Let's all wake up and talk about insomnia.
Insomnia is a very common
condition we see in primary care.
It can promote a lot of anxiety
and worry in my patients.
And the funny thing is that leads to a
cycle where they experience more insomnia.
So, therefore, breaking the cycle
is really, really important.
So, we’ll talk about sleep and
some general properties of sleep
and then focus on defining insomnia
and how to treat it appropriately.
So, I’m going to start with a case.
I’ve got a 50-year-old female.
She experiences early and middle
insomnia and she has daytime fatigue.
That means she has trouble initiating sleep.
She has trouble with staying asleep in
the middle of the night and she gets tired.
You know what fatigue is.
She gets tired in the day.
She doesn’t have any significant
medical illnesses thankfully.
And a review of systems and a
physical examination are negative.
So, what do you do now?
Is it, A, do you recommend sleep
hygiene and a sleep diary?
B, initiate a laboratory evaluation?
C, just start treating with something
like a melatonin antagonist or agonist?
Or D, initiate a 4 to 6 week
trial with a hypnotic drug?
Here, I would strongly argue for A
because this patient, we don’t know
enough about her insomnia yet.
A sleep diary can be a great way to actually document
just how severe the insomnia is when it bothers her.
May give some clues too with –
maybe it's stress
or something related to her life,
with her work,
her family, where she has certain
shifts where she’s staying up late.
And then working on sleep hygiene is
always a good idea and highly effective.
And we’ll be talking about that quite a bit.
So, just to define insomnia,
it's a subjective perception
of difficulty with sleep initiation,
consolidation or quality that occurs
despite the adequate opportunity for sleep.
So, in a situation where you're sharing a bedroom with like
14 other people and you're having a hard time sleeping,
that doesn't necessarily qualify
it’s insomnia because that's
not really an adequate opportunity.
If you’re sleeping on a factory floor,
that's not an adequate opportunity.
And it also needs to involve
some form of daytime impairment.
Acute insomnia is considered
less than three months in duration
and chronic is longer than that,
longer than three months.
So, in terms of epidemiology,
it's very common.
Insomnia affects 10 to 30% of adults.
It’s more common in women.
It’s more common as you get older.
It’s definitely more
common in chronic pain.
Chronic pain and insomnia
tend to go hand-in-hand.
they exacerbate each other.
So, patients who sleep
less also have more pain.
And it can be hereditary.
It tends to run in families, insomnia.
And it is also associated with –
besides feeling tired during the day,
it is associated with some
more severe consequences,
such as cognitive difficulty.
It’s also associated with a
higher risk of accidents.
And it’s also associated with a
higher risk of mood disorders as well.
So, insomnia can be a
feature of anxiety and depression,
but it can also promote
worse anxiety and depression.
chronic insomnia is linked
to intravascular inflammation
and a higher risk for
Now, sleep does change with age and
I think it's important to counsel older adults
because many of them are less
satisfied with their sleep overall.
So, it's good to think about
how sleep naturally changes with age.
There's more of a latency.
So, patients may complain
of early insomnia symptoms.
It takes longer to get to sleep.
They also have reduced time in REM as you
get older and they are more likely to wake up.
That said, it's a fallacy that sleep always –
duration always decreases as you get older.
It can also stay about the same.
But generally, as I said,
patients who are older have
less satisfaction with their sleep.
And it’s due to all of those causes.
It takes longer to fall asleep.
Plus, they are waking up
more in the middle of the night.
And so, therefore,
it's something to counsel patients about and
tell them this is going to be a normal part of aging.
Just that reassurance is a good
start as a therapeutic relationship.