Miscellaneous

Medicolegal Pitfalls

• Use sedative hypnotics with caution in patients with a prior history of drug or alcohol abuse.
• Sedative hypnotics should also be used with caution in patients with a history of insufficient sleep syndrome, particularly in patients prone to alcohol use since this group can be predisposed to the development of parasomnias (eg, sleep-walking or sleep-related eating disorder).
• Counsel patients to allow for at least 8 hours of sleep and avoid concomitant alcohol use when using sedative hypnotic medications.
• Use sleep restriction therapy with caution in commercial truck drivers, those that operate heavy machinery, pilots, and those in occupations where sleep deprivation can have devastating consequences.

Special Concerns

Insomnia in the elderly

• The satisfaction of sleep declines with age. This probably is related to changes in sleep associated with age, such as a decrease in slow-wave sleep, increased time awake after sleep onset, and a tendency to go to bed early and rise early.
• However, aging should not be assumed to be the explanation for insomnia. Multiple factors affect sleep in the elderly, including nocturia, pain syndromes, and many medical disorders (eg, heart failure, COPD, Parkinson disease). Other factors include restless legs syndrome, periodic leg movement disorder, sleep apnea (all of which have increased frequency in the elderly), dementia, and, frequently, changing situational factors such as retirement, bereavement, or financial difficulties, which lead to anxiety and depression.
• As in younger patients, nonpharmacologic treatment should take precedence over pharmacologic treatment.
• Hypnotics should be prescribed cautiously and in lower doses than for younger patients. Drugs tend to have longer duration of effect due to changes in metabolism and elimination. This can lead to increased incidence of falls and bone fractures at night (if the patient gets up to use the bathroom not fully awake or ataxic) and decrements in daytime alertness and performance (including increased incidence of motor vehicle accidents).

Insomnia Follow Up

Patient Education

All patients with insomnia, whether transient or chronic, should be educated about sleep and the elements of good sleep hygiene. Sleep hygiene refers to daily activities and habits that are consistent with and/or promote the maintenance of good quality sleep and full daytime alertness. Educate patients on the following elements of good sleep hygiene:

• Develop regular sleep habits: This means keeping a regular sleep and wake time, sleeping as much as needed to feel refreshed the following day, but not spending more time in bed than needed. Daytime naps should be avoided. If a nap is necessary, keep it short (less than 1 hour) and avoid napping after 3 pm. Avoid staying in bed in the morning to catch up on sleep.
• Keep a regular schedule. Regular times for meals, medications, chores, and other activities helps keep the inner body clock running smoothly.
• Do not read, write, eat, watch TV, talk on the phone, or play cards in bed.
• Avoid caffeine after lunch. Avoid alcohol within 6 hours of bedtime. Avoid nicotine before bedtime.
• Do not go to bed hungry, but do not eat a big meal near bedtime either.
• Avoid sleeping pills, particularly over-the-counter remedies.
• Slow down and unwind before bed (beginning at least 30 minutes before bedtime); a light snack may be helpful. Create a bedtime ritual such as getting ready for bed, wearing night clothes, listening to relaxing music, or reading a magazine, newspaper or book. Avoid watching TV in the bedroom or sleeping on the sofa and then going to bed later in the night.
• Avoid stimulating activities prior to bedtime (eg, vigorous exercise, discussing or reviewing finances, or discussing stressful issues with a spouse or partner or ruminating about them with oneself.
• Keep the bedroom dark, quiet, and at a comfortable temperature.
• Exercise daily: This is best performed in the late afternoon or early evening (but not later than 6-7 pm).
• Do not force yourself to sleep: If you are unable to fall asleep within 15-30 minutes, get up and do something relaxing until sleepy (eg, read a book in a dimly lit room, watch a nonstimulating TV program). Avoid watching the clock or worrying about the perceived consequences of not getting enough sleep.

Insomnia Multimedia

Multimedia

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Media file 1: Theoretical model of the factors causing chronic insomnia. Chronic insomnia is believed to primarily occur in patients with predisposing or constitutional factors. These factors may cause the occasional night of poor sleep but not chronic insomnia. A precipitating factor, such as a major life event, causes the patient to have acute insomnia. If poor sleep habits or other perpetuating factors occur in the following weeks to months, chronic insomnia develops despite the removal of the precipitating factor. Adapted from Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec;10(4):541-53.

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Media file 2: Mallampati airway scoring.

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Media file 3: Diagnostic algorithm for major depression.

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Media file 4: Diagnostic criteria for generalized anxiety disorder.

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Media file 5: Sleep diary.

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Media file 6: GABAA receptor subunit function(s).

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Media file 7: GABAA receptor complex subunits and schematic representation of agonist binding sites.

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Media file 8: Sleep-wake cycle.

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Media file 9: The ascending arousal system. Adapted from Saper et al. Hypothalamic Regulation of Sleep and Circadian Rhythms. Nature2005;437:1257-1263.

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Media file 10: Ventrolateral pre-optic nucleus inhibitory projections to main components of the arousal system to promote sleep.

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Media file 11: Schematic flip-flop switch model. Adapted from Saper C et al. Hypothalamic regulation of sleep and circadian rhythms. Nature 2005;437:1257-1263.

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Media file 12: Epworth Sleepiness Scale.

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Media file 13: Frequency of insomnia causes.