Insomnia – BCguidelines 2004

1 In patients presenting with sleep complaints, take a careful history to:

  • distinguish insomnia from other sleep-related complaints that require more specific treatment (e.g., sleep apnea or other sleep disorders, including periodic limb movements, restless legs syndrome, sleepwalking, or sleep talking).
  • assess the contribution of drugs (prescription, over-the-counter, recreational), caffeine, and alcohol.
  • make a specific psychiatric diagnosis if one is present.
Nocturnal Myoclonus
  • Middle-aged and elderly
  • Myoclonic jerks Q20-40s
  • Bed partner complaints
  • Tx: BZD (clonazepam, nitrazepam)

 

 2 When assessing patients with sleep complaints, obtain a collateral history from the bed partner, if possible.

Assess the sleep complaint by a:
  • history of the sleep complaint
  • sleep diary completed over one week (see insert)
  • history from the bed partner, if appropriate
  • systems review
  • medication and drug history (include over-the-counter medications and recreational drugs)
  • psychiatric history with special attention to the family and personal history of mood and anxiety disorders
  • focused physical exam

Insomnia

  • If the problem is insomnia (trouble falling asleep or maintaining sleep), assess the degree of daytime impairment.

If daytime impairment is mild to moderate (little or no impairment in social or occupational functioning and complaints of non-restorative sleep, dysphoria, and tiredness after fewer than half the sleeps):

  • ensure that the patient is practicing all the rules of good sleep hygiene – see A Guide for Patients
  • establish a regular rising time
  • commence one of the behavioural interventions below:
1. Stimulus control
  • re-establishes the association of the bed and bedroom with sleep, rather than with the frustration and anxiety of trying to sleep.
  • The patient should go to bed only when sleepy, and get up at the same time each day regardless of how much he or she slept.
  • The patient should get up, go to another room if unable to fall asleep, or return to sleep, after 15 to 20 minutes (without clock-watching) and return to bed only when drowsy-tired.
2. Sleep restriction
  • limits the time in bed to the amount of time a patient actually sleeps usually. Estimate the average sleep time from at least three days of a sleep diary.
  • For example, if a patient sleeps an average of six hours a night, the total time in bed is limited to six hours. Ask patients to set their preferred rising time and to retire six hours earlier. They should maintain this bedtime for a few days to induce a mild degree of sleep deprivation – this will help them sleep more efficiently.
  • Then they should go to bed ten minutes earlier every few days until their sleep becomes disrupted. Finally they will set their new bedtime 10 minutes later than the time they went to bed when their sleep became disturbed.

If daytime impairment is severe

– significant impairment in social or occupational functioning and complaints of non-restorative sleep, dysphoria, and tiredness after more than half the sleeps:

  • ensure that the patient is practicing all the rules of good sleep hygiene – see A Guide for Patients
  • set a regular rising time
  • commence a short course of hypnotics (14 days or less) but do not extend sleeping hours
    • prior to discontinuing medication (always taper through a half-dose) limit the time in bed to 30 minutes less than the mean total sleep time on medication to induce a modest degree of sleep restriction
    • add 10 minutes to the sleep time every few days until sleep becomes disrupted, then take off 10 minutes to assign the final time in bed

If severe daytime impairment persists after two to three treatment trials refer the patient to an appropriate specialist.


Hypersomnia

If the problem is hypersomnia (excessive sleepiness) and the patient has disruptive snoring and/or witnessed pauses in breathing during sleep, refer to the Assessment and Management of OSA in Adults.

Otherwise:

  • ensure that the patient is following all the rules of good sleep hygiene-see A Guide for Patients
  • ensure patient is getting sufficient sleep
  • manage any psychiatric disorders (especially depression or bipolar affective illness)

If the problem persists refer the patient to an appropriate specialist with an interest in sleep disorders.


Parasomnia

If the problem is parasomnia (unusual behavioural or physiological events during sleep caused by activation of the autonomic nervous system, motor system, or cognitive processes, e.g., sleep terror, sleepwalking, sleep talking):

Ensure that the sleeper and bed partner are safe.

If mild (talking/shouting only or physical activity limited to occasional restlessness < 3 nights per week):

  • ensure practice of good sleep hygiene – see A Guide for Patients
  • prevent sleep deprivation
  • general stress reduction strategies (time management, exercise, counselling, etc.)
  • avoid excessive alcohol intake and recreational drug use.

If moderate to severe (activity places patient and/or partner at risk >3x per week and/or daytime impairment):

  • commence trial of benzodiazepine; clonazepam (0.25-1.5 mg hs) is commonly used
    • but all are likely effective (no studies demonstrate superiority of a single agent)
  • effective trials should be continued for a year and slowly tapered with the same safety precautions as for mild parasomnia
  • avoid excessive alcohol intake and recreational drug use.

If the problem persists refer the patient to an appropriate specialist with an interest in sleep disorders.


3 In all patients with insomnia, provide advice about sleep hygiene (e.g., limiting caffeine, limiting naps, restricting bedroom activities to sleep and sex, using an alarm clock to get up at the same time each day).

Sleep Hygiene: A GUIDE FOR PATIENTS

Follow these rules for healthy sleep.

  • Get up at the same time each day, seven days a week, to reinforce your body’s internal clock.
  • Go to bed only when you are sleepy.
  • If you’re not asleep after about 20 minutes, go to another room and do something relaxing. Return to bed when you are drowsy-tired.
  • Use your bed only for sleeping or sex. Don’t worry or watch TV in bed so your body learns the bed is for sleeping.
  • Keep your bedroom dark and comfortably cool.
  • Exercise during the day (three to four hours before bedtime).
  • Don’t drink coffee or tea within six hours of bedtime.
  • Don’t drink alcohol in the evening. It can make you wake up in the middle of the night.
  • Try eating a light carbohydrate snack before bed.

4 In appropriate patients with insomnia, use hypnotic medication judiciously (e.g., prescribe it when there is a severe impact on function, but do not prescribe it without a clear indication). – see above


Reference:

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Posted in 53 Insomnia, 99 Priority Topics, FM 99 priority topics, Psych

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