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BASICS

  • Insomnia: difficulty initiating or maintaining sleep or nonrestorative sleep despite adequate opportunity.
  • Daytime impairments include fatigue, concentration issues, mood disturbance, daytime sleepiness, and reduced social/vocational function.
  • Prevalence: 5-35% general population; chronic insomnia ~10% in middle-aged adults; 1/3 in >65 years.
  • Female predominance (5:1 ratio).
  • Increases with age.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Transient/Intermittent (<30 days), Short-term (<3 months):
  • Usually linked to identifiable stressors (physical, psychological, psychosocial, interpersonal).

  • Often resolves with removal of stressor.

  • Chronic (>3 months):

  • Multifactorial, no single cause.
  • Medical (GERD, sleep apnea, chronic pain), psychiatric (mood/anxiety/psychotic disorders), primary sleep disorders.
  • Circadian rhythm disorders (jet lag, shift work).
  • Environmental (noise, light, movements).
  • Behavioral (poor sleep hygiene).

  • Substance-induced (medications, drugs).

  • Medications implicated: antihypertensives, antidepressants, corticosteroids, levodopa, phenytoin, quinidine, theophylline, thyroid hormones.

RISK FACTORS

  • Age
  • Female sex
  • Medical comorbidities
  • Unemployment
  • Psychiatric illness
  • Impaired social relationships
  • Shift work
  • Separation from partner
  • Substance abuse
  • Family or personal history of insomnia

GENERAL PREVENTION

  • Maintain consistent sleep hygiene:
  • Fixed bedtimes and wake-up times daily.
  • Avoid naps.
  • Sleep in cool, dark, quiet environment.
  • Use bedroom only for sleep/sex.
  • 30-minute wind-down before sleep.
  • If unable to sleep in 20 minutes, move to another room for quiet activity.
  • Limit caffeine intake to mornings.
  • Avoid alcohol after 4 PM.
  • Regular moderate exercise.
  • Avoid medications interfering with sleep.

COMMONLY ASSOCIATED CONDITIONS

  • Psychiatric disorders
  • Painful musculoskeletal conditions
  • Obstructive sleep apnea
  • Restless legs syndrome
  • Substance addiction/dependence

DIAGNOSIS

History

  • Sleep latency, maintenance, early awakening, nonrestorative sleep.
  • Sleep environment, hygiene, bedtime habits.
  • Caffeine, alcohol, medication, supplement use.
  • Psychiatric symptoms.
  • Restless legs, periodic limb movements.
  • Snoring or apnea symptoms.
  • Sleep diary/log for 7 days.

Physical Exam

  • Usually nonspecific.

Differential Diagnosis

  • Obstructive sleep apnea
  • Narcolepsy
  • Circadian rhythm sleep disorders
  • Sleep-related movement disorders
  • Insomnia secondary to medical/neurologic or psychiatric disorders

DIAGNOSTIC TESTS & INTERPRETATION

  • Polysomnography generally not required unless suspicion of sleep apnea or periodic limb movement disorder.
  • Labs/imaging based on clinical context to assess comorbidities.

TREATMENT

Transient/Short-term Insomnia

  • May use short-term hypnotics cautiously.
  • Avoid self-medication with alcohol.

Chronic Insomnia

  • Treat underlying conditions (depression, anxiety, pain, substance abuse).
  • Emphasize good sleep hygiene.
  • Cognitive-behavioral therapy for insomnia (CBT-I) is first-line treatment.
  • Behavioral therapy effective long-term; superior to pharmacotherapy.

MEDICATION

Hypnotics for Short-term Use

  • Nonbenzodiazepine hypnotics (Z-drugs):
  • Zaleplon, zolpidem, eszopiclone.
  • Benzodiazepines:
  • Triazolam, temazepam, estazolam, flurazepam, quazepam.
  • Avoid long-term use due to tolerance, dependence, daytime sedation.
  • Melatonin receptor agonist:
  • Ramelteon; no abuse potential.
  • Sedating antidepressants:
  • Doxepin (FDA-approved for insomnia), trazodone, mirtazapine, amitriptyline.
  • Orexin receptor antagonists:
  • Suvorexant, lemborexant, daridorexant.
  • Avoid sedating antihistamines.
  • Antipsychotics only if psychiatric indication.

Precautions

  • Avoid benzodiazepines and sedatives in elderly, pregnancy, substance abuse, cognitive impairment.
  • Nonbenzodiazepines may cause parasomnias.
  • Monitor side effects and dependency risk.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Melatonin: effective for delayed sleep phase; no strong evidence for chronic insomnia.
  • Valerian: inconsistent efficacy; slow onset.
  • CBT-I and relaxation techniques highly recommended.
  • Mindfulness may improve sleep quality in older adults.

ONGOING CARE

  • Encourage daily exercise (avoid within 4 hours of bedtime).
  • Regularly reassess medication need; avoid standing prescriptions.
  • Monitor treatment response with sleep diaries.
  • Counsel on habit-forming potential of hypnotics.

DIET

  • Limit caffeine (prefer morning only).
  • Avoid heavy late-night meals; light snack may help.
  • Avoid alcohol within 6 hours of bedtime.

PROGNOSIS

  • Situational insomnia often resolves with time.
  • Chronic insomnia requires sustained management.

COMPLICATIONS

  • Daytime sleepiness, cognitive dysfunction.
  • Pulmonary hypertension if untreated sleep apnea.
  • Associated risks: hypertension, stroke, cardiac ischemia.

REFERENCES

  1. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for polysomnography and related procedures: update for 2005. Sleep. 2005;28(4):499-521.
  2. Qaseem A, Kansagara D, Forciea MA, et al.; ACP Clinical Guidelines Committee. Management of chronic insomnia disorder in adults: clinical practice guideline. Ann Intern Med. 2016;165(2):125-133.
  3. Ebben MR, Spielman AJ. Non-pharmacological treatments for insomnia. J Behav Med. 2009;32(3):244-254.
  4. Verster GC. Melatonin and its agonists, circadian rhythms and psychiatry. Afr J Psychiatry. 2009;12(1):42-46.

CLINICAL PEARLS

  • Treat underlying causes and maintain consistent sleep hygiene.
  • CBT is first-line for chronic insomnia; medications reserved for short-term use.
  • Avoid benzodiazepines in elderly due to fall and cognitive risk.
  • Melatonin may help delayed sleep phase disorders but lacks strong evidence for chronic insomnia.