Hedges, Christine PhD, RN, ACNS-BC; Ruggiero, Jeanne S. PhD, RN
According to the National Center for Sleep Disorders Research (NCSDR), approximately 30 to 40% of the adult population is afflicted with insomnia.1 The prevalence of chronic, clinically significant insomnia is currently approaching 10% of the population.2 NCSDR projections indicate that by the mid-21st century, an estimated 100 million Americans will suffer from insomnia.3
Complaints of insomnia, including reports of difficulty initiating and remaining asleep, are often reported to primary healthcare providers. Many adults who suffer from insomnia will continue to participate in daily activities and routines. But insomnia and resultant sleep-related functional disturbances can have dire consequences, affecting physical, cognitive, and emotional states. Despite the fact that individuals spend about 1/3 of their lives sleeping, it is unknown how many primary healthcare providers include the assessment of sleep and evaluation of insomnia during physical exams. Although many patients who suffer from insomnia report these symptoms, others will not unless questioned appropriately during the interview and health history portion of the physical exam.
Insomnia is the most common form of sleep disturbance in the United States. According to the NCSDR, insomnia is defined as difficulty initiating and maintaining sleep and short sleep duration.1 This difficulty, which occurs at least three times a week for a minimum of 1 month, is present despite adequate opportunities to sleep and is associated with daytime impairment or distress.4 Insomnia can present in the following time frames:
1. Transient, lasting less than 1 week
2. Short-term, lasting 1 to 4 weeks
3. Chronic, lasting longer than 1 month.5
Although insomnia can occur at any age, older adults experience symptoms more often than younger adults and women are affected more often than men.6
Associated medical conditions
Insomnia can be a primary sleep-wake disturbance or it can occur comorbidly with other conditions such as a psychiatric disturbance or medical disease.2 The most common comorbidity is psychiatric disorders including depression, anxiety, panic and adjustment disorders, and somatoform and personality disorders.7 Comorbid insomnia is also associated with hyperthyroidism, arthritis, cancer, heart failure, asthma, sleep apnea, diabetes, gastroesophageal reflux disease, overactive thyroid, stroke, Parkinson disease, Alzheimer disease, chronic pain, and restless legs syndrome.
Insomnia may also occur secondary to the use of prescription medications such as antidepressants, antihypertensives, stimulants (such as methylphenidate), and corticosteroids. Many over-the-counter (OTC) medications are associated with insomnia, including some decongestants, acetaminophen/caffeine pain relievers, and weight-loss products. Caffeine, alcohol, and nicotine may lead to insomnia as well. Alcohol initially causes sleepiness but the individual usually wakes up within a few hours, unable to fall back to sleep.
Insomnia can also be attributed to external conditions. There are numerous extrinsic factors that can cause insomnia and most are related to disruptions in the circadian rhythm process. The circadian process is a 23–25-hour “biologic clock” that is closely aligned with other physiologic and behavioral functions in the body. It has been described as an internal pacemaker or oscillator and is synchronized with 24-hour environmental cues such as light and temperature.8 Jet lag and shift work are two commonly cited extrinsic causes for insomnia. In the hospitalized patient, changes in the environment such as loss of control over lighting, temperature, and schedules can have the same effect.
Insomnia and the elderly
The elderly represent a rapidly growing population in the United States and it is estimated that 21% of the population will be at least 65 years old by the year 2030.9 Therefore, the elderly are a large percentage of the patient population seen by nurse practitioners (NPs). Changes in sleep patterns and symptoms of insomnia are prevalent in the elderly population and carry significant consequences. Estimated national costs attributed to delirium (a common consequence associated with insomnia in acute care) range from $38 to $152 billion per year.10 As NPs encounter older and sicker patients in both acute care and community settings, they will be challenged to identify those patients at risk for insomnia. In order to provide appropriate sleep promotion for elderly patients, it is important to understand age-related sleep changes and potential complications associated with sleep disturbances in this population.
The normal sleep of a young adult is divided into stages of nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep is subdivided into four stages, with entry to sleep occurring in the lighter stage 1 NREM and progressing to the deeper NREM stages 3 and 4. Alternate cycles of NREM and REM sleep occur about five to six times throughout the night or sleep period. Normal aging processes affect all body systems including neurologic age-related sleep changes. Poor sleep quality and changes in sleep architecture related to aging have both been described in research studies. Foley et al.11 studied over 9,000 community-dwelling elderly adults (ages 65 and older) in a National Institute on Aging study and found the majority reported at least one complaint such as trouble falling asleep, waking up, waking too early, napping, or not feeling rested. Studies employing objective sleep measures (polysomnography) to explore age-related sleep changes indicated there were alterations in sleep architecture, circadian rhythm, and hormonal levels. Sleep characteristics associated with aging in healthy older adults included increased sleep latency, increased percentage of stage 1 and stage 2 NREM sleep, and increased wake after sleep onset (WASO). Other polysomnographic characteristics included decreased total sleep time, poorer sleep efficiency, decreased percentage of stage 3 and stage 4 (NREM) slow wave sleep, and decreased percentage of REM sleep.12 Decreases in growth hormone and changes in parasympathetic activity may explain some of these variations.13 These normal age-related sleep changes are compounded by additional intrinsic factors found with insomnia, such as the impact of chronic diseases, sleep-disordered breathing, delirium, dementia, the effects of sedatives and hypnotics, and environmental alterations.
Community/health issues: When compared with individuals without sleep problems, patients with insomnia are more likely to report other chronic health problems, visit healthcare providers, use prescription and OTC medications (especially for sleep), and use alcohol as a sleep aid.14 Sleep disorders such as insomnia are costly to individuals and society. There are direct costs such as medical intervention and drugs, indirect costs such as loss of work time and productivity, related costs such as accident-related property damage, and intangible costs such as decreased quality of life and loss of activities of daily living.15
Driving accidents: Individuals with insomnia are more prone to motor vehicle accidents because of the daytime sleepiness and shortened sleep patterns that are associated with them. Drivers who reported sleepiness and less than 5 hours of sleep within 24 hours were more likely to be injured in a motor vehicle accident than alert drivers who had more than 5 hours of sleep in a 24-hour period.16
Poor work productivity and safety: When compared with good sleepers, those with insomnia are more prone to reduced work productivity and non-motor vehicle accidents.14 They have a higher rate of absenteeism, decreased concentration, difficulty performing work duties, and work-related accidents.17
Impacts on the hospitalized patient: Sleep deprivation, especially in the elderly, can lead to excessive use of sedatives and hypnotics that subsequently may contribute to cognitive alterations, confusion, and falls, and thus increasing length of stay. Insomnia also may contribute to impaired wound healing, decreased protein synthesis, and cellular immunity at a time when the body's healing function is needed.18
The assessment of sleep to detect reports of insomnia should become a priority during physical exam and personal health assessments in both hospitalized and community-dwelling patients. During the review of symptoms portion of the interview, the NP should question the patient about sleep patterns, including how long the problem has been occurring, usual bedtime, “lights-out” time, and wake time. Be sure to ask the patient about nighttime awakenings including the reason for awakenings (if known), such as shortness of breath or getting up to use the bathroom, and the ability to return to sleep. Inquire about daytime sleepiness, naps, and use of sleep aids, including OTC medications and herbal/alternative medicine products. Inquire whether the patient sleeps alone or with a partner and whether the partner has any sleep difficulties (such as snoring) that keep the patient awake.
The functional assessment portion of the health history may elicit even more information about sleep and insomnia. These queries include asking the patient about how well rested he or she feels upon awakening, the presence of fatigue, and whether or not he or she has sufficient energy to carry out daily activities. Insomnia complaints may become evident if the patient reports light sleep, difficulty falling asleep, and frequent or early morning awakenings. The functional assessment should include asking the patient about schedules and routines including whether insomnia worsens with a lack of a daily schedule.19 Sleep diaries can be used to uncover symptoms of insomnia and there are numerous questionnaires and screening tools available to assist the NP in taking a comprehensive sleep history, and include: the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, the Sleep Behaviors Scale 60+, and the Sleep Disturbance Questionnaire. A comprehensive physical exam combined with a sleep history may uncover the possibility of more serious concerns such as sleep-disordered breathing or obstructive sleep apnea syndrome. In that case, the NP is advised to refer the patient for a thorough sleep evaluation by a sleep specialist.
Initial management of insomnia includes the identification of the cause. If the insomnia is secondary to a psychiatric or medical illness, treatment of the illness may help reduce insomnia. If a primary sleep disorder is suspected, the patient may need a full sleep study with polysomnographic evaluation. Referral to a sleep specialist is warranted. There are numerous nonpharmacologic interventions known as cognitive behavioral therapies (CBTs) that can be employed for insomnia such as progressive muscle relaxation therapy, guided imagery, light therapy, chronotherapy, or progressive delay of bedtime (used with younger patients and adolescents). The effectiveness of CBT has been supported in clinical trials, but the therapy is not available in all medical centers.20,21 In addition to CBT, the NP can educate the patient about healthy sleep practices and sleep hygiene measures that promote sleep. Sleep hygiene is a set of behaviors and habits used to promote healthy and adequate sleep and is a useful treatment particularly for mild insomnia22,23 (see Sleep hygiene).
A wide range of pharmacologic agents 24 (see Common pharmacologic agents) is available to manage insomnia including over-the-counter (OTC) and prescription medications. Medications used for insomnia can be classified as to their usage for sleep onset induction or sleep maintenance. Common drug categories in use today include benzodiazepine receptor agonists (including non-benzodiazepines and benzodiazepines), melatonin receptor agonists, and off-label uses of antipsychotics, sedating antidepressants, and antihistamines (such as diphenhydramine). Diphenhydramine is used as an OTC sleep aid. However, routine use of diphenhydramine for insomnia treatment, especially in the elderly, is not effective and not recommended. Adverse reactions include decreased alertness, impaired cognitive function, delirium, dry mouth, and urinary retention.24 There is little evidence to suggest that off-label use of antipsychotic drugs improves insomnia, and these drugs have potentially significant adverse reactions.24
Melatonin and the herbal preparation, valerian, are two OTC preparations used to treat insomnia. Melatonin may not be useful in the treatment of insomnia except for individuals with delayed sleep phase or low melatonin levels.24 More research is needed to determine the effectiveness of melatonin. A few moderate or high-quality studies have evaluated valerian for the treatment of insomnia; however findings did not show a benefit beyond the placebo effect. Valerian may cause hepatotoxicity, and as with other natural preparations, there is a risk of contamination with undesirable substances.24
The prescriber should carefully consider the type of drug, major adverse reactions, duration of usage, and age of the patient when ordering pharmacotherapy for insomnia as some drugs may carry unwanted adverse reaction profiles including dizziness, amnesia, or risk for falls, especially in the elderly.25
Current evidence supports an individualized approach to insomnia treatment beginning with exploring and addressing the underlying physical or psychological cause. If insomnia persists, the NP should consider a course of behavioral therapy, either alone or combined with pharmacologic therapy for 6 weeks. If the patient experiences improvement in sleep, the medications can begin to be tapered or reduced to an as needed order. If the patient continues to experience prolonged insomnia, a formal sleep evaluation referral is warranted.24
Table Common pharmac...Image Tools
Insomnia is a common sleep problem and often a complaint of patients who present to primary healthcare providers. Numerous pharmacologic and nonpharmacologic treatments are available, but it is important to keep in mind that insomnia is often a symptom of a psychiatric or medical illness. It is important for the primary healthcare provider to screen patients for insomnia and treat it promptly to avoid risks to health and safety.
Techniques for sleep hygiene
* Avoid stimulants for several hours prior to bedtime (including caffeine and nicotine).
* Avoid alcohol prior to bedtime (leads to awakenings from sleep).
* Exercise regularly (avoid exercise 6 hours or less prior to bedtime).
* Allow at least 1 hour to relax before bedtime and employ bedtime rituals (such as eating a bedtime snack and brushing teeth).
* Use the bedroom only for sleep or sex.
* Keep the bedroom quiet, dark, and slightly cool to promote better sleep.
* Maintain the same sleep schedule each day (arise and retire at the same times daily including weekends).
* Avoid naps or retiring unless sleepy.
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