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InsomniaAka: Disorder of Initiating and Maintaining Sleep, DIMS

Causes
1. See Insomnia Causes
Diagnosis
1. Complaints consistent with insomnia (one or more)
  1. Difficulty initiating or maintaining sleep
  2. Poor quality sleep
  3. Early awakening
  4. Difficult sleep despite adequate conditions
2. Daytime Impairment due to insomnia (one or more)
  1. Impaired memory, concentration, attention
  2. Excessive Worry about sleep
  3. Daytime somnolence, Fatigue, or malaise
  4. Depressed mood, irritability or poor motivation
  5. Accidents or errors while working or driving
  6. Poor work or school performance
  7. Tension Headaches or gastrointestinal upset
3. Duration
  1. Acute insomnia: <30 days
  2. Chronic insomnia: 30 days or more
4. Subtypes based on cause
  1. Primary insomnia (no cause): <20% of chronic cases
  2. Comorbid insomnia (insomnia secondary to other cause)
Evaluation
1. History
  1. Sleep habits and history of problems
  2. Substance use
  3. Limb Movement Disorders
  4. Sleep Apnea
  5. Psychiatric Illness (Depression, Bipolar Disorder)
  6. Substance use or abuse (e.g. caffeine, Alcohol)
2. Sleep diary
  1. Keep 2 week sleep log
  2. Times: Bedtime, Awakening, Naps, Total sleep time
  3. Sleep onset latency
  4. Number of nighttime awakenings
  5. Well rested on awakening?
3. Examination
  1. Thyroid examination
  2. Neurologic Examination
  3. Mini-Mental Status Exam (MMSE)
Complications
1. Cognitive decline in over age 65 years (especially men)
  1. Insomnia is an independent risk factor
  2. Cricco (2001) J Am Geriatr Soc 49:1185
Management: Non-Pharmacologic
1. See Sleep Hygiene
2. Consider written sleep plan
3. Regular Exercise (6 hours before bedtime)
4. Stimulus control therapy
  1. Go to be only when sleeping
  2. No reading or television in bed
  3. Out of be if awake longer than 20 minutes
  4. Keep waking up time constant
  5. No napping
5. Sleep restriction therapy
  1. Goal: time in bed should be time asleep
  2. Limit time in bed to 6 hours
6. Relaxation
  1. Progressive muscle relaxation
  2. Mental imaging
  3. Meditation
7. Cognitive behavior therapy
  1. Refocuses attention on positive factors
    1. Turns off cycle: worrying about not sleeping
  2. More effective for sleep than Ambien (Zolpidem)
  3. Jacobs (2004) Arch Intern Med 164:1888
Management: Sedative-Hypnotic Drugs
1. Indications: Short term Insomnia treatment
  1. Avoid use more than 3 weeks
  2. Start with lowest effective dose
  3. Taper slowly if longer use
2. Adverse Effects
  1. Daytime somnolence
  2. Amnesia
  3. Early morning insomnia
  4. Daytime anxiety & confusion
  5. Ataxia and falls in elderly
3. Preparations: Nonbenzodiazepine hypnotic agents
  1. Short-acting agents
    1. Zolpidem (Ambien)
    2. Zaleplon (Sonata)
      1. Helpful in early night awakening
  2. Longer-acting agents (better sleep maintenance)
    1. Zolpidem CR (Ambien CR)
    2. Eszopiclone (Lunesta)
4. Preparations: Benzodiazepines
  1. Temazepam (Restoril) 7.5 to 30 mg, 15 min before bed
  2. Estazolam (Prosom) 1 to 2 mg, 15 min before bed
Management: Tricyclic Antidepressants
1. Indications: Insomnia with comorbidity
  1. Major Depression
  2. Bruxism
  3. Fibrositis
  4. Hyperactivity history
2. Adverse effects
  1. Anticholinergic side effects are common
  2. Long half lives lead to hangover effect in AM
3. Preparations
  1. Doxepin (Adapin, Sinequan)
  2. Trazodone (Desyrel) 50 to 150 mg at bedtime
  3. Amitriptyline (Elavil) 25 to 100 mg at bedtime
    1. Avoid Elavil in elderly (anticholinergic effects)
  4. Mirtazipine (Remeron) 15-45 mg daily
Management: Antihistamines
1. Indications: Insomnia
2. Adverse effects
  1. Anticholinergic adverse effects
  2. Paradoxical CNS agitation may occur
  3. Exacerbates Restless Leg Syndrome
3. Preparations
  1. Diphenhydramine (Benadryl) 25 to 50 mg at bedtime
  2. Doxylamine (Unisom) 12.5 to 25 mg at bedtime
  3. Hydroxyzine (Vistaril) 25 to 100 mg at bedtime
Management: Herbals
1. Melatonin
2. Ramelteon (Rozerem)
  1. Melatonin receptor agonist
  2. May be more effective in shifted sleep phase
3. Valerian Root
Management: Bright Light Exposure
1. Mechanism
  1. Bright lights reset circadian rhythm
  2. Bright light sources
    1. Outdoor light
    2. Light box
2. Indications
  1. Delayed sleep phase
    1. Young adults who do not get sleepy until midnight
    2. Use bright light in early morning (6 to 7 am)
  2. Early Sleep phase
    1. Elderly have onset of tiredness at 6 pm
    2. Use bright light in late afternoon
Books: Non-medical
1. Bishop (2000) Hello Midnight: Insomniac's ... Companion
  1. Paid Link to Amazon.com (ISBN 0684848341)
References

Sleeplessness (C0917801)
Definition (NCI)	Difficulty in going to sleep or getting enough sleep.
Concepts	Sign or Symptom (T184)
ICD9	780.52
Basque	LOAREN PERTURBAZIOA/LOGABETASUNA
Danish	Sovnforstyrrelser/sovnloshed
Dutch	Slapeloosheid/andere slaapstoornis
English	Disturbances of sleep/insomnia, Insomnia, INSOMNIA DIS, Insomnia Disorder, Insomnia Disorders, Insomnia symptom, Insomnias, Sleeplessness
French	Troubles du sommeil/insomnie
German	gestoerter Schlaf/Schlaflosigkeit
Hebrew	hafraot beshena
Hungarian	alvaszavar/insomnia
Italian	Disturbi del sonno/insonnia
Norwegian	SOVNFORSTYRRELSER/SOVNLOSHET
Portuguese	Perturbacao do sono/insonia
Spanish	Alteracion del sueno/insomnio, desvelo, insomnio
Swedish	SOMNRUBBNING/SOMNLOSHET
Credits	Derived from the NIH UMLS (Unified Medical Language System)

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InsomniaAka: Disorder of Initiating and Maintaining Sleep, DIMS

Sleeplessness (C0917801)

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