Red flag symptoms: Insomnia

Dr Suneeta Kochhar describes the symptoms associated with insomnia that will indicate when further investigation is needed and explores the possible causes of insomnia.

Red flag symptoms

  • Sleep attacks - may occur while driving
  • Gasping/choking and apnoea during sleep, reported by patient's partner
  • Unstable cardiac or pulmonary condition
  • Recent cardiovascular accident
  • Injury to self or others during sleep
  • Frequent sleepwalking
  • Excessive daytime sleepiness
  • Substance misuse
  • Depression and anxiety

Initial insomnia is defined as difficulty falling asleep and may involve psychological factors, such as stress.

Difficulty falling asleep after waking in the night is defined as sleep maintenance insomnia. This is usually related to physical problems. Patients may also report early morning waking or unrefreshing sleep.

Insomnia can result in excessive daytime sleepiness. This, in turn, may affect daytime functioning, owing to memory and/or concentration problems, as well as mood disturbance. Insomnia may affect up to one-third of the UK population.

Insomnia is classified as primary or secondary. In the former, there may be 'learned' sleep difficulties in the absence of comorbidities. The trigger for this may be a stressful event.

Psychiatric and medical conditions, as well as substance misuse, may result in secondary insomnia. Insomnia lasting one to four weeks is considered short-term. If it lasts longer than four weeks, it is considered long-term.

Clinical assessment

It is important to consider the patient's age, because average sleep requirement changes with age. Most healthy adults sleep for seven to nine hours a night, but this varies. Total sleep time and number of awakenings increase with age.

It is helpful to establish what the patient means by insomnia; for example, they may have a reduced sleep requirement with no effect on daytime functioning, or their perception of their sleeping habits may be relevant. It is also relevant to assess the impact of the insomnia on the patient's daytime functioning, employment, relationships, mood and driving.

It may be helpful to ask the patient to keep a sleep diary for at least two weeks, to identify any patterns that might be amenable to behavioural treatment. This should record times of going to bed and rising, time taken to fall asleep, night-time awakenings, daytime tiredness, napping, sleep quality and meal times. Patients should also be asked about snoring and breathing patterns.

Secondary causes

Excessive daytime sleepiness, snoring, apnoeas or choking episodes may suggest the presence of obstructive sleep apnoea.

Circadian rhythm disorders result from shift working and delayed sleep phase syndrome. The latter is commonly seen in adolescents, where the total sleep time is normal, but sleeping and rising times are delayed.

Systemic review may be suggestive of parasomnias, such as restless legs syndrome or periodic limb movement disorder. Restless legs syndrome may be accompanied by paraesthesias, and may be relieved on stretching the limbs.

Periodic limb movement disorder may be characterised by repeated twitching or kicking movements of the legs during sleep. Patients may be unaware of their symptoms and often report unrefreshing sleep related to arousals following twitching movements during sleep.

Psychological factors, such as the presence of stress, anxiety and depression, are important to elicit. Alcohol, caffeine and other drug intake may be contributory, for example caffeine-containing medications, nicotine patches, antidepressants and corticosteroids.

Other factors include medical comorbidities, such as COPD, heart failure, gastro-oesophageal reflux disease, neurodegenerative disorders, menopause, benign prostatic hyperplasia, and pain secondary to conditions such as rheumatoid arthritis. Obstructive sleep apnoea may be more likely in those who are obese and have cardiovascular disease.

Physical examination can indicate medical comorbidities which might result in insomnia. It is important to assess for signs associated with obstructive sleep apnoea.

Causes of secondary insomnia
  • Obstructive sleep apnoea
  • Circadian rhythm disorder, for example in shift work
  • Parasomnias - restless legs syndrome, periodic limb movement disorder, sleepwalking, narcolepsy
  • Stressful life event
  • Psychiatric conditions - depression and anxiety
  • Medical - for example heart failure, COPD, neurological disorders, gastro-oesophageal reflux disease, pain, drug and substance misuse

Management

In the case of suspected obstructive sleep apnoea, parasomnias or diagnostic difficulty, referral to a sleep clinic may be useful. It is important to advise patients not to drive if they are experiencing excessive daytime somnolence.

Good sleep hygiene should be advocated. This involves fixed times for going to bed and rising, relaxation techniques, creating a comfortable environment conducive to sleeping and avoiding daytime napping.

Limiting caffeine, nicotine and alcohol may be helpful. Exercising close to bedtime should be avoided.

A short-term hypnotic may be considered in some circumstances. Short-acting benzodiazepines such as temazepam and non-benzodiazepine hypnotics such as zopiclone may be considered. The lowest effective dose should be used for the shortest time interval and hypnotics should not be prescribed for longer than 2 weeks. If symptoms of insomnia persist for over a couple of weeks, cognitive behavioural therapy may be considered.

Excessive sleepiness and driving
  • People with excessive sleepiness due to suspected or mild obstructive sleep apnoea syndrome must not drive motorcycles or cars (Group 1 vehicles), or buses or lorries (Group 2 vehicles). Driving may resume only after satisfactory symptom control, and if symptom control cannot be achieved in 3 months the DVLA must be notified
  • People with excessive sleepiness due to moderate or severe obstructive sleep apnoea syndrome must not drive group 1 or 2 vehicles and must notify the DVLA. Subsequent licensing will require control of the condition, improved sleepiness and treatment adherence
  • People with primary or central hypersomnias, such as narcolepsy, must not drive group 1 or 2 vehicles and must notify the DVLA
  • Dr Kochhar is a GP in St Leonards, East Sussex

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This is an updated version of an article that was first published in May 2015.

Picture: iStock

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