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Insomnia-Assessment

DSM V describes insomnia as longstanding ( more than 3 months ) subjective difficulty initiating sleep , maintaining sleep or waking too early , accompanied by distress about the experience of daytime fatigue and its impact on day time functioning. The difficulty occurs atleast
 3 nights / week , despite adequate opportunity for sleep.

How common –Insomnia is common affecting up to 1 in 3 adults in the UK, N America , Europe and Australia It is the most common sleep disorder and Morin et al in 2006 reported that insomnia 
symptoms affect approximately 1/3rd of the population at any given time Cross sectional studies estimate the prevalence in patients attending primary care between 10-50 % ( BMJ 2011 )-most common sleeping disorder seen in family medicine A recent article in BMC Family Practice reports that up to 50 % of patients attending family practice experience insomnia – but this is often not screened for or not discussed within this setting ( Rowan P Ogeil et al 2020 ) Longitudinal cohort studies show that the prevalence of insomnia is rising coupled with increasing use of sedative-hypnotic use over the last decade ( Pallesen, Siversten , Nordhus , & Bjorvatn 2014 ) Jeffrey L Goodie et al report that primary care providers who see 20-30 patients a day may see as much as 3-5 patients with chronic insomnia Data from Australia shows that the rate of GP consultation for a sleep disorder is high and quite similar to the rate for chronic diseases such as diabetes ( Britt et al 2015 ) Prevalence increases with age ,and it is more common in women.

DSM Five subtypes –DSM V describes 5 subtypes of insomnia- sleep initiation insomnia , sleep maintenance insomnia , early morning awakening , a combination of the 3 or non-restorative sleep

International Classification of Sleep Disorders ( ICSD 2 )-Describes 4 chronic insomnia subtypes psychophysiological , idiopathic , paradoxical and inadequate sleep hygiene

Insomnia disorder- Now recognised as a condition requiring independent clinical attention , regardless of other medical problems that may be present. For a diagnosis of Insomnia disorder it should be clinically significant on its own , even though it may occur at the same time as another physical or mental condition.

Primary and secondary –These definitions have been removed from DSM V and ICSD-3 but have been used widely in literature. Primary describes an insomnia that is not directly attributable to a medical , psychiatric or environmental cause. 
Secondary is due to an underlying cause as a medical condition , medication or substance misuse ,mental disorder etc .

Acute/ chronic insomnia –Acute- sudden onset and short course of insomnia , usually < 3 months
Chronic – regarded as established after 3 months of persistent poor sleep

 

Why is insomnia important –Substantial direct and indirect costs Negative impact on QoL and health of affected person , incd healthcare utilisation Insomnia often co-occurs with other behavioural health and medical diagnoses as
-depression
- anxiety
- substance misuse
- chronic pain
- congestive heart failure It is now thought that the relationship between insomnia and such conditions is complex and bidirectional Now insomnia is considered to be a risk factor for major depression , anxiety disorders , substance use disorders , suicidality , hypertension and diabetes
Hence insomnia is both related to and is a risk factor for these conditions ( almost half of all diagnosed insomnia is comorbid with a psychiatric disorder ) Lack of productivity at work , absenteeism , accidents at work and RTA’s are increased High economic cost – estimated to exceed 100 Billion $s / year in the USA in 2016 and at 50 Billion $s ( 1.86 % of the GDP ) to the British economy in 2017.

Presentation – Direct questioning about sleep habits
- difficulty getting to sleep and / or staying asleep
- does this happen on most nights
- do you wake tired or unrefreshed despite many hrs of sleep Impact on daytime activities Ask what triggered the problem for e.g
 – stressful life event 
- change in job situation . shift work Co-existing psychiatric illness such as anxiety , depression – they frequently co-exist in as many as 1/2 the cases Any co-existing medical conditions as CCF , diabetes , COPD , GORD , CVD , renal disease ( about 50 % of patients with ESRF have insomnia and other sleep disorders ) ask about pain , RLS features , nausea , pruritus Neurological conditions as Parkinson’s , epilepsy , traumatic brain injury are associated with sleep disorders Excessive alcohol use and substance misuse R/O Obstructive sleep apnoea Social / occupational history / Noise levels Medications- can affect sleep architecture.

3P model –3 P model developed by 
Spielman can help the 
clinician focus a sleep history – factors predisposing and individual to insomnia e.g genetic and personality traits leading to physiologic and cognitive hyperarousal factors precipitating an acute episode of insomnia and e,g stressful events factors perpetuating the insomnia from acute to chronic e.g behaviors and thought structures that nay appear to offer short term relief yet cause long term harm.

Diagnosis –Insomnia is a clinical diagnosis and no objective test exist ,approach to establishing a diagnosis is 
- appraisal against diagnostic criteria
- clinical observations
- use of validated rating scales A physical examination is usually not helpful in diagnosis – history is the key and the main diagnostic tool You may consider examination if you suspect Obstructive Sleep Apnoea or a neurological disorder like Parkinson’s disease BMI and neck circumference Blood tests may be done to
- r/o hyperthyroidism
- ferritin level ( if RLS suspected )
- CKD/ diabetes Polysomnography ( overnight sleep study ) Actigraphy -device typically worn on the wrist that records movements and employs an algorithm to estimate sleep and awake periods Personal monitoring devices.

Barriers in recognition and treatment –Patients trivialize the sleep problem and delay in seeking help Knowledge gap in general public – lack of awareness of consequences of insomnia and available treatment options Time poor -most patients present in primary care setting , typical GP consultations last 10-15 minutes which may not be adequate for assessment of a sleep disorder Direct questions about sleep are not included in health history taking Lack of clear treatment guidelines Insomnia is not a clear priority for GPs – failure to recognize the negative impacts associated with insomnia Perception – that insomnia patients are after a prescription Concerns about long term tolerance and addiction , safety of using sedative medications Lack of knowledge , limited expertise and training opportunities

General approach –The normal range of sleep is 7-9 hrs day Normal sleep consists of 2 major stages
- Non rapid eye movement ( NREM )
- Rapid eye movement ( REM )

NREM comprises 70-80 % of total sleep and normal sleep begins with NREM and then alternates between NREM and REM every 90 minutes

It is thought that NREM sleep is necessary for physiological restorations
 Other sleep disorders that can present with the complaint of insomnia include circadian rhythm sleep-wake disorders , restless leg syndrome , periodic limb movement disorders and obstructive sleep apnoea Management of insomnia remains suboptimal in primary care – due to low rates of recognition coupled with inadequate treatment strategies ( Lages and Poursain 2005 ) Nature of sleep changes with age- older age is associated with poorer objectively-measured sleep with shorter sleep time , diminished sleep efficiency and more arousal’s Tools as ( find them under links )
- sleep diaries
- sleep disorder assessment questionnaire
- Insomnia severity index
- sleep condition indicator
- Pittsburgh Sleep Quality Index
- Stanford Sleepiness Scale Major studies have shown that the cost of treating insomnia is less than the cost of not treating insomnia and that treatment costs appear to be recouped within 6-12 months
 ( Morgan et al 2004 ; Warwick et al 2016 ) Clear referral pathways for bahevioural treatment and training primary HCPs with skills in addressing real or perceived patient barriers to non-drug treatment would improve insomnia management ( Janet MY 
Cheung et al )

Non-pharmacological first line

Cognitive behaviour therapy for insomnia –recommended 1st line Rx robust evidence of effectiveness multi-component strategy using cognitive and behavioural techniques shorter/ brief versions have been developed for primary care use CBTi is the cornerstone of treatment of insomnia can be delivered via internet CBT-i has been shown to be superior to pharmacotherapy both in the long and short term CBTi has several components that include
- sleep restriction therapy
- stimulus control therapy
- cognitive therapy
- relaxation techniques has minimal SEs typical duration may be from 4-8 weeks Links for online validated CBTi programmes can be found under links.

Sleep hygiene – often 1st line treatment advised by primary care clinicians consists of simple recommendations to improve sleep as daily exercise , avoiding caffeine after 6 PM very little empiric support as a stand-alone treatment easy to deliver but little evidence of efficacy on its own.

Pharmacological – short term Start with a short term prescription ( if using sedatives, hypnotics ) and arrange a follow-up , usually within 1-2 week but within 4 weeks Do not advice using OTC sleep aids or OTC medications with drowsiness as a SE Issue quantity limited medications and not on automatic refill/ repeat Discuss adverse effects , dependence and tolerance to sedative / hypnotic medication The British Association of Psychopharmacology states that in case of treatment failure , unavailability of CBTi , or inability to engage with CBTi , pharmacological treatment with an evidence base should be offered CKS advice on acute insomnia
- consider a short course ( 3-7 days ) of a non-benzodiazepine hypnotic medication ie a Z-drug Discuss the potential for drowsiness and driving


Long term –Management of chronic insomnia can be challenging Most guidance advice against the use of hypnotic for chronic insomnia and particularly in the elderly CBT-i is the recommended 1st line and pharmacological treatment should only be used after due consideration of non-pharmacological measures In cases which are severe , disabling or causing the person extreme distress- the lowest dose that controls symptoms should be used
( intermittently if possible ) and discussion on risks and benefits must take place Hypnotic drugs should not be used for long term use due to safety concerns Consider using prolonged release melatonin as mono-therapy for short term treatment ( max is 13 weeks -sleep cycle is likely to be fully regulated in that period ) of primary insomnia in people over 55 ( CKS )

Referral –Refer if another sleep disorder is suspected for e.g parasomnia , narcolepsy or OSA Refer if CBTi fails Consider referral and advice for cases where treatment in primary care has failed Significant associated physical / psychiatric co-morbidities ( e.g OSA ) Uncertainity about the diagnosis or if any safety concerns have been identified like excessive daytime sleepinness


Discussion-Studies have shown that patients often prefer non-pharmacological alternatives over pharmacological treatment given that treatments were equally effective Only a few ( 9.6 % ) were offered this option ( Omvik et al 2010 ) and the likely reason for this are systemic constraints of the healthcare systems and other reasons as
-high patient volume
- lack of clear referral pathways
- lack of availability of psychological interventions which are accessible quickly GPs are more confident in managing short term acute episodes of insomnia which are often time limited and have less psycho-social component Evidence supporting the use of therapeutic medications is limited , the information that is available is from questionable sources and/or the study cohort are very small.

Insomnia disorder frequently co-exists with other physical and mental disorders , traditional approach has been to treat the co-morbid condition with the expectation that the insomnia will resolve. It is now thought that treating both conditions simultaneously may improve the outcome of each ( Roth T 2009 ).

PATIENT RESOURCES

Online CBT from Sleepio https://www.sleepio.com/

App for chronic insomniahttps://somryst.com/

CBT https://blog.dreem.com/en/cbt-for-insomnia/

Insomnia clinic https://www.theinsomniaclinic.co.uk/cognitive-behavioural-process

Sleepstation online CBT  https://www.sleepstation.org.uk/evidence/

National Sleep Foundation on Insomnia https://www.sleepfoundation.org/sleep-disorders/insomnia

American Academy of Sleep Medicine https://aasm.org/clinical-resources/patient-info/

Free online course from This Way Up https://thiswayup.org.au/how-we-can-help/courses/managing-insomnia/

Links to download sleep diary

NHS 1 week with sleep hygiene https://www.nhs.uk/livewell/insomnia/documents/sleepdiary.pdf

National Sleep Foundation https://www.sleepfoundation.org/sites/default/files/inline-files/SleepDiaryv6.pdf

Sleep council UK https://sleepcouncil.org.uk/advice-support/sleep-tools/sleep-diary/

Sleep Hygiene leaflets

1 page printable from CCI health was au https://www.cci.health.wa.gov.au/~/media/cci/mental%20health%20professionals/sleep/sleep%20-%20information%20sheets/sleep%20information%20sheet%20-%2004%20-%20sleep%20hygiene.pdf

Sleep council https://sleepcouncil.org.uk/category/sleep-hygiene/

National rheumatoid arthritis society on sleep hygiene https://www.nras.org.uk/data/files/Publications/Sleep%20Mind%20Map.pdf

QUESTIONNAIRES TO ASSESS SLEEP DISORDER

Alberta doctors Sleep Disorder questionnaire https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/Sleep-Disorders-Questionnaire.pdf

Insomnia Severity Index https://www.ons.org/sites/default/files/InsomniaSeverityIndex_ISI.pdf

Sleep Condition Indicator https://www.sleepio.com/sleep-condition-indicator/

Pittsburgh Sleep Quality Index https://consultgeri.org/try-this/general-assessment/issue-6.1.pdf

Stanford Sleepiness Scale https://web.stanford.edu/~dement/sss.html

 

 

References

    1. Comorbid Insomnia: Current Directions and Future Challenges Thomas Roth, PhD Am J Manag Care. 2009;15:S6-S13 https://www.ajmc.com/journals/supplement/2009/2008-12-vol15-n1suppl/a228_09feb_roth_s6tos13
    2. CKS NHS Insomnia https://cks.nice.org.uk/insomnia#!scenario:1
    3. Ogeil, R.P., Chakraborty, S.P., Young, A.C. et al. Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework. BMC Fam Pract 21, 1 (2020). https://doi.org/10.1186/s12875-019-1070-0 https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-019-1070-0#citeas
    4. The Epidemiology of Insomnia in Older Adults and Current Treatment Landscape
    5. Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework Rowan P. Ogeil1,2* , Samantha P. Chakraborty3, Alan C. Young4 and Dan I. Lubman1,2 Ogeil et al. BMC Family Practice (2020) 21:1 https://doi.org/10.1186/s12875-019-1070-0
    6. Cheung Janet M. Y., Atternäs Kristina, Melchior Madeleine, Marshall Nathaniel S., Fois Romano A., Saini Bandana (2013) Primary health care practitioner perspectives on the management of insomnia: a pilot study. Australian Journal of Primary Health 20, 103-112. https://www.publish.csiro.au/py/ExportCitation/PY12021
    7. Assessment to Management of Adult Insomnia Clinical Practice Guideline Dec 2015 Toward Optimized Practice Alberta Doctors Org via https://top.albertadoctors.org/CPGs/Lists/CPGDocumentList/Adult-Insomnia-CPG.pdf
    8. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update Sue Wilson1, Kirstie Anderson2, David Baldwin3, Derk-Jan Dijk4, Audrey Espie5, Colin Espie6, Paul Gringras7, Andrew Krystal8, David Nutt1, Hugh Selsick9 and Ann Sharpley10 Journal of Psychopharmacology 2019, Vol. 33(8) 923 –947 https://www.bap.org.uk/pdfs/BAP_Guidelines-Sleep.pdf
    9. F Sake, K Wong, D Bartlett, B Saini, 0351 INSOMNIA: A TRIVIALIZED CONDITION IN PRIMARY CARE SETTING, Sleep, Volume 40, Issue suppl_1, 28 April 2017, Page A131, https://doi.org/10.1093/sleepj/zsx050.350
    10. Practical Guidance for Targeting Insomnia in Primary Care Setting Jeffrey L Goodie , Christopher I  Hunter Cognitive and Bahavioral Practice 21 ( 2014 ) 261-268 https://www.sbm.org/UserFiles/file/PracticalGuidanceforTargetingInsomniainPrimaryCareSettings_GoodieHunter_2014.pdf
    11. Hilty, Donald et al. “Algorithms for the assessment and management of insomnia in primary care.” Patient preference and adherence vol. 3 9-20. 3 Nov. 2009, doi:10.2147/ppa.s2670 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778437/
    12. Krystal, A.D., Prather, A.A. and Ashbrook, L.H. (2019), The assessment and management of insomnia: an update. World Psychiatry, 18: 337-352. doi:
    13. Fatema-Tun-Naher Sake, Keith Wong, Delwyn J. Bartlett & Bandana Saini (2017): Insomnia Management in the Australian Primary Care Setting, Behavioral Sleep Medicine, DOI: 10.1080/15402002.2016.1266491 https://www.med.upenn.edu/cbti/assets/user-content/documents/2017_Sake_etal_InsomniaManagementinAustralianPrimaryCareSetting.pdf
    14. The assessment and management of insomnia in primary care Karen Falloon et al BMJ 2011;342:d2899

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