Red flag symptoms: Insomnia

Disordered sleep can lead to physical and emotional problems.

Respiratory conditions such as sleep apnoea, can cause insomnia
Respiratory conditions such as sleep apnoea, can cause insomnia

Sleep problems are widespread and probably under-reported. Apart from individual differences, it is quite clear that quality of sleep tends to worsen with age.

Disordered sleep can lead to a range of physical and emotional problems. The potential negative impact of insomnia on reaction time, memory, work-efficiency, emotional stability, motor skills and risk of accidents and conflicts can be profound.

Red flag symptoms
  • Repeated sleep attacks
  • Breathing disturbance during sleep
  • Excessive daytime sleepiness in potentially dangerous situations
  • Unstable cardiac or pulmonary situation
  • Significant sleep walking
  • Violent behaviours or injury to self or others during sleep
  • Behaviour changes

It is important to distinguish between the two main types of insomnia. Initial insomnia is a problem falling asleep and is usually the result of emotional or situational stress.

Sleep maintenance insomnia is the inability to fall back asleep after waking in the night and is more typically caused by physical problems.

Causes
Psycho-physiological insomnia is learned insomnia, which can develop through shift work, poor sleep hygiene and in times of stress. Insomnia is common in people with mental health problems; it is estimated that 40 per cent of patients with chronic insomnia have a mental disorder, typically a mood disorder.

This can express itself with excessive sleep walking and problematic behaviours, including violence during sleep.

Hormone levels can cause insomnia, for example, increased sex hormones during pregnancy, or endocrine conditions, such as hyperthyroidism, hypoor hyperglycaemia, phaeochromocytoma or Addison's disease.

Other causes for insomnia include bladder disturbances, prostate disease, pain, cardiovascular problems, respiratory conditions or gastro-oesophageal reflux.

Obstructive sleep apnoea tends to affect overweight, male smokers with a history of heart disease, hypertension or nasal trauma. Other causes include tinnitus and scleritis but these are rarer.

Neurological causes include minor epilepsy, narcolepsy and restless legs syndrome or other limb movement disorders.

Insomnia related to substances may indicate dependency on sedatives or stimulants including caffeine, alcohol, nicotine or illegal substances such as amphetamines.

Prescribed medications can cause insomnia as a direct side-effect or as indirect side-effects (diuretics).

Management
As well as taking a history of the sleep disruption, ensure BP and pulse are measured and review mediation.

Consider the Epworth sleepiness scale and polysomnography if the problem persists.

Fitness to drive or implications to perform certain types of work should be documented in severe cases of sleep disruption.

  • Dr Jacobi is a salaried GP in York.
Possible causes
  • Significant stress and mental illness.
  • Obstructive sleep apnoea.
  • Restless legs syndrome.
  • Effects of substances.
  • Chronic illness.

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