Approach
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational 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: 2018A medical and sleep history are often sufficient to diagnose the condition.
Sleep diaries that conform to the structure of a consensus sleep diary are an essential tool for providing data that allow for the targeting of treatment.[94] Actigraphy performed for several days may aid diagnosis, particularly when the sleep history is inconsistent or unreliable. Polysomnography is not routinely indicated, but consider it in patients with suspected obstructive sleep apnea or periodic limb movement disorder, or when insomnia is poorly responsive to conventional treatments, such as cognitive behavioral therapy for insomnia (CBT-I) or hypnotic agents.[95]
Due to its high prevalence, primary care physicians should consider incorporating screening for insomnia during regular checkups (e.g., annual physical exams, if performed). The Insomnia Severity Index (a 7-item questionnaire with a point system identifying the presence of clinical insomnia) has good reliability, validity, and responsiveness.[96][97]
History and risk factors
Interview patients to assess common conditions in the history, and typical signs and symptoms. The patient's bedmate also may add valuable information regarding sleep habits and patterns. First, quantify the patient's sleep: ask about the time they go to bed, time of onset of sleep, total duration of sleep, final wake time, time out of bed, perceived quality of sleep, and whether the patient has multiple awakenings in the night. 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) and/or spending 30 minutes or more awake during the night (if sleep maintenance difficulties are present).[89] Patients with early-morning awakening typically wake up at least 30 minutes before their intended wake-up time. Ask about the duration of sleep disturbance. Acute insomnia conventionally means a duration less than 3 months, often occurring in response to an identifiable stressor (e.g., medical illness, employment difficulties, or interpersonal conflict). Insomnia disorder as defined by the current international diagnostic criteria is essentially chronic insomnia as it stipulates a duration of 3 months.[1][2]
Patients often report waking symptoms of fatigue; reduced concentration, motivation, attention, or memory; and irritability or low mood.[2] They may report a desire to nap but are often unable to do so.[2]
Explore the effect of the sleep disturbance on the patient's work or academic performance, and their social functioning.[2]
Enquire about any other medical symptoms or conditions that might be contributing to impaired sleep (e.g., chronic pain, hot flashes, thyroid dysfunction, restless legs, or snoring/gasping).
Ask about concurrent psychiatric illness such as bipolar disorder, schizophrenia, depression, anxiety, or attention deficit disorder. The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) are reliable tools for user-friendly screening for depression and anxiety, respectively.[98][99]
Review the patient's usual medications to identify any drugs that may cause or worsen insomnia (e.g., stimulants, corticosteroids, diuretics, antidepressants, sedatives). Enquire about any history of hypnotic use (prescription and nonprescription) and any associated adverse events, particularly complex sleep-related behaviors, sudden-onset sleepiness, and falls or accidents.
Ask about irregular work hours or shift work, which may contribute to sleeplessness. Recent flight travel, especially crossing numerous time zones and requiring significant adjustment to sleep schedule, is commonly related to very short-term insomnia (<1 week). Ask about pets in the bedroom, because there may be synergistic effects, so that issues that were benign may become problematic in the context of other risk factors.
A key part of the history is to explore the amount of distress and anxiety associated with sleeplessness at night, and specific concerns about the consequences of insomnia. Ask about daytime consequences of impaired sleep, such as poor work functioning, accidents, or clumsiness arising from insufficient sleep, taking daytime naps, and use of stimulants (e.g., caffeine, nicotine), drugs, alcohol, and medication.
Questionnaires may be helpful to quantify the degree of sleep problems, aiding diagnosis. The Pittsburgh Sleep Quality Index measures 7 areas of sleep, allowing patients to rate their own sleep. The Insomnia Severity Index is a 7-item questionnaire with a point system identifying the presence of clinical insomnia. The Stanford Sleepiness Scale rates sleepiness on a scale of 1 (very awake) to 7 (very sleepy).[96] The Epworth Sleepiness Scale rates sleepiness in 8 categories on a 0 (no chance of dozing) to 3 (high chance of dozing) scale.[100] Finally, the Athens Insomnia Scale is an 8-item questionnaire based on the WHO International Classification of Diseases (ICD-11) diagnostic criteria for insomnia.[101]
Physical exam
The physical exam is an important element of the consultation, as it may help identify comorbid medical conditions or other sleep disorders that may be associated with awakenings from sleep, such as sleep apnea or hyperthyroidism. Examine the oral cavity to identify the presence of enlarged tonsils, micrognathia or retrognathia, a lateral narrowing of the oropharynx, or increased tongue size, which may contribute to obstructive sleep apnea. Palpate the neck for potential enlarged thyroid or nodules, and listen to the heart for irregularities, and the lungs for any breathing abnormalities. Check for the presence of lower-extremity edema. A basic neurologic exam should determine any sensory, motor, balance, or ambulation abnormalities. In older patients, a brief cognitive screen, such as the Montreal Cognitive Assessment (MoCA) or the Mini Mental State Examination (MMSE), should detect any overt cognitive dysfunction.[102]
Sleep diary
Sleep diaries that conform to the basic parameters contained within the consensus sleep diary help clarify the patient's diagnosis, elaborate symptom reports, and provide a tool that facilitates communication between the doctor and patient.[94] Ask the patient to fill out a questionnaire each morning for 1-2 weeks, identifying the quality and quantity of the previous night's sleep, with details of their bedtime and rise time, total time slept, and number of nocturnal awakenings. As well, the diary should note amounts and doses of medications and substances used each day, such as hypnotics, caffeine, and alcohol.
Sleep diaries may also be helpful in determining the effectiveness of therapy for insomnia.
Polysomnography (PSG)
The PSG monitors multiple physiologic variables during sleep, including brain activity (via electroencephalogram), eye movements, muscle activity (via electromyogram), heart rhythm (via ECG), and breathing function. PSG recordings are typically performed during an overnight visit to a sleep laboratory.
PSG is the most efficacious test for evaluating sleep disorders, but should typically be restricted to investigation of insomnia when comorbid conditions such as sleep apnea or periodic limb movement disorder are suspected, or when patients have failed to respond to conventional treatment, such as CBT-I or hypnotic agents.[2] Do not routinely perform PSG in patients with chronic insomnia unless there is concern for a comorbid sleep disorder.[2][103][104]
PSG abnormalities in patients with insomnia include longer latency to persistent sleep, higher amounts of wakefulness after sleep onset, less total sleep time and sleep efficiency, and higher number of awakenings compared with people without insomnia. However, 1 or 2 nights of in-lab PSG results may be normal in certain patients with psychophysiologic insomnia (also called "reverse first night effect") or environmentally induced sleep disorder.[89]
Actigraphy
Actigraphy performed for several days (together with sleep diaries) may aid diagnosis, particularly when the sleep history is inconsistent or unreliable. Actigraphy allows for a more accurate assessment of a patient's sleep within their naturalistic environment over time and within different settings and situations. It should be noted that actigraphy tends to overestimate sleep compared with PSG.[105] Importantly, because evidence-based treatments are oriented toward the patient's subjective reports, actigraphy should not supplant the sleep diary.
Laboratory studies
A complete blood count, along with iron binding studies, can be helpful if restless legs syndrome is suspected. Measure thyroid-stimulating hormone levels if thyroid dysfunction is suspected. A urine or serum substance use panel should be considered in patients with suspected substance use disorder.[89]
Use of this content is subject to our disclaimer