Insomnia

Insomnia is the perception by patients that their sleep is inadequate or abnormal. Insomnia may affect as many as 69% of adult primary care patients. The incidence of sleep problems increases with age. Younger persons are apt to have trouble falling asleep, whereas older persons tend to have prolonged awakenings during the night.

Causes of insomnia

Situational stress concerning job loss or problems often disrupt sleep. Patients under stress may experience interference with sleep onset and early morning awakening. Attempting to sleep in a new place, changes in time zones, or changing bedtimes due to shift work may interfere with sleep. Drugs associated with insomnia include antihypertensives, caffeine, diuretics, oral contraceptives, phenytoin, selective serotonin reuptake inhibitors, protriptyline, corticosteroids, stimulants, theophylline, and thyroid hormone.

Psychiatric disorders. Depression is a common cause of poor sleep, often characterized by early morning awakening. Associated findings include hopelessness, sadness, loss of appetite, and reduced enjoyment of formerly pleasurable activities. Anxiety disorders and substance abuse may cause insomnia.

Obstructive sleep apnea syndrome

This sleep disorder occurs in 5-15% of adults. It is characterized by recurrent discontinuation of breathing during sleep for at least 10 seconds. Abnormal oxygen saturation and sleep patterns result in excessive daytime fatigue and drowsiness. Loud snoring is typical. Overweight, middle-aged men are particularly predisposed. Weight loss can be helpful in obese patients.

Diagnosis is by polysomnography. Use of hypnotic agents is contraindicated since they increase the frequency and the severity of apneic episodes.

Clinical evaluation of insomnia

Acute personal and medical problems should be sought, and the duration and pattern of symptoms and use of any psychoactive agents should be investigated. Substance abuse, leg movements, sleep apnea, loud snoring, nocturia, and daytime napping or fatigue should be sought.

Consumption of caffeinated beverages, prescribed drugs, over-the-counter medications, and illegal substances should be sought.

Stimulus restriction. Patients are advised to lie in bed only when they are sleepy and not when reading, eating, or watching television. If they do not fall asleep after a few minutes, they should get out of bed and read until they are sleepy.

Sleep restriction may be helpful. Each night, patients reduce the time in bed 30 minutes until reaching 4 hours per night; thereafter, they may add 15 minutes each night until 85% of time in bed is spent sleeping. Relaxation therapy may include abdominal breathing, yoga or meditation, autogenic training, progressive muscle relaxation, and biofeedback.

Zolpidem (Ambien) and zaleplon (Sonata) have the advantage of achieving hypnotic effects with less tolerance and fewer adverse effects. Hypnotics are the primary drugs used in the management of insomnia. These drugs include the benzodiazepines and the benzodiazepine receptor agonists in the imidazopyridine or pyrazolopyrimidine classes. The safety profile of these benzodiazepines and benzodiazepine receptor agonists is good; lethal overdose is rare, except when benzodiazepines are taken with alcohol. Sedative effects may be enhanced when benzodiazepines are used in conjunction with other central nervous system depressants.

Zolpidem (Ambien) is a benzodiazepine agonist with a short elimination half-life that is effective in inducing sleep onset and promoting sleep maintenance. Zolpidem may be associated with greater residual impairment in memory and psychomotor performance than zaleplon.

Zaleplon (Sonata) is a benzodiazepine receptor agonist that is rapidly absorbed (TMAX = 1 hour) and has a short elimination half-life of 1 hour. Zaleplon does not impair memory or psychomotor functioning at as early as 2 hours after administration, or on morning awakening. Zaleplon does not cause residual impairment when the drug is given in the middle of the night. Zaleplon can be used at bedtime or after the patient has tried to fall asleep naturally.

Benzodiazepines with long half-lives, such as flurazepam (Dalmane), may be effective in promoting sleep onset and sustaining sleep. These drugs may have effects that extend beyond the desired sleep period, however, resulting in daytime sedation or functional impairment. Patients with daytime anxiety may benefit from the residual anxiolytic effect of a long-acting benzodiazepine administered at bedtime. Benzodiazepines with intermediate half-lives, such as temazepam (Restoril), facilitate sleep onset and maintenance with less risk of daytime residual effects.

Benzodiazepines with short half-lives, such as triazolam (Halcion), are effective in promoting the initiation of sleep but may not contribute to sleep maintenance.

Sedating antidepressants are sometimes used as an alternative to benzodiazepines or benzodiazepine receptor agonists. Amitriptyline (Elavil), 25-50 mg at bedtime, or trazodone (Desyrel), 50-100 mg, are common choices.


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