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