodically; avoid standing prescriptions.
  • Caution patients that nonbenzodiazepine agonists (zolpidem, zaleplon, eszopiclone), as well as benzodiazepines, can be habit forming.
  • Studies suggest an association between receiving a hypnotic prescription and a >3-fold increase in hazards of death, even when prescribed <18 pills per year (9)[B].
DIET
  • Avoid caffeine or reserve for morning only.
  • Avoid heavy late-night snacks (light snack at bedtime may help).
  • Avoid alcohol within 6 hours of bedtime.
PROGNOSIS
  • Situational insomnia should resolve with time.
  • Treatment of underlying etiology and consistent sleep hygiene are the mainstays of treatment.
REFERENCES
1. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499-521.
2. Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2003;(1):CD003161.
3. Ebben MR, Spielman AJ. Non-pharmacological treatments for insomnia. J Behav Med. 2009;32(3):244-254.
4. Reynoldson JN, Elliott E Sr, Nelson LA. Ramelteon: a novel approach in the treatment of insomnia. Ann Pharmacother. 2008;42(9):1262-1271.
5. Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev. 2002;(4):CD003346.
6. Verster GC. Melatonin and its agonists, circadian rhythms, and psychiatry. Afr J Psychiatry (Johannesbg). 2009;12(1):42-46.
7. Cheuk DK, Yeung WF, Chung KF, et al. Acupuncture for insomnia. Cochrane Database Syst Rev. 2012;(9):CD005472.
8. Black DS, O'Reilly GA, Olmstead R, et al. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015;175(4):494-501.
9. Kripke DF, Langer RD, Kline LE. Hypnotics' association with mortality or cancer: a matched cohort study. BMJ Open. 2012;2(1):e000850.
Additional Reading
&NA;
Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: metaanalysis of risks and benefits. BMJ. 2005;331(7526):1169.
See Also
&NA;
  • Anxiety; Depression; Fibromyalgia; Sleep Apnea, Obstructive
  • Algorithms: Anxiety; Insomnia, Chronic; Restless Legs Syndrome (RLS)
Codes
&NA;
ICD10
  • G47.00 Insomnia, unspecified
  • F51.02 Adjustment insomnia
  • F51.01 Primary insomnia
Clinical Pearls
&NA;
  • Treatment of underlying etiology of the insomnia and consistent sleep hygiene are key.
  • Most medications are indicated for short-term use only.
  • Sedative hypnotics are not recommended in the elderly because risks may outweigh benefits.
  • Patients with chronic insomnia benefit from cognitive-behavioral therapy.