Insomnia is a subjective complaint of non-restorative sleep that may involve difficulty falling asleep, frequent or prolonged nocturnal awakenings, and early morning awakenings. Insomnia, whether transient, short-term, or chronic, appears to contribute to increased rates of absenteeism, healthcare utilization, and social disability. Pharmacologic and behavioral modification therapy are the treatment modalities currently employed to treat insomnia. The etiology, duration of symptoms, and patient-specific factors such as age and concomitant disease states should govern therapy. Despite half of American adults reporting periodic symptoms of insomnia, less than 15% of individuals with chronic
insomnia receive treatment.
Types of Insomnia
Insomnia can be subdivided into categories based on duration and etiology of symptoms. Transient insomnia generally lasts a few days, and is a result of acute illness or social stress, changes in circadian rhythm such as jet lag or work shift changes, and environmental disturbances such as noise, light, and temperature. Short-term insomnia can be caused by grief, emotional stress, or the use of stimulants or other medications that can cause sleep disturbances. Short-term insomnia lasts a few weeks, whereas chronic insomnia lasts for more than three weeks and may be related to psychophysiologic insomnia or insomnia caused by arousal or anxiety at bedtime that usually surrounds a negative expectation of sleep. Chronic insomnia may also result from poor sleep hygiene, medical or psychiatric disorders, chronic stress, and bereavement.
Mood and anxiety-related disorders are the predominate causes of psychiatric-related chronic insomnia. Other medical conditions such as chronic pain, respiratory disease (e.g., asthma), cardiovascular disease (e.g., congestive heart failure) endocrine disorders (e.g., diabetes, hyperthyroidism), gastrointestinal etiologies (e.g., gastroesophageal reflux, ulcers), neurologic disorders (e.g., delirium, Parkinson’s disease), and hormonal changes associated with pregnancy and menopause can cause chronic insomnia.
Several prescription drugs, nonprescription drugs, and drugs of abuse can cause sleep difficulty. The potential for any drug to cause sleep disturbance is related to dose, lipophilicity, and patient-related factors. Stimulants, bronchodilators, xanthines, decongestants, beta-blockers, corticosteroids, stimulating antidepressants, nicotine, alcohol, and caffeine can cause sleep disturbances.
Insomnia can be associated with several specific sleep disorders including sleep apnea, periodic limb movement disorder (PLMD), and restless legs syndrome (RLS). Sleep apnea (central or obstructive) can be described as transient periods of breathing cessation during sleep. Central sleep apnea results from stimulation failure by the respiratory centers in the medulla, whereas obstructive sleep apnea is caused by collapse or obstruction of the airway. Periodic limb movement disorder is characterized by repetitive jerking or twitching movements in the lower extremities. These movements occur every 20 to 90 seconds and can lead to arousals that are not usually perceived by the patient. Restless legs syndrome is associated with uncomfortable sensations of the legs and feet that are temporarily alleviated by moving the limbs. Frequent adjustment of position results in recurrent arousals.
Once secondary causes of insomnia are identified or treated, the remaining insomnia can be classified as primary insomnia. Primary insomnia is often correlated with behavioral conditioning, poor sleep hygiene, and chronic stress.
Assessment of Sleep Complaints
Assessing the nature of one’s sleep complaint is imperative to selecting an appropriate treatment regimen. Determining potential causes of insomnia should begin with a detailed patient history from the patient and his or her sleep partner. Identifying the duration of symptoms and whether insomnia problems are rooted in difficulty falling asleep, maintaining sleep, or waking early is also important in guiding treatment. A complete medical, psychiatric, and medication history, including dose and administration time, should also be obtained. Having the patient keep a sleep journal can also help to identify sleep patterns. Patients who suffer from severe snoring or apneic spells, or for whom a causative factor for long-term insomnia cannot be identified, should be referred to a sleep disorder center.
Nonpharmacological Treatment
The focus of nonpharmacological treatment is to alter maladaptive sleep habits and to erase dysfunctional beliefs about sleep that have become linked with insomnia. Relaxation therapy (e.g., abdominal breathing, progressive muscle relaxation, and imagery), sleep restriction therapy (e.g., curtailing the amount of time spent in bed to increase sleep efficiency), and stimulus control therapy (e.g., reassociating the bedroom with sleep) are several different approaches taken to alleviate insomnia. There are several simple adjustments that can be recommended by a pharmacist to correct poor sleep hygiene (Table 1).
| Table 1: Behavior Modification Tips |
| - Establish a regular bedtime and wake time schedule.
- Use the bed for sleep and intimacy only. - Create a comfortable environment; avoid extremes in temperature, light, and noise. - Avoid long periods of wakefulness in bed. Leave the bedroom when unable to sleep and return when sleepy. - Avoid daytime naps or limit naps to 30 minutes or less. - Exercise routinely, but not close to bedtime. - Avoid large quantities of fluids before bedtime to avoid nocturia. - Avoid use of diuretics in the evening. - Avoid caffeine-containing products after noon. - Avoid or limit the use of alcohol. - Avoid stimulating medications if possible. - Avoid excessive fullness or hunger at bedtime. |