Insomnia in Adults: Etiology and Management

Kathleen Reeve; Barbara Bailes

Journal for Nurse Practitioners. 2010;6(1):53-60.

Abstract and Introduction

Abstract

Insomnia is a significant problem in adults that frequently goes undiagnosed and untreated. Untreated insomnia is often associated with undiagnosed medical or psychiatric disorders that increase morbidity and mortality. Sleep patterns change with aging, and the presence of comorbid conditions leads to a higher prevalence of sleep disorders in older adults. Practitioners should inquire about sleep disorders with every patient encounter to increase diagnosis and treatment. Effective treatment of insomnia is available with nonpharmacologic and pharmacologic treatment modes.

Introduction

Sleep disturbance is a common complaint. Approximately 40 million Americans suffer from chronic insomnia; an additional 20 million experience episodic insomnia. These disorders cost an estimated 16 billion dollars in direct medical costs annually. Even greater are the indirect costs of productivity and lost work days. Many individuals experiencing problems falling asleep or staying asleep use prescription or over-the-counter sleep medications. Sleep disorders affect all age groups, occur more frequently in women than in men, and are especially problematic in the elderly.^[1–4]

1 2 3 4

Next Section

Abstract and Introduction
Sleep Physiology
Sleep Disorders
Insomnia
References

Table 1. Stages of Sleep
Stage	Time Period	Characteristics
*Non Rapid Eye Movement*
Stage 1	Transitional period	Theta waves; 5–10 minutes; Wakens easily; hypnic myoclonia (muscle contractions)
Stage II	Light sleep	Sleep spindles and K complexes; 40–50% of total sleep time. Heart rate slows; body temperature drops
Stage III	Deep sleep	Delta waves (slow waves) < 50% of time
Stage IV	Deepest sleep; difficult to awaken	Delta waves (slow waves) > 0% of time
*Rapid Eye Movement (REM)* ^**		Alpha, beta, and dyschronous waves; 30% of total sleep time. Heart rate and respirations increase; face, fingers, and legs twitch; paralysis major muscle groups. Occurs 90 minutes after sleep onset

Complete sleep cycle = 90–100 minutes.
^** REM sleep cycle relative short early in night; longer REM as morning nears. Adapted from Stevens.^[8]

Table 2. Major Categories of Sleep Disorders
Sleep Disorder	Selected Classifications^*
Insomnia	Acute: adjustment insomnia; short-term insomnia; transient insomnia. Chronic: depression/anxiety
Sleep-related breathing disorders	Central sleep apnea
	Obstructive sleep apnea
	Sleep-related hypoventilation/hypoxemia syndromes
Hypersomnias of central origin	Narcoplexy with/without cataplexy
	Idiopathic hypersomnia (with/without long sleep time)
Circadian rhythm sleep disorders	Time zone syndrome (Jet Lag)
	Shift work sleep disorder
	Delayed sleep phase type
	Advanced sleep phase type
	Associated with medical condition
Parasomnias	NREM associated: sleep walking; sleep terrors; confusional arousals: REM associated: sleep paralysis nightmares
Sleep-related movement disorders	Restless leg syndrome
	Periodic limb movement disorder
	Sleep-related bruxism
Isolated symptoms and normal variants	Sleep starts; sleep talking
Other sleep disorders	Environmental sleep disorder (noise, temperature, etc) Physiologic sleep disorder – unspecified

Adapted from [9, 12]
^*Not a complete list of sleep disorders.

Table 3. Common Secondary Causes of Insomnia
Medical Conditions	Medications
Angina	Anticholinergics
Asthma	Antidepressants
Cancer	Antiepileptics
Chronic pain syndrome	Antihistamines
Chronic fatigue syndrome	Beta blockers
Chronic obstructive pulmonary disease (COPD)	Bronchodilators
Congestive heart failure	CNS stimulants
Degenerative disease	Diuretics
Gastroesophageal reflux disorder (GERD)	Nicotine
Hyperthyroidism	Oral contraceptives
Pregnancy	Progesterone
Stress	Steroids
Stroke	Thyroid hormone

Adapted from [3, 18, 20]

Table 4. Common Psychiatric Causes of Insomnia
Psychiatric Disorders	Examples
Mood disorders	Major depressive disorder, bipolar mood disorder, dysthymia
Anxiety disorders	Generalized anxiety disorder, panic disorder, PTSD, OCD
Psychotic disorders	Schizophrenia, schizoaffective disorder
Amnestic disorders	Alzheimer disease, dementias
Childhood/adolescence disorders	ADD
Others	Adjustment disorders, personality disorders, bereavement, stress

Adapted from [3, 15, 18, 20]

Table 5. Nonpharmacologic Treatment
Treatment	Description
Relaxation	Objective: mental relaxation secondary to physical relaxation
	Meditation, progressive muscle relaxation, biofeedback, imagery
Stimulus control^*	Objective: associate bed/bedroom with rapid onset of sleep
	Develop regular sleep-wake cycle; use bed for sleep; go to another room if unable to sleep
Sleep restriction^*	Objective: reduce time in bed
	Limit time in bed to actual sleep time; mild sleep deprivation promotes more efficient sleep
Paradoxical intention	Objective: change unrealistic sleep expectations
	Decrease anxiety about falling asleep by staying awake as long as possible
CBT	Objective: replace identified dysfunctional attitudes about sleep with adaptive substitutes
	Correct unrealistic expectations and consequences of sleeplessness, plan coping responses, balance anxious autonomic thoughts, reappraisal, attention shifting

^*Most effective strategies.
Adapted from [2, 3, 17-20]

Table 6. Sleep Hygiene
Guidelines
Get out of bed at same time every day, even after a poor night's sleep
Go to bed at the same time every night
Exercise regularly no later than 3–4 hours before bedtime
Develop relaxing routine before bedtime
Keep bedroom quiet, cool, dark
Use bed/bedroom only for sleep and sex
Avoid heavy meals and liquids 2–3 hours before bedtime
Avoid napping
Avoid caffeine and nicotine 4–6 hours before bedtime
Avoid watching the clock; remove bedside clock if necessary

Adapted from [2, 17, 28]

Table 7. Commonly Prescribed Sleep Agents
Name	Dosage (mg)	Peak Action (hours)	Half-life (hours)	Considerations
Benzodiazepines
Triazolam (Halcion)	0.124–0.5	1–2	1.5–5	Rapid onset, short half-life; REM sleep rebound, drowsiness, dizziness, headache, nervousness, lightheadedness, coordination disorders/ataxia, nausea/vomiting; CYP3A4 dependent metabolism
Estazolam	1–2	2–5	10–24	Rapid onset, daytime sleepiness, abnormal coordination, constipation, dizziness, hangover, malaise, headache, decreased memory, somnolence
Temazepam (Restoril)	7.5–30	1.2–1.6	3.5–18.4	Daytime sleepiness, dizziness, lightheadedness, uncoordination; less effective sleep induction; rule out sleep apnea prior to prescribing
Nondiazepines
Eszopiclone (Lunesta)	2–3	1	4–6	Indicated for chronic insomnia; approve for long-term use; unpleasant taste; minimal amnesia, hallucinations, worsening depression; CYP3A4 dependent metabolism
Zolpidem (Ambien)	5–10	0.5	2–3	Headache, dizziness, myalgia, URTI, residual drowsiness; minimal rebound insomnia; sleep onset; CR formula better for sleep maintenance; CYP3A4 dependent metabolism
Zaleplon (Sonata)	5–10	0.5	1	Headache, altered color perception, dyspepsia, dysmenorrhea, hyperacusis, vertigo, malaise, epistaxis; better for sleep maintenance; administered upon night awakening; CYP3A4 dependent metabolism
Antidepressant
Trazodone (Desyrel)	50–150	0.5–2	8	Anticholinergic, daytime somnolence, accidents, hypotension, blurred vision, dizziness, insomnia, rare cardiac toxicity, sexual dysfunction; SSRI interaction, exacerbates restless legs syndrome; decreasing efficacy over time; CYP2D6 dependent metabolism
Melatonin Receptor Agonist
Ramelteon (Rozerem)	8–16	0.3	2–5	Regulate circadian rhythm; decreased absorption after high fat meal; no abuse potential; not limited to short-term use; caution with hepatic/renal disease

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.