Insomnia

Insomnia: Excerpt from In a Page: Signs and Symptoms

Insomnia may be a primary diagnosis or a complaint or symptom secondary to an underlying acute or chronic disorder. Many patients have insomnia but do not tell their doctors, so questions about sleep quality should be asked during health maintenance visits. A careful history of sleep habits, including the time spent in bed or trying to sleep elsewhere, bed mate, noise level, safety, and interruptions, is imperative for diagnosing and treating all sleep disorders.

Differential Diagnosis

• Unnecessary concern about deviation from “normal” sleeping patterns
• Acute, transient insomnia (<4 weeks)
  –Situational stress (most common)
  –Acute illness or injury
  –Medications or drugs (e.g., cocaine)
  –Change in sleep environment or hours
• Chronic insomnia (>4 weeks)
  –Difficulty falling asleep: May be due to poor sleep hygiene, conditioned insomnia (initial acute insomnia progresses to chronic due to maladaptive distorted sleep cognitions), medications (e.g., sedatives, decongestants, oral contraceptive use, antidepressants, bronchodilators), drugs (including over-the-counter and herbal preparations, alcohol, nicotine, illicit drugs), and caffeine (e.g., coffee, soda, medications)
  –Difficulty staying asleep: May be due to sleep apnea, medications and drugs (e.g., alcohol), depression, anxiety, dementia, psychosis, mania, post-traumatic stress disorder, and various medical conditions (e.g., COPD, asthma, CHF, angina, GERD, peptic ulcer disease, IBD, BPH, UTI, pregnancy, uremia, diabetes mellitus, hyperthyroidism, menopause, pain, pruritus, seizures)

• RLS
  –“Creepy-crawly” unpleasant sensations in the legs and/or feet
  –Temporarily relieved by moving limbs

• Periodic limb movement disorder
  –Arms and/or legs jerk during sleep
  –May be a primary disorder or secondary to uremia, neuropathy, or iron deficiency
  –Often in the elderly
  –Often occurs with restless legs syndrome

Workup and Diagnosis

• Sleep and medication/drug history, including bed partner history
• Sleep diary is the most effective specific assessment tool
  –Should be recorded each morning
  –Include time in bed, time asleep, awakenings, estimate of
  sleep quality, associated symptoms (e.g., pain, dyspnea, urinary frequency)
• A focused physical examination to evaluate cardiovascular, pulmonary, and neurologic systems and mental status will improve diagnostic accuracy
• Polysomnography (sleep study) is useful to evaluate sleep apnea, restless legs syndrome, periodic limb movement disorder, and REM-behavior disorder
• “Insomnia” is a self-reported condition; labs or other testing is often unnecessary unless underlying medical conditions are suspected
  –ECG, chest X-ray, echocardiogram, pulmonary function tests if suspect undiagnosed cardiac or pulmonary disease
  –EEG if suspect undiagnosed seizure disorder
  –TSH and free T₄ if suspect thyroid disease
  –Iron studies and BUN/creatinine if suspect restless legs syndrome or periodic limb movement disorder (iron deficiency and renal failure are risk factors for both)
  –Consider blood alcohol level, CBC and MCV, LFTs, and toxicology screen if suspect alcohol or illicit drug abuse

Treatment

• Acute transient insomnia: Reassurance, address stressors, treat identifiable underlying causes (e.g., pain), hypnotic agents for up to 7–10 days

• Chronic insomnia
  –Improve sleep hygiene (e.g., consistent bed/wake time, sleep environment, medications/drugs, daytime exercise, avoid naps, hot bath near bedtime)
  –Treat pain and underlying medical/psychiatric issues
  –Behavioral treatments: Relaxation therapy, sleep restriction therapy (curtail time in bed to improve sleep efficiency), stimulus control therapy (bed only for sleep), cognitive therapy (restructure negative thoughts about sleep/daytime functioning)
  –Medications are often used but none has demonstrated long-term efficacy nor safety

• Obstructive sleep apnea: Weight loss, CPAP, surgery
• RLS: Dopaminergic agents (e.g., carbidopa/levodopa, pergolide), benzodiazepines, opiates
• Narcolepsy: Modafinil, amphetamines

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Problem Sleepiness

• Back to disease: Problem Sleepiness: Introduction
• Next Book Extract About Problem Sleepiness: INSOMNIA (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: INSOMNIA (Differential Diagnosis in Primary Care)

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