On Call: Insomnia

Insomnia

Definition

  • Insomnia – Difficulty Falling or Staying Asleep
  • Classification:
    • Acute Insomnia – Occurs for Less Than 3 Months
      • Often Lasts Only a Few Days-Weeks in Response to an Acute Stressor
    • Chronic Insomnia – Occurs ≥ 3 Times Per Week for ≥ 3 Months

Risk Factors

  • Elderly
  • Female Sex
  • Neurologic Disorders:
    • Dementia
    • Delirium
    • Stroke
    • Traumatic Brain Injury
    • Depression & Anxiety
  • Medication:
    • Steroids
    • Antidepressants
    • CNS Stimulants & Depressants
  • Chronic Pain
  • Caffeine
  • Substance Abuse
  • Sleep Apnea
  • COPD
  • Heart Failure
  • Diabetes
  • Cancer

Complications

  • Delirium
  • Fatigue
  • Agitation
  • Depression & Anxiety
  • Increased Risk of Cardiovascular Events
  • Impaired Immune Function

Management

General Approach

  • Support Sleep Hygiene as Able
  • Avoid Aggravating Factor & Stimulants
  • Treat Any Underling Psychologic or Physiologic Factors Causing Acute Stress
  • Indications for Pharmacologic Treatment:
    • Severe Acute Insomnia
    • Acute Insomnia Causing Substantial Distress
  • Consider Cognitive Behavioral Therapy (CBT) as the First-Line Treatment for Chronic Insomnia

Sleep Hygiene

  • Maintain a Regular Sleep Schedule
  • Maintain a Regular Day-Night Cycle
    • Keep the Room Dark at Night
    • Keep the Room Light During the Day
  • Avoid Excessive Sleep During the Day
  • Avoid Evening Caffeine
  • Avoid Tobacco/Smoking
  • Avoid Electronic Screens at Bedtime (Television/Laptop/Cellphone)
  • Avoid “Watching the Clock”
  • Avoid Excessive Noise or Frequent Nighttime “Checks” if Not Necessary

Pharmacologic Therapy

  • Melatonin
    • Generally the First-Line Medication
    • Minimal Side Effects
    • Dose: 1-10 mg 30-60 Minutes Before Bedtime
  • Antihistamines
    • Agents: Diphenhydramine (Benadryl) & Doxylamine (Unisom)
    • Dose: 25 mg at Bedtime
      • Up to 50 mg Benadryl
    • Increased Risk of Delirium – Avoid in the Elderly
  • Trazodone
    • Mechanism: Serotonin Reuptake Antagonist
    • Dose: 50-100 mg at Bedtime
  • Ramelteon (Rozerem)
    • Mechanism: Melatonin Receptor Agonist
    • Dose: 8 mg within 30 Minutes of Bedtime
  • Benzodiazepine Receptor Agonists
    • Agents: Zolpidem (Ambien), Zaleplon (Sonata) & Eszopiclone (Lunesta)
    • More Commonly Used in the Outpatient Setting
    • Increased Risk of Delirium – Avoid in the Elderly