Sleep problems

Patients presenting with insomnia should be taken seriously, writes Dr Lizzie Croton.

Up to 15 per cent of adults report persistent and/or severe symptoms of insomnia (Photograph: SPL)
Up to 15 per cent of adults report persistent and/or severe symptoms of insomnia (Photograph: SPL)

Poor sleep is a common modern day health complaint. It is a challenging topic for a time-pressed GP as the opening gambit of 'I can't sleep doctor' opens up a potentially endless minefield of causes.

It is essential to do the basics well and explore the patient's agenda and expectations for the consultation. It is also important that the GP practises good housekeeping and realises that getting to the root of complex sleeping problems requires time.

1. An introduction to sleep
Insomnia is a subjective complaint of poor sleep, either in terms of duration or quality. It is so common that up to 15 per cent of adults report persistent and/or severe symptoms.

Unsurprisingly these rates are higher in women, the elderly and those with concurrent psychiatric illness.

Ongoing symptoms of insomnia can have a huge impact on a patient's life, resulting in coexistent mood disorders, occupational difficulties and poorer interpersonal relationships.1

2. Aetiological factors
The precise cause of a sleep problem is often impossible to pin down with certainty as 'satisfactory sleep' means different things to different people.

Individuals vary as to the amount of sleep required per night. Estimates range from three to four hours in some to eight hours in others. These amounts may drop with age.

A Patient UK article provides a useful breakdown of terminology used in insomnia. Primary insomnia is thought to represent between 12 to 30 per cent of chronic insomnia. This is a diagnosis of exclusion once secondary causes have been ruled out.

Temporary insomnia is familiar to us, as we have probably all suffered from it at some point in our lives. It is associated with stress, short-term illness, anxiety/depression and excessive caffeine intake. There are many causes of secondary insomnia (see box below).

COMMON CAUSES OF SECONDARY INSOMNIA
  • Pain, for example, arthritis.
  • Respiratory, for example, cough, obstructive sleep apnoea.
  • Nocturia, for example, benign prostatic hyperplasia, diuretics.
  • Pruritus, for example, eczema.
  • Pharmacological.
  • Drug withdrawal (consider alcohol misuse and hypnotics).
  • Some antidepressants, for example, SSRIs.
  • Sympathomimetics, for example, OTC decongestants.
  • Physiological.
  • Poor sleep hygiene - daytime 'catnapping'.
  • Unfavourable sleeping environment, for example, noise or disturbed routine with shift work.
  • Excessive worry about not sleeping.
  • Depression.

3. Presentation
Patients with sleep problems tend to present in three main ways: the sleep crisis, the 'by the way, doctor' and the silent sufferer.

With the sleep crisis, the patient's sleep patterns become worse over a period of time and they present 'in crisis', often having not slept for some nights. Their presentation may be triggered by a need for sleep due to a forthcoming important event, such as an exam.

In the second type of presentation, a patient may drop in the fact that they have been sleeping poorly for some time as an aside in a consultation. They may be unhappy about their sleep pattern but are usually not in crisis.

Silent sufferers may not volunteer a sleep problem per se. They may present with other symptoms, for example fatigue or depression, suggesting a concurrent sleep issue, and it is then up to the doctor to ask specifically about sleep.

4. Practical management
The golden rule is to take the patient seriously. The key to taking a good sleep history is to listen more than talk and allow the patient to describe their problem as they see it.

This takes time and a good way of sharing management with the patient is to ask them to complete a sleep diary that can be used as a basis for discussion in future consultations.

A focused history, examination and review of the medical notes are useful for medical conditions contributing to secondary insomnia. Suspected alcohol and/or drug misuse can be difficult to pick up due to patient factors, such as denial and dishonesty, and doctor factors, such as forgetting to ask, or unfamiliarity with the topic.

As always, a good doctor-patient rapport establishes trust and a patient may then share such issues. Mood disorders are common in patients who misuse alcohol and drugs and it is important to screen for these.

Generally, treatment of the secondary cause improves sleep but patients need to be warned that this may take time and patience on their part.

The management of primary insomnia aims to help the patient to help themselves and there are useful internet resources available, in particular the Sleep Council website.

The Sleep Council's 'four Rs' - regularity, routine, restful bedroom and right bed - is a useful mnemonic and is well worth trying.

For patients with smart phones, downloadable applications based on self-hypnosis may promote relaxation around bedtime.

5. Pharmacological treatment
Committee on Safety of Medicines guidelines2 have long suggested that hypnotic drugs should be limited to short courses as tolerance rapidly develops, and avoided in the elderly because of the increased risk of falls and polypharmacy.

Currently marketed hypnotic drugs have been shown to promote sleep in the short term but there is little good evidence for long-term use and a real risk of dependence.

Sharing these guidelines with patients before prescribing such drugs helps an understanding of the correct use of hypnotics. NICE currently recommends the most cost-effective drug - usually temazepam.

6. Non-pharmacological treatments
There are numerous patient-led methods for promoting better sleep that have been shown to be comparable in the short term with hypnotics (although slower in action), with benefits maintained at six months.

They require routine and lifestyle changes and therefore motivation on the part of the patient. Common terminology for these techniques includes sleep hygiene, stimulus control therapy and sleep restriction techniques.

  • Dr Croton is a GP in Birmingham.

References

1. Silber MH. Clinical practice. Chronic insomnia. N Engl J Med 2005; 353(8): 803-10.

2. DoH. Patient safety: benzodiazepines warning. CMO Update 2004; 37: 4.

Resources

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
  • Make a mind map poster detailing the causes, consequences and treatments of insomnia for your consulting room.
  • Post a blog or notice on your practice website, bulletin board or newsletter emphasising the importance of sleep hygiene and the four ‘R’s.
  • Video some of your consultations and review how much you listen and allow your patient to narrate their story.

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