34 CLINICAL
Assessment of insomnia It is important to take a history as this may point out a cause that can be remedied . Always ask what the patient means by ‘ not sleeping ’. As mentioned above , this means many things and you may find that sleep quality is good and the issue is with the patient ’ s perception of how refreshing their sleep is .
Assess the patient for possible causes of insomnia and – if appropriate – arrange tests to check thyroid function , iron ( low levels of which may trigger restless leg syndrome ) and HbA1c to pick up any new diagnosis of diabetes .
Always ask the patient to keep a sleep diary for at least two weeks . This should include the bedtime , total sleep time , use of medication , number of awakenings , time of waking and feelings on rising . If symptoms such as daytime somnolence and snoring with apnoeic episodes raise the possibility of obstructive sleep apnoea , refer for an overnight sleep study . It is important not to rush to prescribe medication , however tempting that may be – give sleep hygiene advice first as about one-third of patients with primary insomnia will improve with this alone .
Management of insomnia If any clear cause has been identified , it should be addressed as this alone may solve the problem . If further advice is required this should include the following : Limit caffeine intake ( ideally to one cup in morning ). Avoid napping , however tired you feel ( unless driving ). Exercise in the day , not late in the evening . Avoid heavy meals before bed . Shut down any computer screens one to two hours before bedtime because of the impact of digital ‘ blue light ’ on the body ’ s natural rhythms and melatonin levels . Avoid looking at the clock on waking . Use the bedroom for sleep , not for watching TV or working . Make sure you have a comfortable bed and bedroom .
Get up at the same time and don ’ t lie in . Don ’ t keep mobile phones or other devices nearby – or if you do , put them on ‘ silent ’.
Treating insomnia is appropriate when it causes significant distress or marked impairment to daytime functioning , and when there is no remediable cause and simple hygiene measures have not helped .
Many patients expect to be prescribed a ‘ sleeping tablet ’, but this should not be considered until sleep hygiene advice is given . Also , both the Royal College of Psychiatrists and the Medicines and Healthcare products Regulatory Agency ( MHRA ) have long advised that hypnotics should be limited to the lowest effective dose for the shortest time possible , with a maximum four-week treatment period . They should be avoided , where possible , in the elderly . If available , offer cognitive behavioural therapy ( CBT ) first as this is effective , either individually or in small groups . It has been shown to be as effective as medication for the short-term treatment of chronic insomnia . The benefits of CBT often last well beyond the end of active treatment , and systematic reviews consistently confirm the benefit of CBT in insomnia .
If drug treatment is considered , the National Institute for Health and Care Excellence ( NICE ) says a short course ( three to seven days ) of a non-benzodiazepine hypnotic medication ( a ‘ z-drug ’) may be considered , but hypnotics should not be used routinely , and should only be given if the patient is acutely distressed and in short courses . Hypnotics should not be prescribed to older people or women who are pregnant or breastfeeding . The many risks associated with hypnotics such as falls , cognitive impairment , dependence and withdrawal symptoms are well recognised . There is no evidence of benefit of switching between z-class drugs .
There are several reasons why hypnotics should be avoided whenever possible in the elderly . These patients are at increased risk of developing ataxia , confusion and falling as they eliminate the drugs more slowly , are more susceptible to central nervous system depression and are more likely to be on other medications with potential interactions . Benzodiazepines and z-drugs also appear to be linked to increased risk of falls and hip fractures in the elderly , often as a result of ‘ hip sway ’ – where a person gets up from sleep under the influence of these drugs , is unsteady , then falls over . Any marginal improvement in sleep quality in the elderly is also usually outweighed by the risk of other adverse events and this is especially marked where patients have risk factors for cognitive or psychomotor problems .
In the over-55 age group , prolonged-release melatonin is now licensed and appears to improve sleep onset and quality in patients who have persistent insomnia . The recommended initial treatment period is three weeks and if effective , may be used for up to 13 weeks . It should be avoided in hepatic impairment , autoimmune disease and in pregnancy , breastfeeding and women planning a pregnancy . Risks are similar to those of other hypnotics including falls , fractures , dependence and withdrawal symptoms .
Many other treatments have been tried for insomnia , including antidepressants , but there is limited evidence for effectiveness . Amitriptyline 10mg is widely used but there are no controlled studies for its use in insomnia . Antipsychotics have been used but the cardiac risks are significant , side-effects are common and data are inconclusive so they should be avoided . Sedating antihistamines may have a limited role in some people , with hydroxyzine and promethazine being the most sedative , but hangovers are common . Diphenhydramine is an OTC drug but lacks good evidence of efficacy . Also , rebound insomnia can occur after long use . Herbal remedies such as valerian are popular but there is no evidence for their effectiveness .
Dr Roger Henderson is a GP in Dumfries and Galloway , Scotland
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