Insomnia

=Insomnia=

What it is
Insomnia is a symptom, not a disease with up to 25% of Australians reporting trouble getting enough sleep. This may be caused by difficulties in either falling or staying asleep. Self-reported sleeping problems, dissatisfaction with sleep quality and daytime tiredness are the only defining characteristics of insomnia because it is such an individual experience. Long-term chronic insomnia needs professional support from a sleep disorder clinic.

Transient or short-term insomnia is typically caused by such things as stressful episodes, jet lag, change in sleeping environments, some acute medical illnesses and stimulant medications. Normal sleeping habits return once the acute event is over. If a person has experienced sleeping difficulties for a month or more, this is called persistent or chronic insomnia.
 * Causes:**

//Psychiatric Factors// - Anxiety disorders: associated with rumination over particular worries or concerns - Depression: typical to have middle insomnia (waking in the early hours of the morning) and late insomnia (waking earlier in the morning than is usual and being unable to get back to sleep). - Alcohol abuse: patient goes to sleep in the evening when intoxicated only to wake a few hours later when their blood alcohol concentration drops

//Environmental Factors// - Bedroom being too hot/cold, noisy (crying baby), or bed is cramped or uncomfortable

//Physical factors// - illnesses such as cardiac and respiratory failure, and pain syndromes

//Jet lag// - therapeutic key is to settle into the new time zone as quickly as possible by adjusting to the local sleep-wake cycle by approximately one hour per days - this is quicker following east to west travel than west to east

//Secondary insomnia// – due to a range of medical and psychiatric problems and the chronic use of drugs and alcohol. //Primary sleep disorders// – include circadian rhythm disorders, central sleep apnoea-insomnia syndrome, inadequate sleep syndromes and periodic limb movement or restless legs syndromes. //Idiopathic insomnia// – sleeplessness without a known cause, formerly called childhood onset insomnia.
 * Types of chronic insomnia:**

Quantitative indices for chronic insomnia: - sleep onset latency (>30mins) - sleep efficiency (<85% bed time sleep)
 * Insomnia Diagnosis:**

It is also worth asking in detail about the patient's sleep pattern, including asking them to complete a sleep log over a few days. This is to determine: - habits and patterns of getting ready to go to bed - time of going to bed - time of going to sleep - time(s) of waking(s) - time(s) to get back to sleep - what the patient does when awake in the night - features (if any) that help the patient settle - features that tend to add to the patient's disturbance - any daytime sleeping, times and duration

Symptoms
The concept of ‘a good sleep’ differs widely from person to person. While the average night’s sleep for an adult is around seven or eight hours, some people only need four, while others like up to 10 hours or more. What seems like insomnia to one person might be considered a good sleep by another.

How to Treat
- Treat or improve the management of underlying problems such as restless legs syndrome or chronic airways limitation

**Non-drug treatments (sleep hygeine):** //should always be first-line therapy for insomnia// Routines that incorporate the following techniques will help older people, whatever their residential setting, have a better sleep: - Get up about the same time every day regardless of the amount of sleep that night. Going to bed at a constant time is not as important but might help. - The bedroom should be comfortable and quiet, not the focus of arguments, anger or distress. Avoid clock-watching - Avoid daytime naps especially in the late afternoon asthe patient will not wake refreshed because they have less sleep at night. - Use bed only for sleep and sex, not for eating, reading or watching television. - Indulge in relaxing evening activities, such as meditation or having a warm bath - anxiety management may assist in controlling their concerns - If unable to sleep, get up and do something, do not think about sleeping. - Avoid alcohol and stimulants such as caffeine and nicotine for 2–3 hours before going to bed. - Vigorous exercise, hard work, or activities requiring considerable concentration and arousal should stop some time before going to bed. - Avoid ‘judging’ your sleep on a day-to-day basis.

//Short acting BZDs (temazepam, oxazepam) -// for difficulty falling asleep //Medium to long acting BZDs (nitrazepam, lorazepam, diazepam)// - difficulty maintaining sleep, early morning awakenings Short term use (7 days)
 * Pharmacological Treatment:** //should only be prescribed if the duration of use is likely to be less than four weeks, and preferably less than one or two weeks//

Ensure there is a clear exit strategy so that the patient does not require continued drug treatment. For example, some personal and social crises can result in the patient becoming so distressed and dysfunctional with insomnia that a few nights assisted sleep helps them reintegrate. They could then be expected to cope with the stresses in their life without the need for ongoing drug treatment.

//Others:// - antihistamines (OTC) - low dose TCAs: have prominent anticholinergic effects which can result in confusion, especially in children or the elderly and should have little or no place in the management of insomnia - chloral hydrate - melatonin

Other advice
Establishing a clear expectation of short-term use when starting pharmacological treatment can increase the chances of avoiding the trap of long-term dependency. If the insomnia persists, it is particularly difficult to stop treatment as the patient fears that stopping the hypnotic will make their insomnia worse: - reinforce sleep hygeine techniques, gradually reduce doses (introduce intermittent use) and use the hypnotic as 'rescue medication' when needed

Additional Resources
[|Australian Prescriber - The Management of Insomnia] [|NPS - Prescribing benzodiazepines: ongoing dilemma for the GP] [|NPS - Benzodiazepines: reviewing long term use]: includes a sample withdrawal schedule [|NPS - Case Study: benzodiazepine use]: about prescribing in the elderly //AP 400// [|Sleep Disorders] //Pharmacology 301// [|Sedative - Hypnotics]
 * Lecture Notes:**