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Insomnia


Insomnia is often a symptom of another disorder. The key to treating insomnia is to search for the underlying cause. As with any consultation, each patient deserves a complete evaluation and appropriate treatment. It is tempting to quickly prescribe sedating medications for patients complaining of sleeplessness, especially if you are fatigued. Beware of medicating patients for insomnia, however, without first assessing them. This will avoid inappropriate treatment for those with hidden medical, psychiatric, or more serious sleep disorders.

Insomnia is the complaint of insufficient sleep associated with adverse daytime consequences such as anergy, malaise, cognitive slowness, and irritability. Insomnia is best understood as a symptom with numerous potential underlying causes. Mild transient sleep disturbance secondary to anxiety or physical discomfort is very common in hospitalized patients. If the patient has no compromise in daytime functioning, it is acceptable to monitor the insomnia and defer treatment with hypnotics.

Phone call

Questions

  • 1.

    Who is requesting help—the patient or the staff?

  • 2.

    What is the patient’s admission diagnosis, and when was he or she admitted to the hospital?

  • 3.

    Is the patient also anxious, agitated, or acting strangely?

Remember that a patient who is sleepless and agitated or acting bizarrely requires prompt evaluation to rule out an acute psychiatric illness or delirium.

  • 4.

    Has the patient had complaints of insomnia previous to this hospitalization or this consultation? If so, what forms of treatment were suggested? Were these beneficial to the patient?

  • 5.

    Has there been any recent change in the patient’s clinical status or medications?

Orders

When the patient is well known to the staff, has no symptoms of acute medical or psychiatric distress, or has an established history of difficulty initiating or maintaining sleep and responded well to medication in the past, it is acceptable to consider renewing sleep medications over the phone. However, if this is a patient with a new complaint, an in-person assessment is important.

Inform RN

“Will arrive in … minutes.”

Remember

A patient who is sleepless and agitated or acting bizarrely requires prompt evaluation.

Elevator thoughts

What causes insomnia?

The etiology will often be readily identified by assessing the onset, duration, and nature of the patient’s sleep complaint.

  • 1.

    Environmental and behavioral factors

    • a.

      Unpleasant or noisy sleep environment

    • b.

      Situational anxiety

    • c.

      Preoccupation with falling asleep

    • d.

      Disrupted circadian rhythm (e.g., shift work or jet lag)

  • 2.

    Psychiatric and neurologic disorders

    • a.

      Affective disorders (e.g., depression or mania)

    • b.

      Anxiety disorders (e.g., generalized anxiety disorder, obsessive-compulsive disorder, panic attacks, posttraumatic stress disorder, adjustment disorder with anxiety)

    • c.

      Psychosis (e.g., intrusive hallucinations or paranoia)

    • d.

      Akathisia

    • e.

      Dementia

    • f.

      Neurodegenerative disorders (e.g., Parkinson disease, Alzheimer disease)

  • 3.

    Substance abuse and withdrawal symptoms

    • a.

      Stimulant intoxication (including caffeine)

    • b.

      Alcohol or sedative withdrawal

    • c.

      Nicotine withdrawal

  • 4.

    Medications ( Box 21.1 )

    Box 21.1
    Possible Iatrogenic Causes of Insomnia

    • Antiasthmatics: β2-agonists, theophylline

    • Anticonvulsants: Phenytoin, carbamazepine, valproic acid

    • Antidepressants: Phenelzine, tranylcypromine, protriptyline, desipramine, imipramine, amoxapine, selective serotonin reuptake inhibitors, tricyclic withdrawal, venlafaxine, bupropion

    • Antihypertensives: Beta blockers, methyldopa, diuretics, reserpine, clonidine

    • Antipsychotics: Phenothiazines, butyrophenones

    • Cimetidine

    • Decongestants: Pseudoephedrine, phenylephrine

    • Levodopa, baclofen, methysergide

    • Sedative-hypnotics (rebound insomnia), barbiturates, benzodiazepines, narcotics

    • Stimulants: amphetamines, methylphenidate, pemoline

    • Tetracycline

    • Thyroxine, steroids, birth control pills

  • 5.

    Related medical problems ( Box 21.2 )

    Box 21.2
    Common Medical Causes of Insomnia

    Neurologic Disorders

    • 1.

      Stroke

      • a.

        Increased incidence of obstructive sleep apnea, central sleep apnea, or periodic limb movement disorder

      • b.

        Increased incidence of depression after stroke

    • 2.

      Alzheimer disease—In later stages is associated with circadian rhythm disorder

    • 3.

      Parkinson disease—Associated with parasomnias (e.g., rapid eye movement [REM] behavior disorder) and insomnia

    • 4.

      Chronic pain—Produces difficulty in initiating and maintaining sleep

    Cardiovascular Disease

    • 1.

      Nocturnal angina pectoris

    • 2.

      Congestive heart failure (CHF)

      • a.

        Supine posture redistributes blood to the central circulatory system, worsening paroxysmal nocturnal dyspnea.

      • b.

        CHF is accompanied by Cheyne-Stokes respiration, leading to repeated awakenings.

    • 3.

      Hypertension—Insomnia may be caused by uncontrolled hypertension or may be secondary to use of antihypertensive medications.

    Pulmonary Disease a

    a Drug therapies for COPD and asthma, including methylxanthines, oral beta-agonists, and oral glucocorticoids, can also cause insomnia.

    • 1.

      Chronic obstructive pulmonary disease (COPD)—Note: Nasal canula O 2 reduces sleep-onset latency, increases the duration of uninterrupted sleep, and improves nocturnal oxygen saturation in this population.

    • 2.

      Obstructive sleep apnea (OSA)—Insomnia may be related to awakenings due to obstructed airway, or poor tolerance of or discomfort with continuous positive airway pressure (CPAP) treatment.

    • 3.

      Asthma

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