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Insomnia

Brief Overview: According to UpToDate, “Insomnia symptoms that occur at least three times per week and persist for at least three months are considered chronic insomnia. In practice, however, most individuals with chronic insomnia report symptoms for many years. Some individuals recall an initial stressful event that triggered insomnia, but others report nearly lifelong symptoms without an identifiable trigger. Night-to-night variability and a waxing and waning course related to psychosocial stressors and psychiatric or medical comorbidities are common.”

Prevalence: According to UpToDate, “Prevalence estimates vary according to the study design and definition of insomnia used. In cross-sectional surveys of ambulatory patients, one-third to two-thirds of adults report insomnia symptoms of any severity, and approximately 10 to 15 percent have chronic insomnia with daytime consequences (insomnia disorder).”

Etiology: Insomnia is often multifactorial and may be:

  • Primary (insomnia disorder) related to learned sleep behaviors, hyperarousal, and conditioned wakefulness
  • Secondary/Comorbid with medical conditions, psychiatric conditions, medications/substances, or other sleep disorders (e.g., OSA, RLS)

Risk Factors:

  • Age
  • Female
  • Family history of insomnia
  • Light sleepers
  • Psychiatric disorders
  • Certain medications
  • Substance use
  • Poor sleep habits
  • Shift work

Commonly Associated Conditions:

  • Depression, anxiety, PTSD, substance use disorder
  • HTN
  • OSA, RLS
  • Chronic pain
  • Diabetes
  • Obesity
  • Pulmonary disease
  • Heart failure

Common Medications:

  • Nonbenzodiazepine BZRAs – eszopiclone, zaleplon, zolpidem
  • Benzodiazepine hypnotics – estazolam, flurazepam, temazepam, triazolam
  • Dual orexin receptor antagonists (DORAs) – daridorexant, lemborexant, suvorexant
  • Low-dose doxepin
  • Ramelteon
  • Off-label – trazodone, mirtazepine, amitriptyline
  • Over-the-counter (caution in older adults) – diphenhydramine, doxylamine
  • Dietary supplements – melatonin

Common Labs, Imaging, and Tests:

  • No routine labs needed
  • Sleep diary
  • Select tests may be ordered: echo, thyroid studies, glucose, HgbA1c, BUN, creatinine, iron studies, polysomnography, actigraphy

Common Symptoms:

  • Difficulty initiating or maintaining sleep
  • Waking up too early
  • Non-restorative sleep
  • Compromised daytime function, including, but not limited to:
    • Fatigue
    • Irritability, mood disturbance
    • Daytime sleepiness
    • Delayed responses/reaction times
    • Decreased attention/concentration, increased errors/accidents

Common Treatments:

  • Medications (see above)
  • Cognitive-Behavioral Therapy (CBT)

Physical Findings:

  • Often normal physical exam
  • Elevated blood pressure or HTN may be present
  • Increased oropharyngeal tissue if OSA
  • Lower extremity edema if HF
  • Abnormal mental status if dementia

Potential Complications and Contraindications:

  • Complications
    • Depression/anxiety worsening; reduced quality of life
    • Falls (especially with sedatives), driving/work accidents
    • Worsening control of chronic medical conditions
    • Dependence/tolerance if sedatives used long-term
  • Contraindications/cautions
    • History of complex sleep behaviors on Z-drugs (avoid)
    • High fall risk/frailty/cognitive impairment: avoid anticholinergics and long-acting sedatives
    • Untreated OSA or respiratory compromise: sedatives can worsen breathing

General Health and Lifestyle Guidance:

  • Consistent schedule (same wake time daily; limit sleeping in)
  • Wind-down routine; reduce screen/light exposure 1–2 hours before bed
  • Avoid caffeine after late morning/early afternoon; limit nicotine; avoid alcohol near bedtime
  • Naps: avoid if possible; if needed, keep <20–30 minutes and before mid-afternoon
  • Bedroom: cool, dark, quiet; bed for sleep only
  • Exercise most days (not vigorous right before bedtime) – as approved by healthcare provider
  • If awake >~20–30 minutes, get out of bed and do a quiet activity until sleepy (“break the association”)

Suggested Questions to Ask Patients:

  • What is the main issue: falling asleep, staying asleep, or waking too early?
  • How many nights per week? How long has this been going on?
  • What time do you go to bed/wake up? Any naps? Caffeine/alcohol?
  • Any new stressors, pain, reflux, hot flashes, depression/anxiety symptoms?
  • Snoring, witnessed apneas, morning headaches, daytime sleepiness (OSA screen)?
  • Restless legs symptoms (urge to move legs at night)?
  • Current sleep meds/supplements (including OTC diphenhydramine, melatonin) and how often?
  • Safety: any drowsy driving, falls, confusion, or unusual behaviors during sleep?

Suggested Talking Points:

  • Chronic insomnia is common and treatable. The most effective long-term treatment is CBT-I, which works to retrain sleep patterns.
  • Sleep medications can help short-term, but the goal is to find a plan that improves sleep without long-term side effects.
  • If you snore loudly or stop breathing at night, you should report this to your healthcare provider so they can determine if they need to evaluate for sleep apnea—treating that can dramatically improve sleep.
  • If you ever have unusual behaviors during sleep (sleepwalking/sleep driving), stop the sleep med and contact your clinician right away.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.