Insomnia is a frequent complaint of patients in both the medical and psychiatric settings. Nearly 30% of adult will have issues with trouble falling or staying asleep at some point, however most of these issues are generally time limited and not impairing. For others, it is a very troubling issue.
Insomnia Defined: ―trouble with either falling asleep, staying asleep or early awakenings at least 3 nights a week for at least a month associated with significant functional impairment or distress.
The major causes of insomnia include medical conditions and psychiatric disorders, yet about 6% of adults will present with a primary insomnia for which no underlying illness or condition can be identified.
Both physical and psychiatric causes of poor sleep should be evaluated when a patients presents with complaints of insomnia.
– Common medical issues to assess include problems with pain, restless leg syndrome, sleep apnea, thyroid or other endocrine/metabolic disorders and any drug/medication use that could be affecting sleep.
– Psychiatric conditions can affect sleep as well and treatment of the underlying psychiatric issues, particularly anxiety and mood disorders, will frequently lead to improved sleep.
Assessment of the sleep problem should include a history of what the sleep problem is like– is it mainly trouble initiating sleep, staying asleep, early awakening or a combination of these. Sleep onset insomnia is the most common complaint but each case has its own profile and determining when a patient goes to bed, how long it takes to fall asleep, the number of times they awaken at night, when and how they finally arise and if they take naps during the day is important.
Additional information to review includes any routines the patient has prior to going to bed, any other activities they do in bed (eating, TV, reading, etc), use of caffeine, alcohol, or other substances and what they do when they are not falling asleep (toss and turn, trying to force the sleep to come, watching TV, reading, etc.
The first step in treating the insomnia should be to address issues of sleep hygiene. This includes having a set bed time, minimizing napping during the day, avoiding caffeine, alcohol or other stimulating substances at night, not eating large meals close to bed time, and having a sleep routine.
Establishing a nightly sleep routine of sleep preparation can be suggested, with the goal of winding things down—this may include terminating ―screen time (TV, computers, phones) and using relaxation techniques (deep breathing, muscle relaxation) for 30 – 60 minutes prior to the chosen and established bedtime.
A problem arises for many people when the bed and bedroom becomes paired with behaviors that are not conducive or compatible with sleep– such as watching TV in bed, eating in bed, and/or discussing the day’s anxieties and frustrations. Good sleep hygiene limits activities such as these.
Patients who have not fallen asleep within 15-30 min of going to bed should be advised to get up rather than to toss and turn restlessly. For some, efforts to relax, listening to quiet music, reading with limited light exposure may be more helpful than staying in bed tossing and turning or worrying as these behaviors can become paired to being in the bed.
If serious efforts to implement sleep hygiene do not prove helpful, use of a medication may be appropriate. Next week’s e-Weekly will discuss the various pharmacologic approaches including both OTC and prescription medication options.