Insomnia is defined as a complaint of difficulty falling or staying asleep or early morning awakening, which is associated with significant distress or impairment in daytime function. The sleep disturbance must occur despite adequate opportunity for sleep in a safe, dark environment. Daytime dysfunction can manifest in several ways. Some symptoms reported are fatigue, malaise; impairment in attention, concentration, or memory; impaired performance, mood disturbance, irritability, sleepiness, hyperactivity, impulsivity, aggression, reduced motivation and an increased propensity for errors.
Women more commonly report symptoms of insomnia and daytime consequences and are more likely to be diagnosed with the sleep disorder than men. In both men and women, the prevalence of insomnia increases with age. It is strongly associated with mental disorders, most commonly depression, anxiety and post‐traumatic stress disorder. Insomnia is experienced more frequently in patients from lower income and lower educational levels, as well as in individuals who are divorced or widowed. Additionally, the disorder is frequently experienced in patients with pulmonary, cardiac, gastrointestinal, endocrine, neurological, musculoskeletal and genitourinary disorders.
With the recent pandemic, many individuals experienced episodes of insomnia due to disrupted routines and ongoing uncertainty. During this time, the sleep disorder has been referred to as coronasomnia by some. Difficulty sleeping may be secondary to an increase in anxiety that leads to racing thoughts and worrying at bedtime. Additionally, working from home may decrease the exposure to daytime environmental cues that a patient commonly experiences during the day when going to work in an office setting leading to disruption of the patient’s circadian rhythm.
Medications can contribute to insomnia. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs),and monoamine oxidase inhibitors (MAOIs) can cause both sedation and stimulation. Dosing of these medications can be timed differently to determine how they impact sleep for each individual (i.e. from morning to evening or vice versa). Over‐the‐counter allergy medications often contain stimulants such as pseudoephedrine or phenylephrine and can contribute to insomnia. Withdrawal from alcohol, benzodiazepines, or opioids can also contribute to the disorder.
Cognitive behavioral therapy for insomnia (CBT‐I) is a structured program that helps patients identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, CBT-I helps you overcome the underlying causes of your sleep problems. CBT-I is currently recommended as the first-line treatment for adults with insomnia. CBT‐I can be delivered using many different formats, including face‐to‐face individual and group delivered therapy. Some CBT-I providers now offer telemedicine appointments for therapy. There are also self‐help manuals, books and videos that have been developed, which allow patients to carry out treatment on their own. In general, all modalities are effective, though some evidence suggests that face‐to‐face therapy outperforms self‐help.
Sleep medications can be an effective short-term treatment for insomnia. Pharmacologic therapies, such as benzodiazepines, “z‐drugs”, melatonin receptor agonists and orexin antagonists, are commonly used and approved.
Other common sleep disorders that need to be evaluated in patients with insomnia complaints are obstructive sleep apnea and restless legs syndrome. Common symptoms of obstructive sleep apnea are snoring, choking/gasping, nocturnal awakenings, restless sleep, morning headaches and bruxism, waking up not feeling refreshed and daytime sleepiness. Patients who are overweight and those with large neck sizes (17inches or larger in men and 16inches or larger in women) are most at risk. Common treatments for obstructive sleep apnea are weight loss, CPAP therapy and oral appliance therapy in the appropriate patient.
Restless legs syndrome is an uncomfortable sensation in the legs at night accompanied by an urge to move them in order to experience relief. The patient’s bed partner may report repetitive movements in the patient’s legs and or arms that occur while the patient is sleeping. Lifestyle modifications, leg massages and warm baths can be used to treat restless leg syndrome. Iron supplementation is started in patients found to be iron deficient as evident by low serum ferritin levels and several prescription medications can be started if the above therapies are ineffective.
As appeared in the Summer 2022 issue of Scripts.