Insomnia: Therapeutic Approach

, MD, , MD, , Department of Psychiatry and Behavioral Medicine, University of Louisville School of Medicine, Louisville, Ky

South Med J. 2001;94(9) 

In This Article

Diagnosis of Probable Causes

Evaluation

In assessing possible causes of a patient's insomnia, the physician should obtain a complete history and perform the appropriate physical examination or laboratory studies. Knowing the duration and type of sleep complaint is critical.[8] Medical problems that can cause insomnia include a wide range of endocrine, cardiovascular, pulmonary, gastrointestinal, and other disorders.[11] A patient-recorded sleep diary may be diagnostically helpful. Psychiatric symptoms might reveal mental illness, especially depression, or emotional factors, such as grief. Questionnaires on well-being and sleep habits can provide information.[12] Symptomatology may suggest a primary sleep disorder.[13]

Determine whether pharmacologic agents are the cause of insomnia. Stimulants, bronchodilators, xanthines, decongestants, diuretics, histamine antagonists, antihypertensives, and steroids are drugs that may cause sleep difficulty.[14,15,16,17] Some activating antidepressant medicines (eg, fluoxetine) can induce insomnia. The same applies to illegal stimulants (eg, cocaine). Nicotine, alcohol, and caffeine frequently cause or exacerbate sleep disturbances and should be avoided at night.[15,17] Alcohol does overcome sleep latencies but often results in less restorative sleep with nocturnal awakenings. The negative implications of caffeine and/or ethanol consumption on sleep is common, yet underappreciated. Check for substance abuses and recent discontinuance of ethanol or sedatives to explain insomnia.[15]

Other Factors

Check for stress factors such as the loss of a loved one, divorce, a job problem, or family or health concerns.[1,14,18] Always consider depression, anxiety, and stress-related disorders.[5,14,18,19] Pain can be a factor. Patients sometimes may be unaware of their sleep problem, and in such cases, interview a bed partner familiar with the person's habits, complaints, moods, movements, or breathing and snoring.[20] Sleep phase disorders with an aberrant circadian cycle can result in sleep deficiency with alertness difficulties.[7,14,18,19] Table 2 reviews these altered patterns of sleep timing, with suggested phototherapy.

Elderly people exhibit insomnia more often than youthful ones and have greater problems when taking pharmaceuticals. Their sleep is characterized by low stress tolerance, with frequent awakenings. They are more prone to troubled sleep from medical, psychiatric, and/or sleep disorders.[8,21,22] Comorbidity increases risk for polypharmacy drug interactions.[23] Aged patients are more susceptible to drug side effects, such as sedation or orthostasis, which results in a higher risk for injury from falling.[5,24] Readily predictable insomnias also occur more frequently (eg, before hospitalizations or during a painful illness).[15,20]

Insomnia is subjective,[17,25] yet doctor-patient communication can provide clues to diagnosing a primary sleep disorder (eg, apneic spells associated with loud snoring). Referral to a sleep disorder center is considered when a causative factor for long-term insomnia cannot be identified, when therapy is not effective, or when primary sleep disorders are suspected.[20] Such centers evaluate people in a controlled environment using such methods as polysomnography.[26]

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