History and exam

Your Organisational Guidance

ebpracticenet urges you to prioritise the following organisational guidance:

Aanpak van slaapklachten en insomnie (slapeloosheid) bij volwassenen in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2018Prise en charge des problèmes de sommeil et de l’insomnie chez l’adulte en première lignePublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2018

Key diagnostic factors

common

presence of risk factors

Key risk factors include female sex, advancing age, chronic physical or psychological illness, and use of alcohol, drugs, or stimulants.

sleep partner complaints

Often the sleep partner's rest will suffer, or the patient's signs and symptoms may be confirmed or identified by interview.

delayed sleep onset

Key to determining a treatment approach, especially the choice of a particular hypnotic agent, is defining whether the patient experiences sleep initiation or sleep maintenance (continuity) difficulties, or both.[104]​​

Insomnia is a subjective problem, but as a general guide, patients with insomnia typically report taking 30 minutes or more to fall asleep if sleep initiation difficulties are present.[89] Although patients are often able to correctly identify sleep difficulties when subjective reports are compared with objectively measured sleep parameters, such as polysomnography or actigraphy, patients with paradoxical insomnia (previously termed sleep state misperception) typically describe much more sleep disturbance than is recorded by objective sleep measures obtained during polysomnography.[89]

multiple or long awakenings

Insomnia is a subjective problem, but as a general guide, patients with insomnia typically report spending 30 minutes or more awake during the night if sleep maintenance difficulties are present.[89] Although patients are often able to correctly identify sleep difficulties when subjective reports are compared with objectively measured sleep parameters, such as polysomnography or actigraphy, patients with paradoxical insomnia (previously termed sleep state misperception) typically describe much more sleep disturbance than is recorded by objective sleep measures obtained during polysomnography. As noted, actigraphy conducted over the course of 1-2 weeks, along with the sleep diary, may be more useful in determining a discrepancy between objective and subjective evidence regarding the patient's sleep, and the presence of paradoxical insomnia, a condition that may not be appropriate for hypnotic treatment.[95]

Other diagnostic factors

common

impairment of functioning

A diagnosis of insomnia requires significant distress due to the sleeplessness and/or a report of daytime impairment in performance or in function believed to be due to the sleep disturbance. The Insomnia Severity Index (ISI) can serve as a current and ongoing marker for the patient's perceived distress regarding their daytime impairment.

accidents

Due to poor sleep, there may be minor to major injury to self or others due to the patient's increased clumsiness, poor concentration, and somnolence.

decreased sleep time

Total duration of sleep should be quantified.

uncommon

daytime napping

Uncommon. Patients with insomnia often have a desire to nap but are unable to do so.[2]​ Involuntary daytime sleep episodes are more characteristic of other sleep disorders, such as obstructive sleep apnoea and narcolepsy.[2]

thyrotoxicosis

Patients with hyperthyroidism commonly experience insomnia.

chronic pain

Patients with chronic pain commonly experience insomnia.

restless legs syndrome

Patients with restless legs syndrome (who experience unpleasant restless feelings in their legs that can be relieved by movement) commonly experience insomnia.

obstructive sleep apnoea

Associated with increased risk of insomnia. Physical signs may include enlarged tonsils or tongue, micrognathia or retrognathia, and lateral narrowing of the oropharynx.

Risk factors

strong

female sex

Women report significantly more insomnia than men in every age cohort.[15][16][17]​​ This association results partly from women being likely to experience more depression and anxiety.[17][73]​​ In the absence of mood disorders, the hormonal and biological changes that occur during menses, pregnancy, perimenopause, and menopause may also trigger episodes of insomnia.[74][75]

advanced age

Reports of difficulty falling and staying asleep increase with age. There is controversy as to whether insomnia in older adults is due primarily to the health complications common in advanced age or to physiological changes in sleep inherent in the ageing process itself.​[12][13]​​​[14]

chronic medical conditions

Multiple studies have found that patients with chronic medical illnesses such as cancer, heart failure, benign prostatic hyperplasia, COPD, and obstructive sleep apnoea have a higher prevalence of insomnia than the general population.[32][33][34]​​[76][77][78][79]​​

chronic pain

Multiple studies have found that patients with chronic pain have a higher prevalence of insomnia than the general population.[32][33][34]​​[36][37]​​​​​

psychiatric illness

Anxiety and depression are highly associated with insomnia.[16][24]​​ In particular, bipolar disorder and post-traumatic stress disorder can produce extended periods of sleeplessness. Attention deficit disorder, apart from associated stimulant or serotonin-noradrenaline reuptake inhibitor (SNRI) treatment, is also associated with insomnia.[80]

alcohol or substance misuse

People who misuse alcohol or substances report insomnia symptoms more frequently than the general population.​[23][24]​​ Alcohol can acutely reduce sleep latency; however, it is rapidly metabolised, which can lead to excitotoxic rebound symptoms later in the night (disrupted sleep, increased rapid eye movement sleep, nightmares, and arousal).[81]

stimulant use

The use of stimulants can interfere with normal sleep. Caffeine prolongs sleep latency, reduces total sleep time and sleep efficiency, and worsens perceived sleep quality, and, with a half-life ranging from 1.5 to 9 hours, the effects can last as long as 8-14 hours after ingestion.[82][83]​ Nicotine has a similar effect to caffeine.[84] Prescribed stimulants for ADHD can interfere with falling and staying asleep.

poor sleep hygiene

People with poor sleep hygiene may be prone to insomnia.

These people report irregular bedtimes, irregular rise times, and napping, and maintain poor sleep environments or may have other poor sleep habits.

traumatic brain injury

Insomnia has been reported in 30% to 60% of people after traumatic brain injuries of all severities; it may be more common after mild injuries. Repetitive traumatic head injuries may increase the risk of developing insomnia. Care is needed to diagnose insomnia correctly, as traumatic brain injury is also associated with other sleep-wake disturbances.[85]

neuropsychiatric illness

Neurodegenerative illness, such as Parkinson's disease and Alzheimer's dementia, is associated with insomnia.[86]

weak

use of certain medications

Prescription or over-the-counter medications that may chronically or initially hyperstimulate the patient may lead to insomnia. These medications include theophylline, salbutamol, pseudoephedrine, phenylephrine, phenylpropanolamine, and selective serotonin reuptake inhibitors.[31]

recent travel across time zones

Jet lag results in desynchrony between the sleeper's biological clock, which plays a key role in the control of sleep and wakefulness, and the desired sleep periods in the destination time zone. This may result in insomnia, with a report of difficulty falling asleep or staying asleep at desired times.[87] Insomnia reported in this context may meet criteria for jet lag. Eastward travel can be associated with sleep-onset insomnia. On the other hand, westward flights more commonly produce earlier-than-desired awakenings.

night work

Night-time and rotating shift work creates a discontinuity between sleep-wake schedules and endogenous circadian rhythms.[88][89]​ As a result, night workers and rotating shift workers report more disturbed sleep and excessive sleepiness than regular daytime workers.[88][90][91] Insomnia during daytime sleep following night shift work may be indicative of a circadian rhythm disorder known as shift work sleep disorder.

hyperthyroidism

Patients with hyperthyroidism may report insomnia.

participation in elite sport

Elite athletes show a high overall prevalence of reported insomnia symptoms, including prolonged sleep latency, increased sleep fragmentation, non-restorative sleep, and excessive daytime sleepiness.[92]

sedentary behaviour

Prolonged sedentary behaviour tends to be associated with an increased risk of insomnia and sleep disturbance.[93]

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