The basics - Insomnia

Patients need careful assessment before prescribing, says Dr Keith Barnard.

There was a time when patients presenting with insomnia were given a cursory assessment and prescribed a long-acting benzodiazepine or, even further back, a barbiturate.

Times have changed, and although appropriate benzodiazepines are still occasionally prescribed, they should be considered only as second-line management.

There is the temptation in a busy surgery to reach for a prescription pad, especially if the patient starts with a request for a few sleeping tablets. However, it is better to accept the fact that a patient presenting with insomnia requires a detailed assessment that cannot be done in a couple of minutes.

Is it insomnia?
It is important to establish at the outset whether a patient complaining of not sleeping is describing a real inability to achieve sufficient restorative sleep and, if so, whether this is transient or long standing.

Transient episodes of insomnia may require only reassurance and advice. More persistent insomnia lasting three weeks or more will involve a detailed enquiry, such as how many hours sleep the patient feels they require.

Many people believe that eight hours sleep is necessary every night, but reduced physical activity, physiological changes and increasing age all result in decreased sleep requirements.

Sometimes it is only necessary to reassure the patient that their sleep pattern is normal in the circumstances.

Encourage the patient to talk about any underlying psychological or physical problems to discover if there are any psycho-social, environmental or physical factors causing their insomnia. These problems account for more than 50 per cent of cases.

Relationship problems, financial or work-related pressures, or recent life events may also be relevant.

Ask about the pattern of sleeplessness, as early morning waking may indicate anxiety or depression.

The sleep environment is important, such as a cold, noisy or unduly light bedroom. Shift work contributes to irregular sleeping patterns, and the patient's habits in the evening, such as using alcohol, caffeine-containing drinks, smoking and large meals late in the evening may disturb sleep.

Rigorous exercise in the evening can also be detrimental to sleep, as may work-related activity or the use of a computer. Daytime naps or lying in late can also affecting sleep-wake circadian rhythms.

Physical causes of insomnia are important, such as a persistent cough, dyspnoea, dyspepsia or pain.

Sweating or hot flushes might be a factor in menopausal women. Nocturia may be due to prostatic disease or diabetes.

Pruritus may be due to systemic disease, including uraemia, liver disease or malignancy.

Sleep apnoea may be suggested by daytime somnolence and headaches.

Medication, including diur-etics, steroids, beta-blockers and recreational drugs can all cause disordered sleep.

An appropriate physical examination may be necessary to eliminate any suspicions of conditions such as respiratory and cardiac disease or a thyroid disorder.

In many cases no specific investigations are required but, if indicated, urinalysis, an FBC, ESR, kidney function tests, LFTs, TFTs, hormone profile and a chest X-ray may requested.

Management of psychosocial problems

If anxiety or depression is suspected, the patient should be asked about mood, appetite, enjoyment of life and whether there is a history of depression. In confirmed cases of depression, psychotherapy or cognitive behavioural therapy can be helpful.

More severe depressive symptoms may require referral.

For relationship problems, counselling can be of value. Follow up is important, both to determine how the situation is evolving, and so the patient understands their problem is being taken seriously.

Managing the environment
Basic measures, often termed 'sleep hygiene', may help. These include the use of ear plugs to reduce disturbing noises, the exclusion of light with heavy curtains or blackout blinds, and avoiding work-related tasks or computer use in the evenings.

Dietary measures include the avoidance of caffeine, alcohol, smoking and large meals near bedtime.

Positive steps include moderate day-time exercise and developing up a routine, such as setting a regular time for getting up and going to bed, a relaxing bath and light reading.

A sleep diary, kept for about two weeks, can be useful and the patient could be given a print-out to remind them what should be recorded. This includes evening activities, meal times and when they go to bed and wake up.

This clarifies sleep-wake patterns and also highlights temporary lifestyle situations that may resolve without medication.

Physical symptoms
Adequate analgesia is essential if pain disturbs sleep, and any underlying medical conditions need to be managed.

If sleep apnoea is suspected, specialist advice should be sought. It is important to remember that physical illness may be associated with anxiety or depression requiring treatment.

Second-line management
The prescription of hypnotic drugs may be considered if non-pharmacological management has failed and the insomnia is severe enough to affect normal daily activities.

In particularly troublesome circumstances, a short-acting hypnotic might be offered at the first consultation; an alternative is to discuss the use of hypnotics, but delay prescription until a subsequent visit.

The risks of tolerance and dependency should be discussed. These problems may occur after only one or two weeks use and, because of this, hypnotics should be prescribed only for severe insomnia and for as short a time as possible.

Choice of hypnotics
The Committee on the Safety of Medicines has advised that benzodiazepines such as temazepam or lormetazepam should be chosen as first-line therapy for a maximum of two to four weeks. Alternatives are the so-called 'z drugs' zaleplon, zolpidem and zopiclone, mainly because of their short half-life and lack of hangover effects, although in 2004 NICE rep- orted that there was a lack of evidence to support the use of z drugs ahead of benzodiazepines.

Any patient prescribed benzodiazepines or z drugs should be warned that daytime tasks such as driving may be affected, and drowsiness may occur the next day. Warnings should also be given about the use of alcohol, and in the elderly the risk of falls and subsequent fractures is a significant issue.

Tolerance and dependency may be reduced by taking medication on alternate, or on one in three nights. Any patient prescribed hypnotics should be followed up to consider efficacy and to ensure there are no treatment-related problems.

Patients with insomnia who exhibit some signs of depression are sometimes prescribed a low-dosage sedating tricyclic such as amitriptyline, doxepin or lofepramine. The patient should understand that these are not sleeping tablets for occasional use, and that response may take 10 days or more.

This strategy is the subject of debate, because evidence is lacking on its effectiveness, and to treat depression properly, the dosage needs to be titrated upward. There are also safety issues, because although both benzodiazepines and z drugs are relatively safe in overdose, this is not the case with tricyclics.

In patients who require analgesia at night, low-dosage tricyclics can certainly help, particularly if the pain is neuropathic.

Insomnia is a common complaint that is often short lived and easily dealt with, but sometimes can deeply affect a person's life. Such situations justify careful discussion, investigation and management.

  • Dr Barnard is a former GP in Fareham, Hampshire

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