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Insomnia Management Guidelines

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Insomnia Management Guidelines GUIDELINES FOR THE MANAGEMENT OF INSOMNIA MAY 2019 This policy supersedes all previous policies relating to Insomnia Policy title GUIDELINES FOR THE MANAGEMENT OF INSOMNIA Policy PHA08 reference Policy category CLINICAL Relevant to All CLINICAL STAFF IN THE TRUST Date published May 2019 Implementation May 2019 date Date last May 2019 reviewed Next review May 2022 date Policy lead LUCY REEVES, Chief Pharmacist Contact details Email: [email protected] Telephone: Accountable DR VINCENT KIRCHNER, ACTING MEDICAL DIRECTOR director Approved by Drugs and Therapeutics Committee May 2019 Approved by Quality committee (Committee): Document Date Version Summary of amendments history May 2019 7 Routine review Melatonin restricted for sleep disorders in patients Feb 2017 6 with learning disabilities. Use of hypnotics in medical conditions, tapering Feb 2015 5 schedules, driving offence Mar 2014 4 What is not recommended Mar 2012 3 Zopiclone has been included as a first line hypnotic Mar 2010 2 Review Dec 2007 1 New Guidelines Membership of the policy development/ AUDREY COKER, LEAD PHJARMACIST FOR CLINICAL SERVICES. review team Consultation Dr Lucinda Donaldson, Consultant for Perinatal Services, Dr Gina Waters Consultant for Perinatal Services. DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. Guidelines for the management of insomnia_PHA08_May 2019 i Contents Page 1 Introduction 1 2 Aims and objectives 2 3 Scope of the policy 2 4 Key points 2 5 Assessment of insomnia 3 6 Promote sleep hygiene principles 5 7 Treatment of insomnia 6 8 Monitoring 9 9 Melatonin 10 10 Dissemination and implementation arrangements 10 11 Training requirements 10 12 Monitoring and audit arrangements 10 13 Review of the policy 11 14 References 11 Appendix 1: Algorithm for the assessment and management of transient 13 /short term insomnia. Appendix 2: Medicines for which management of insomnia would be a 16 Non-formulary indication as a main indication. Appendix 3 How to manage withdrawal of long-term benzodiazepine 18 and z-hypnotic use Appendix 4: Equality impact assessment tool 19 Guidelines for the management of insomnia_PHA08_May 2019 ii 1 INTRODUCTION 1.1.1 Insomnia is a condition of unsatisfactory sleep, either in terms of sleep onset, sleep maintenance or early waking. Insomnia impairs daytime well-being and subjective abilities and functioning, and so can be considered a ‘24-hour’ disorder. It is important to recognize that insomnia is a subjective disorder, and its diagnosis is through clinical observations rather than via measurements. However, in some cases it may be possible to identify and remedy a physical cause for insomnia. Insomnia often starts with a specific problem, for example a stressful life event such as the loss of a job or change to a more demanding one, or through something that changes sleep patterns such as the birth of a child or starting shift work. In some people this acute insomnia persists into a chronic state. Factors involved in the persistence of insomnia are not fully established, but include anxiety about sleep, maladaptive sleep habits and the possibility of an underlying vulnerability in sleep-regulating mechanisms. Persistence of the precipitating stressor can also contribute. Some cases of insomnia are precipitated by, or are co-morbid with, other psychiatric disorders, especially anxiety and depression, or by physical illness such as cancer or arthritis. The nature of sleep changes with age. Older age is associated with poorer objectively measured sleep with shorter sleep time, diminished sleep efficiency, and more arousals, and these changes may be more marked in men than in women1. 1.1.2 Insomnia can be classified according to cause: Transient insomnia may occur in those who normally sleep well and may be due to an alteration in the conditions that surround sleeping e.g. noise, or to an unusual pattern of rest e.g. shift work or travelling between time zones (jet lag)2. It may also be associated with acute disorders. It may only be short term, lasting between 1-4 weeks. Primary insomnia is insomnia that occurs when no co-morbidity is identified. Commonly the person has conditioned or learned sleep difficulties with or without heightened arousal in bed. Typically primary insomnia has a duration of at least one month3. 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 misuse3. 1.1.3 Insomnia can also be categorised according to duration or likely duration. Whilst definitions can vary, insomnia is categorised as: Short-term if insomnia lasts between one to four weeks3. Long-term (or persistent) if insomnia lasts for four weeks or longer3. Part of a state of high arousal secondary to severe psychiatric disturbance. 1.1.4 The underlying cause of insomnia also needs to be identified and corrected whenever possible. Relatively short-term insomnia may be helped by a very limited course of a benzodiazepine or other hypnotic medicine, but is more usually managed without hypnotics. Long-term use of hypnotic medication is not justified and may be hazardous or itself be the cause of sleep problems. In chronic insomnia, physical or psychiatric causes should be considered especially in the elderly. Guidelines for the management of insomnia_PHA08_May 2019 1 2 AIMS AND OBJECTIVES 2.1.1 To provide clear guidance on the appropriate and safe use of medication to control insomnia. 3 SCOPE OF THE GUIDELINE 3.1.1 The guideline covers both the benzodiazepine hypnotics and z-hypnotics. It is aimed at all clinical staff working in Camden and Islington NHS Foundation Trust. 3.1.2 This guideline relates to pharmacological management of insomnia. The guideline is only concerned with prescribing benzodiazepines for the treatment of insomnia. Their role in anxiety management is NOT within the scope of this document. 4 KEY POINTS Table 1: Medicine choice in the management of insomnia Options Medicine choice Comments First line Zopiclone 3.75mg tablets, 7.5mg tablets. Sch 4 CD Second line Temazepam 10mg, 20mg tablets, liquid 10mg in 5ml. Sch 3 CD. Third line Zolpidem 5mg tablets, 10mg tablets Pregnant Promethazine NICE CG 192. Off-label. women Sleep disorders Melatonin NICE NG11, NCL JFC approved. in patients with Learning Disabilities 4.1.1 Inpatients should not routinely be written up for hypnotics. This is rarely necessary and may establish a need to continue afterwards. 4.1.2 With increased awareness of the problems of benzodiazepine dependence, proper use and careful patient selection is essential. See Appendix 1 for ‘How to manage withdrawal of long-term benzodiazepine and z-hypnotic use’. CSM ADVICE2 1. Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness. 2. The use of benzodiazepines to treat short – term ‘mild’ anxiety is inappropriate and unsuitable. 3. Benzodiazepines should be used to treat insomnia but only when it is severe, disabling or subjecting the individual to extreme stress. CSM ADVICE Guidelines for the management of insomnia_PHA08_May 2019 2 Table 2: Hypnotic relative effects Drug Cost Elimination half-life 4.1.2.1.1 Dose range (mg) (hours) Adult Elderly Adult Elderly Zopiclone + 7.5 3.75-7.5 3.5 -6.5 8 (sch. 4 CD) Zolpidem + 10 5 2 (2-3) longer Temazepam ++++ 10-20 10 5-11 14+ (sch. 3 CD) Max 30-40 Max 20 5 ASSESSMENT OF INSOMNIA 5.1.1 Algorithm for the assessment & management of transient/short term insomnia is shown in Appendix 2 5.1.2 Before considering medication for the treatment of insomnia an assessment should be done to establish the severity and any underlying causes. Table 3: Assessment of insomnia Take a thorough Assess the person’s beliefs about what they regard as normal sleep and sleep history. the impact of insomnia on the person’s quality of life, ability to drive, employment, relationships and mood3. Determine the Is the sleep pattern normal? Onset of sleep is usually thirty minutes. Total pattern of sleep. sleep time decreases with increasing age3. Is there difficulty sleeping, early morning wakening, day time sleepiness or a general loss of well-being through a perception of a bad night’s sleep4? Is there circadian rhythm disorder? Other factors e.g. jet lag, shift working. Duration of Assess duration of symptoms:- disturbance. Short-term insomnia is diagnosed if insomnia has been present for less than 4 weeks3. Long-term insomnia is diagnosed if insomnia has been present for longer than 4 weeks3. Look for possible See table 4 for other possible causes. If the underlying cause is not clear, causes. consider asking the person to keep a sleep diary for two weeks. This should record the time of going to bed and getting up, time to get to sleep and number and duration of episodes of waking through the night, episodes of daytime tiredness and naps, times of meals, alcohol consumption, caffeine consumption and significant events. Rating of sleep quality from 1 to 5 (1 very poor and 5 very good. An example of a sleep diary can be located at the following link: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf 3 Guidelines for the management of insomnia_PHA08_May 2019 3 5.2 Causes of primary insomnia 5.2.1 Primary insomnia has no identifiable underlying condition causing it. It may occur as a result of a conditioned response in which the person associates the sleeping environment with heightened arousal. It often starts in response to a stressful event, but continues despite resolution of the event3.
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