Causes of insomnia:
Minor and self limiting:
- Noisy environment (including partner snoring)
Around half of those who present with insomnia have mental health problems such as:
- Alcohol misuse
- Night Sweats
- Cardiac failure with paroxysmal nocturnal dyspnoea
- Obstructive sleep apnoea
- Restless legs syndrome
- Circadian Rhythm disorder (eg night shift workers like poor doctors and nurses!)
Approach to treatment
As far as possible, Eliminate physical problems causing sleep problems, for example:
- Optomise treatment for asthma, consider long acting bronchodilator or increase prophylactic steroid for those who are wheezy overnight as a result of asthma.
- Pain: Consider slow release analgesia to last overnight. 10-75mg amitriptyline with evening meal can be useful for those with back neck or neuropathic pain keeping them awake.
- Suspected sleep apnoea: Refer for for further evaluation. CPAP can be useful in this condition.
- It’s usually worth checking renal function, FBC, B12 and folate, TSH and fasting glucose if the patient complains of restless legs.
Worth using a sleep diary or a sleep record application for the patient to get an objective measure of sleep.
Treatment of underlying mental health probalem often improves sleep.
SSRIs should always be given in the morning after breakfast as they can cause arousal and make insomnia worse.
Sleep Hygiene and Relaxation
Relaxatin techniques can be taught by physiotherapists or in relaxation classess. Self help books and CDs are also available. These can be borrowed from GPs or Libraries.
Advice on sleep hygiene:
- Do not go to bed until you feel sleepy
- Do not stay in bed if you are not asleep
- Avoid daytime naps
- Establish a regular bedtime routien
- Reserve a room for sleep only (if possible). Do not eat, read, work or watch TV in it.
- Make sure the bedroom and bed are comfortable, and avoid extremes of noise and temperature.
- Avoid caffeine, alcohol and nicotine.
- Have a war m bath and warm milky drink at bedtime.
- Take regular exercise but avoid late night exercise (sex is fine!)
- Monitor your sleep wit a sleep diary (record both the times you sleep and its quality)
- Rise at the same time every morning regardless of how long you have slept.
- Check out this infographic:
for more on sleep hygiene.
Prescribing for elderly patients with insomnia should be a last resort.
Side effects are common and include amnesia and daytime somnolence.
Most hypnotics do affect daytime performance and may cause falls in the elderly.
Always warn patients about the effect of these drugs – especially with regard to driving and operating machinery.
NICE reccommends that hypontic drugs should only be used for short term insomnia interfering with normal daily life.(Find this here: TA77 April 2004)
The “Z” drugs (zopiclone, zolpidem) have been reported to be dependence forming – so only supply a couple of weeks and don’t give repeats without clinical review.
Difficulty Initiating Sleep – shorter acting drugs (eg zolpidem) may be useful
Waking in early hours – medium acting hypnotic (eg zopliclone) may do the job.
NICE suggests the cheaper drug should be prescribed.