Ep 53 – Management of insomnia
Posted 12 Aug 2022
In this episode, Dr Roger Henderson discusses the common problem of insomnia. He looks at what it is, how it is assessed, what causes it and ways of treating it. He also discusses simple tips patients can do at home that can cure one in three cases of insomnia without the need for any medication and mentions some famous people who suffered from insomnia along the way!
Key references discussed in the episode:
- NICE CKS. Scenario: Managing short-term insomnia (less than 3 months duration). May 2022.
- NICE CKS. Scenario: Managing long-term insomnia (more than 3 months duration). May 2022.
- BMJ Best Practice. Insomnia. 15 June 2021.
- PrescQIPP. Appropriate and cost-effective prescribing of short acting hypnotics. February 2017.
Key take-home points:
- There is no standard definition of a normal sleep requirement. This varies with ageing, and from person to person.
- With increasing age, total sleep time decreases.
- The normal time taken to fall asleep is considered to usually be less than 30 minutes.
- Insomnia is a "24-hour disorder" as it impairs daytime well-being and subjective abilities and functioning.
- It is probably best described as a condition of "unsatisfactory sleep, either in terms of sleep onset, sleep maintenance or early waking".
- It is believed to affect around one-third of the general population in the UK and is between 1.5 and 2 times more prevalent among women.
- People with insomnia are often fatigued or anxious and become more tense and worried as bedtime approaches.
- When assessing insomnia, take a careful history to establish a possible underlying cause. What does the patient mean by "not sleeping"? Examine for possible cause including blood tests – thyroid function tests, iron and HbA1c – and always advise to keep a sleep diary for at least 2 weeks. If obstructive sleep apnoea is possible, consider an overnight sleep study (polysomnography). Do not rush to prescribe; give sleep hygiene advice first.
- About one third of patients with primary insomnia will improve with sleep hygiene advice alone.
- Treatment is only appropriate when insomnia causes significant personal distress or marked impairment.
- Hypnotics should be limited to the lowest effective dose for the shortest time possible, with a maximum 4-week treatment period and avoided where possible among elderly people.
- Prolonged-release melatonin can improve sleep onset and quality in patients aged over 55 with persistent insomnia.