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I Dream of Sleep: Managing Insomnia in Adults

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I Dream of Sleep: Managing Insomnia in Adults MENTAL HEALTH NEUROLOGY I dream of sleep: managing insomnia in adults bpacnz recognises that the assessment and management of insomnia in general practice can be difficult, especially in relation to managing patients expectations about pharmacological treatments. We hope you will find this summary of the effectiveness of both non-pharmacological and pharmacological intervention of assistance. Part 1: Diagnosis and non-pharmacological treatment Adults with insomnia have difficulty initiating or maintaining sleep with adverse effects on their daytime functioning. A sleep diary can help with diagnosis and tracking improvements. Non-pharmacological approaches, such as sleep hygiene and bedtime restriction, are preferred first-line treatments; these are effective and provide greater long-term benefits than pharmacological measures. KEY PRACTICE POINTS: How much sleep is enough? A diagnosis of chronic insomnia can be made based on There is a large amount of individual variation in sleep duration the patient’s sleep symptoms and daytime fatigue after and requirement. The optimal recommended sleep duration ruling out other conditions such as sleep apnoea, dyspepsia, dyspnoea, restless leg syndrome and parasomnias. for adults ranges from seven to nine hours per night, although some people will require more than this, and some will function Non-pharmacological treatment is first-line for all patients: in general, most people who have problems sleeping can well with less (Figure 1). Daytime fatigue is a key feature of the benefit from this intervention even if other conditions, such diagnosis of insomnia, and is usually regarded as the most as depression, anxiety or pain, are contributing to their important feature, rather than the amount of sleep a person insomnia. is getting1 Non-pharmacological treatment should aim to address Almost everyone will have short-term insomnia at some lifestyle factors causing sleep disruption, improve the point in their life, for example due to bereavement, stress sleeping environment and sleeping routine, and strengthen or worry about family, relationships, work or finances. Sleep the link between bed and sleeping (sleep hygiene). It can also include bedtime restriction to maximise sleep problems which have lasted for one to three months are efficiency. These behavioural changes form part of cognitive considered chronic insomnia.2–4 Traditionally, a distinction has behavioural therapy for insomnia (CBTi). been made between secondary insomnia, which arises due www.bpac.org.nz October 2017 1 to another condition, and primary insomnia where a patient day, which may suggest an alternative diagnosis such as has problems sleeping but where there is no underlying narcolepsy or sleep apnoea.7 If patients have problems staying medical cause.4 However, this distinction is now considered awake or have significant fatigue, assess factors such as safety less important because:4, 5 while driving or using machinery, or while caring for children Primary and secondary insomnia may co-exist or others, as reaction times, concentration and judgement may Insomnia does not always resolve when the secondary be affected. cause is treated, e.g. if the patient also has poor sleeping Assess medicine or substance use, lifestyle and home habits factors which could contribute to poor sleep Management principles are the same regardless of diagnosis; research increasingly shows that non- Factors related to a patient’s lifestyle, prescribed medicines, pharmacological approaches can improve sleep in caffeine intake or sleeping environment could cause or further patients who have co-morbid conditions, such as chronic exacerbate problems with sleep or fatigue. pain, depression or anxiety. Smoking increases sleep latency and causes disturbed sleep later in the night.10 Alcohol may cause initial sleepiness Assessing adults who report sleep problems but can disrupt sleep in the later part of the night.11 A number of conditions can be associated with disrupted sleep Consider use of medicines that are associated with sleep and difficulty staying awake during the day (Table 1). disruption and whether it is possible to discontinue, change Chronic insomnia is a diagnosis of exclusion. It is important or alter the timing of the medicine, e.g. SSRIs, opioids, beta- that treatable conditions which cause sleep disturbances, blockers (particularly lipid soluble formulations such as such as sleep apnoea, restless leg syndrome or parasomnias, bisoprolol, metoprolol or carvedilol), statins and diuretics.7 are identified and managed accordingly, which may alleviate the patient’s insomnia symptoms. However, most people who Ask about mental health issues and psychological have problems sleeping can benefit from non-pharmacological stress approaches even if other conditions are contributing to their Insomnia is associated with an increased risk of mental insomnia. health problems, such as depression and anxiety. Conversely, underlying depression or anxiety can contribute to problems Ask patients about their specific sleep symptoms sleeping and can often be the first presenting symptom of the Attention to a patient’s specific problems with sleep or waking mental illness. Research shows that improving sleep in these can help guide diagnosis (Table 2). Accounts from partners or patients benefits their co-morbid depression or anxiety.13,14 room-mates may provide useful information such as witnessed apnoeas, kicking or other movements during sleep. Questionnaires may assist diagnosis The Auckland Sleep Questionnaire can be used to identify Ask about daytime symptoms patients who would like help with problems with sleep or In patients with chronic insomnia, physical and mental fatigue depressive symptoms. The Epworth Sleepiness Score can assist are more common than a tendency to fall asleep during the in the diagnosis of sleep apnoea.15 Age Group 18−25 years Recommended May be appropriate 26−64 years Not recommended ≥ 65 years 4 5 6 7 8 9 10 11 12 Hours of sleep per night Figure 1: Recommended sleep durations across age groups6 2 October 2017 www.bpac.org.nz Table 1: Differential diagnoses which can cause or further exacerbate disrupted sleep, tiredness or non-refreshing sleep.3, 7 ,8 Sleep disorders Restless legs syndrome For further information, see: www.bpac.org.nz/BPJ/2012/december/ restlesslegs.aspx Delayed sleep phase People with this condition have a circadian rhythm where they tend to disorder go to sleep late, e.g. after midnight, and wake late in the morning, which impacts on their social, educational or occupational demands.[9] For further information, see: www.sleep.org.au/documents/item/2683 Advanced sleep phase People with this condition have a circadian rhythm where they feel disorder excessively tired in the evening, go to bed early, e.g. 8–9 pm, and wake early in the morning.9 For further information, see: www.sleep.org.au/ documents/item/2683 Narcolepsy For further information, see sidebar in: www.bpac.org.nz/BPJ/2012/ november/parasomnias.aspx Parasomnias For further information, see: www.bpac.org.nz/BPJ/2012/November/ parasomnias.aspx Respiratory Sleep apnoea See: “Risk factors and signs and symptoms associated with obstructive problems sleep apnoea”. For further information on sleep apnoea, see: www.bpac.org.nz/BPJ/2012/ november/apnoea.aspx Other conditions Depression or anxiety Chronic pain Chronic fatigue syndrome Itch (e.g. atopic eczema, chronic urticaria) Menopause Table 2: Features of disrupted sleep and some associated causes3, 7, 8 In patients with: Consider: Difficulty falling asleep when they The use of stimulants such as caffeine, and medicines with stimulant properties, e.g. first go to bed pseudoephedrine, methylphenidate Restless legs syndrome Delayed sleep phase disorder Lack of time to unwind, e.g. watching an exciting programme before bedtime Anxiety, distress, worry about not getting enough sleep Using computers, tablets, phones or reading e-books or books in bed Smoking (increases sleep latency and causes disturbed sleep later in the night10) Working night shifts or alternating shifts Frequent arousals during the night Sleep apnoea (or typical sleeping time), also known The need for frequent urination, e.g. due to use of diuretics or prostatism as “sleep maintenance insomnia” (see: Alcohol use (can disrupt sleep in the later part of the night11) “Sleep vocabulary”) Difficulty getting back to sleep once Stress, worry and anxiety awake Other health issues: chronic pain, dyspnoea, itch Activities such as using a mobile phone or electronic device after waking Waking up too early Advanced sleep phase disorder Too much light or noise Stress, worry and anxiety Sleeping, but not feeling refreshed or Sleep apnoea (see: “Risk factors and signs and symptoms associated with rested when they wake obstructive sleep apnoea”) Chronic pain Chronic fatigue syndrome Going to bed too late or getting up too early by choice www.bpac.org.nz October 2017 3 The Auckland Sleep Questionnaire (short version) is CBTi is more effective than medicines in the long available at: www.goodfellowunit.org/sites/default/files/ term insomnia/ASQshort_tool.pdf CBTi consists of behavioural changes to improve sleeping The Epworth Sleepiness Score is available at: www. patterns and addressing any unhelpful thoughts or beliefs healthinfo.org.nz/patientinfo/Epworth%20Sleepiness%20 a patient may have about sleeping. The effects of CBTi will Score%20Sheet%20NM.pdf vary, but on average it results in patients getting to sleep approximately 20 minutes earlier, with
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