How would you manage this patients insomnia?

 

(This piece has been derived from a recent article; Insomnia in the Elderly patient, Medicine Today, Vol 2, Number 8, 2001) with permission of Dr N. Singh)

 

 

1)      Rule out contributing secondary causes

a.       Medical

                                                               i.      Cardiac e.g. CCf, IHD

                                                             ii.      Musculoskeletal e.g. arthritis, myalgias, fibromyalgia, cramps

                                                            iii.      Neurological e.g. strokes, dysaethesia

                                                           iv.      Renal e.g. prostatism, bladder dysfunction, nocturia

                                                             v.      Respiratory e.g. asthma, CAL

                                                           vi.      Gastric e.g. GORD, PUD

                                                          vii.      Infections

                                                        viii.      Primary sleep disorder e.g. OSA, periodic limb movement disorder

 

b.      Psychiatric

                                                               i.      Anxiety

                                                             ii.      Cognitive Impairment

                                                            iii.      Depression

 

c.       Medication/ Pharmacological

                                                               i.      OTC e.g. decongestants, antihistamines, stimulants

                                                             ii.      Prescription meds e.g. diurectics, steroids, antidepressants

                                                            iii.      Social drugs e.g. alcohol, caffeine, nicotine

                                                           iv.      Withdrawal Syndromes

 

 

2)      Take a careful history, initially looking for the presence of a sleep disorder

a.       Is the patient satisfied with his/ her sleep?

b.      Does sleepiness affect the patients daily activities?

c.       Does the bed partner report any unusual behaviour during sleep?

 

If the patients responses suggest a sleep disorder, it is necessary to further enquire about;

 

a.       bedtime routine

b.      length of time it takes to fall asleep

c.       number of awakenings during sleep

d.      time of awakening

e.       daytimes functionin

 

 

Try and corroborate the history from the patients partner

 

Management

 

1)      A sleep diary over 2-3 weeks may help clarify issues related to sleep onset, relationship to meals, nap times, etc

2)      See the flow algorithm below;

 

3)      Behavioural treatment – aim to eliminate factors that perpetuate insomnia. Address factors such as those listed below;

1.      Create a quiet and relaxed environment for sleep

2.      Establish a regular sleep pattern, and bedtime ritual

3.      Avoid staying awake in bed for long periods

4.      Refrain from reading or watching television in bed

5.      Do not look at the clock in bed

6.      Avoid consumption of coffee, alcohol and nicotine in the late afternoon or evening

7.      Avoid foods, beverages and medications that may contain stimulants

8.      Go to bed only when ready to sleep

9.      Exercise regularly but not after 6pm

10.  Avoid daytime naps

11.  Do not eat or drink excessively 3 hours before bedtime

12.  Try having a hot bath – it will raise your core temperature and may help initiate sleep

13.  Use the bedroom only for sleep and sexual activity if it is relaxing

14.  Avoid mental and emotional stimulation before bed

15.  Do not worry if you cannot get to sleep

16.  Avoid unfamiliar sleep environments

 

Cognitively impaired patients present difficult problems because they may not be able to comprehend.It may be preferable to allow safe nocturnal wandering in a protected environment rather than using sedatives in an attempt to extinguish poor sleep hygiene. Increased involvement in daily physical activities may also help.

 

4)      Exclude underlying depression / anxiety or other medical condition

5)      Use specific therapies – Remember that patients, clinicians and “significant others” rate combined therapy or cognitive behavioural therapy alone as more effective for chronic insomnia than drug therapy alone.

1.      Short-acting Benzos e.g. temazepam preferred short-acting agents

2.      Long-acting agents have increased falls risks and should be avoided

3.      New agents e.g. zolpidem also effective in chronic insomnia and have a lower side effect profile

4.      Sedating anti-histamines – ften used inappropriately and have lots of side-effects

5.      Tricyclics – again, good for co-existent depression but beware side-effects

 

6)      Treat specific sleep disorders e.g. use of levodopa for restless legs syndrome and periodic limb movement disorder

7)      Encourage exercise – optimal when performed 4 to 8 hours before the desired sleep time.