​Definition

Insomnia is the most common sleep disorder, affecting up to 40-50% of the population at any given time. It is a distressing difficulty with sleep onset, sleep maintenance, or waking up too early, where these “sleep times” take longer than 30 minutes. These symptoms need to occur at least three times or more per week and have been present for more than 3 months to be defined as chronic.

Acute insomnia (lasting 24-48 hours) is commonly associated with stress, family/relationship/financial situations, and/or jet lag. However, it can easily develop into a chronic condition due to these predisposing factors.

It is important that the individual has a “normal” opportunity to sleep – attempting to sleep in bed for approximately 7 hours or longer. These combined symptoms negatively impact the individual’s quality of life, which is further exacerbated by physical and psychiatric comorbidity.

Typical Scenario

• Women are twice as likely to present with insomnia symptoms compared to men.

• Patients often complain of overwhelming daytime fatigue but rarely complain of sleepiness. However, the difference between sleepiness and fatigue may need to be teased out from the patient.

• The patient is dissatisfied with the quantity and quality of their sleep patterns.

• If the individual complains of daytime sleepiness, consider another sleep disorder such as obstructive sleep apnea, restless legs syndrome, periodic limb movements, or depression.

Clinical Presentation

• Often present as being “wired and tired” (fatigued but having difficulty sleeping during the day or night).

• May look fatigued with dark circles under the eyes but may equally look alert and normal.

• May appear anxious and exhibit some perfectionist tendencies.

• It is not uncommon for the patient to state that they are a “light sleeper” and very sensitive to any environmental noise.

• Normal range of body habitus – please note that post-menopausal women with a normal BMI may be diagnosed with sleep maintenance insomnia when they may have undiagnosed OSA.

What to Ask

• How did the patient sleep as a child and teenager?

• What happened, and when did the sleeping patterns change?

• What were the triggers or precipitating events?

• How do other family members and partners sleep?

• What is happening now in terms of sleep – bedtime, behaviors prior to bed, rituals (if any), reading, electronic media, the effect of the partner and their needs?

• Sleep Onset Latency (SOL) from turning out the light: How long does it take the patient to fall asleep? How long do they sleep before waking up? How long is the estimated wake time? What is the sleep time after that first wake? Does the patient stay in bed waiting for sleep, or do they do something else, such as getting up? What is the usual pattern after that? Is an alarm set in the morning, and what is the usual wake-up time?

• Weekends/holidays – is there a change in sleep patterns?

• Can the patient nap – when, where, and for how long on average?

• Overall, what is the estimated Time in Bed (TIB) and Total Sleep Time (TST)? Calculate Sleep Efficiency, which is TST/TIB x 100/1. Healthy sleep is generally 85%, but following treatment for insomnia, achieving 80% is a good starting point.

• Ask about caffeine, alcohol, exercise, eating at night, medications, over-the-counter medications, and recreational drug use.

Other Key Questions

• How often does the patient think about their sleep during the daytime?

• What thoughts is the patient aware of when getting ready for bed or even as darkness approaches?

• What thoughts is the patient aware of when they wake up in the middle of the night?

What to Examine

Check for the possibility of other sleep disorders, such as a narrow airway/overweight as risk factors for OSA, peripheral neuropathy as a risk factor for Restless Legs Syndrome, and flat affect related to depression.

What Investigations to Order Now/Later

Ask the individual to complete the Insomnia Severity Index (ISI) (Bastien CH et al., 2001, Sleep Medicine; 4:297). This questionnaire can be administered and scored very quickly. Any score > 14 is diagnosed as clinical insomnia, and any score > 22 is severe clinical insomnia. Scores from 7-14 are described as subclinical insomnia.

Treatment Plan for Today

Educate

Discuss normal sleep with an emphasis on how most of our sleep is relatively light (45-55% of the night in light sleep, 20% in deep sleep, 25% in dream/REM sleep). Waking up is also normal, and it is what we learn to do with the wakefulness and how we manage it that is most important. Sleep will not improve unless the individual starts to do something different.

What to Do Initially

• Highlight the time currently being spent in bed, which is much greater than the perceived sleep time.

• Reduce time in bed slowly to increase sleep debt and improve sleep quality (i.e., sleep restriction protocol).

• Put in place a constant wake-up time regardless of the previous night’s sleep and combine it with early morning light and exercise.

• Work with the patient to recognize symptoms of anxiety/depression and manage these.

• Assist the patient to Recognize, Acknowledge, and then Do Something (RAD approach), starting with simple measures.

Arrange

For the patient to see a psychologist to re-learn better sleep practices using a cognitive behavioral therapy program for insomnia (CBT-I).
If difficulty accessing a psychologist, an online program can be used (e.g., Sleepio or SHUT-I).

Emphasize the need to have many little strategies to do during the daytime if feeling anxious/stressed, as sleep is a continuation of the day’s events – it is NOT separate.

Future Management

Advise the patient to return for a follow-up visit to assess whether more specialist care is required in relation to other sleep disorders or increasing anxiety, sleep anxiety, or unremitting depression.

Where to Access More Information

Patient Information:
www.sleephealthfoundation.org.au/pdfs/Insomnia.pdf
www.sleep.org.au/professional-resources/health-professionals-information/the-medical-journal-of-australia

Tel: +61 (0)2 9920 1968 www.sleep.org.au