Insomnia

Insomnia is the subjective complaint of poor sleep either in terms of duration or quality, and sometimes that sleep is not refreshing. Some patients also complain of daytime fatigue but not generally of sleepiness during the day, which is more often associated with other sleep complaints such as obstructive sleep apnoea.¹

• It is more common in women and in the elderly.²
• Normal sleep requirements vary widely, from just 3-4 hours per night.
• It is generally accepted that the amount of sleep required tends to decrease with age (although some studies have questioned this).³
• Prevalence depends on what criteria are used, and the need to distinguish between insomnia and sleep dissatisfaction.
• Various studies suggest rates of severe insomnia (with daytime consequences) of around 10-15% (range 10-34%).⁴

• Clarify the problem:
  • Is the problem falling or staying asleep?
  • Is there early morning waking?
  • Are there any daytime consequences?
  • How long has the problem been going on? Longer than 1 month and more than 2-3 nights per week suggests chronic insomnia.
• Ask about previous treatments:
  • Their success or failure and patient attitudes to treatment

• Temporary insomnia is associated with stress, personal problems, painful physical illness, depression, anxiety, excessive alcohol or caffeine.
• No primary cause is found in 15-30% of cases of chronic insomnia.^5,6,7

Physical

• Movement disorders, e.g. restless legs syndrome
• Respiratory disorders, e.g. obstructive sleep apnoea, dyspnoea, and coughing
• Pain, e.g. arthritis, headaches
• Nocturia, e.g. benign prostatic hyperplasia, diabetes mellitus or diabetes insipidus, diuretics
• Endocrine, e.g. hyperthyroidism (sweats)
• Perimenopausal symptoms
• Other physical illnesses, e.g. pruritis, leg cramps

Physiological

• Poor sleep hygiene, e.g. caffeine, daytime naps
• The sleeping environment, e.g. noise, light
• Disturbed sleep routine, e.g. shift work, jetlag, intellectual or physical activity immediately prior to going to bed
• Psychological: e.g. worry, bereavement. Excessive worrying about not sleeping. Nightmares, night terrors, sleepwalking
• Psychiatric: e.g. depression, dementia, anxiety

Pharmacological

• Drug withdrawal, e.g. hypnotics, alcohol (reduces the time to onset of sleep, but disrupts it later in the night)
• Chronic benzodiazepine misuse
• Some antidepressants (especially SSRIs and MAOIs)
• Sympathomimetics
• Corticosteroids (agitation)
• Beta-blockers

• It is essential to consider and treat any possible underlying cause
• It is likely that no investigations are necessary other than further investigation of any possible cause, e.g. night cough
• Liver function tests, gamma GT and the MCV, may show evidence of chronic alcohol misuse

• Before a hypnotic is prescribed the cause of the insomnia should be established and, where possible, underlying factors should be treated. Some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of the insomnia.
• Transient insomnia may occur in those who normally sleep well and may be due to external factors, e.g. noise, shift work or jet lag. If a hypnotic is indicated then one that is rapidly eliminated should be chosen, and only one or two doses should be given.
• Short-term insomnia is usually related to an emotional problem or serious medical illness. It may last for a few weeks and may recur. A hypnotic can be useful but should not be given for more than three weeks (preferably only one week). Intermittent use is desirable with omission of some doses. A rapidly eliminated drug is generally appropriate.
• Chronic insomnia:
  • Is rarely benefited by hypnotics and is often due to mild dependence caused by inappropriate previous prescribing.
  • Psychiatric disorders such as anxiety, depression, and abuse of drugs and alcohol are common causes.
  • Sleep disturbance is very common in depressive illness and early wakening is often a useful pointer. The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia, e.g. clomipramine or mirtazapine prescribed for depression will also help to promote sleep if taken at night.
  • Treatment of other possible causes of insomnia, e.g. daytime cat-napping and physical causes such as pain, pruritus, and dyspnoea.

General advice

• Establish the patient's agenda early. It is essential to address their concerns, and expectations. Take the problem seriously as insomnia can be extremely debilitating.
• Explanation and reassurance
• Address any precipitating factors
• Patient education about sleep hygiene measures. The patient should try these simple measures for a few weeks while keeping a diary:
  • Consistent bedtime routine with same time for going to bed and waking up
  • No daytime napping
  • Spend some part of the day out of doors (morning is best)
  • Regular daytime (but not evening) exercise
  • Avoid stimulants, alcohol and cigarettes
  • Establish bedtime routine: wind down, put light out straight away
  • Solve problems before retiring: record worries; plan and write out strategies in early evening, not at bedtime
  • Bedroom dark, quiet and for sleeping only; no television or books
  • Bed should be comfortable, dark and not too warm or too cold
  • Think pleasant thoughts and learn techniques to slow racing thoughts
• Tell patient to avoid:
  • Getting over excited before going to bed
  • Exercising just before going to bed
  • Tea and coffee in the evening
  • Excessive smoking
  • Excessive use of alcohol
  • Excessive daytime sleeping
  • Large meals late in the evening
  • Lying in bed awake for too long

Psychological treatments

• Comparable with short term hypnotic use
• Brief CBT (cognitive behavioural therapy) helps to re-establish normal sleep patterns and reduce adverse anti-sleep behaviour. Beneficial effects have been shown to last 6 months following therapy (improvements in sleep are slower than with drugs).^{2 5 6 97}
• They are cost effective in Primary Care, but availability may be limited¹⁰

Drugs

Hypnotics should be reserved for short courses to alleviate acute conditions after causal factors have been identified and addressed. Benzodiazepines are the most commonly used hypnotics. Older drugs such as meprobamate and barbiturates are not recommended.⁸

• Short-term treatment with a hypnotic drug is appropriate for:
  • Relief of short-term insomnia when precipitating causes cannot be improved
  • Prevention of progression to long-term problem by re-establishing sleep habit
  • Reduction of vicious cycle of anxiety about sleep itself
• Transient (lasts 2-3 days and is often caused by factors such as noise, shift work, or jetlag): if indicated, use only one or two single doses of a hypnotic, at the minimal effective dose.
• Short-term insomnia (lasts for between a few days and 3 weeks, and may be caused by emotional problems or physical illness). If indicated, use short courses of hypnotics, usually for less than 1 week. Intermittent doses reduce the potential for drug tolerance and dependence. Avoid long term use and repeat prescribing of hypnotics.
• There are no indications for the use of the older drugs such as chloral hydrate, chlormethiazole and barbiturates due to their abuse potential.
• Short-acting benzodiazepines are very effective agents but temazepam is quite widely abused, so care is needed in prescribing it to individuals with a history of drug or alcohol abuse. Zopiclone has also been used in illicit drug use.
• There are no clear advantages or disadvantages of the newer drugs (e.g. zopiclone, zolpidem and zaleplon) compared with benzodiazepines. Therefore, NICE recommends that the cheapest drug should be prescribed and a more expensive hypnotic only used when the initial drug was poorly tolerated. People who have not responded to one hypnotic should not be prescribed any of the others.³

Cautions

• Hypnotics should not be prescribed indiscriminately and routine prescribing is undesirable. They should be reserved for short courses in the acutely distressed.
• Tolerance to their effects develops within 3 to 14 days of continuous use and long-term efficacy cannot be assured.
• A major drawback of long-term use is that withdrawal causes rebound insomnia and precipitates a withdrawal syndrome.
• Where prolonged administration is unavoidable hypnotics should be discontinued as soon as feasible and the patient warned that sleep may be disturbed for a few days before normal rhythm is re-established. Broken sleep with vivid dreams and increased REM (rapid eye movement) sleep may persist for several weeks.
• Children: prescribing hypnotics to children, except for occasional use such as for night terrors and sleep-walking, is not justified.
• Elderly: hypnotics should be avoided in the elderly, who are at risk of becoming ataxic and confused and so liable to fall and injure themselves.

Adverse effects of medication

• Benzodiazepines may cause a paradoxical increase in hostility and aggression. Adjustment of the dose usually attenuates the impulses. Increased anxiety and perceptual disorders are other paradoxical effects.
• Hypnotics may impair judgement and increase reaction time. The hangover effects of a night dose may affect ability to drive or operate machinery during the following day. Hypnotics also increase the effects of alcohol.

Benzodiazepine dependence and withdrawal⁸

• Abrupt benzodiazepine withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens.
• Benzodiazepine withdrawal symptoms may develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a few hours in the case of a short-acting benzodiazepine.
• Withdrawal symptoms include insomnia, anxiety, loss of appetite, weight loss, tremor, perspiration, tinnitus, and perceptual disturbances.
• Withdrawal of long term benzodiazepines can be achieved in many patients by gradually reducing the dose and providing support with or without formal counseling.
• A benzodiazepine can be withdrawn in steps of about one-eighth (range one-tenth to one-quarter) of the daily dose every fortnight.
• If withdrawing the hypnotic medication is difficult then transfer patient to equivalent daily dose of diazepam preferably taken at night.
• If withdrawal symptoms occur, maintain the same dose until symptoms improve.
• Use small steps when reducing. It is better to reduce too slowly rather than too quickly.

Treatment of long-term insomnia

• There is usually a conditioning element and patients often sleep better in a strange environment that is not associated, in their experience, with poor sleep.
• Often there is poor sleep hygiene and the patient becomes excessively anxious about trying to sleep.
• It is important to change the patient's behaviour and understanding relating to sleep. This requires a defined programme which can take a great deal of time.

• Insomnia is independently associated with worsened health-related quality of life to almost the same extent as chronic conditions such as congestive heart failure and clinical depression.¹¹ There is an increased risk of stroke and ischaemic heart disease.^{12 13}
• The feeling of constant tiredness and poor performance experienced by many insomniac patients is a major health problem that considerably reduces their quality of life.
• Chronic insomnia may lead to depression and/or alcohol abuse.
• Hypnotic medication may cause daytime drowsiness and therefore an increased risk of accidents the following day.