Fast Fact and Concept #101: Insomnia--Patient Assessment

Author(s): Miller M; Arnold R

Sleep disorders are very common in the general population, the elderly, and in terminally ill patients. Difficulty sleeping causes significant suffering, contributing to fatigue that prevents patients from participating in meaningful daytime activities and decreasing their quality of life. This Fast Fact will focus on the assessment of insomnia.

Definitions

• Insomnia: insufficient quantity or poor quality of sleep affecting an individual during the day
• Parasomnia: a disruptive physical act that occurs during sleep which may cause awakening or other disturbance in sleep
• Sleep apnea: cessation of breathing for short periods during sleep, can be obstructive or central in origin
• Restless Legs Syndrome: a disorder characterized by paresthesias and dysesthesias of the legs that typically occur in the evening or at night and may be relieved by movement; causes insomnia by interfering with sleep onset and interrupting sleep
• Conditioned Insomnia: learned or psychological insomnia; an acute event such as a significant life stress, pain, or illness which causes insomnia; the individual no longer associates the bed with sleeping and may have ongoing insomnia
• Narcolepsy: a disorder of excessive daytime fatigue associated with abnormalities in REM sleep

Sleep History
Obtain a focused sleep history from the patient and bed partner.

Sleep hygiene: has the patient altered their bedtime routine (e.g. change in bedtime, use of sleep aids, laying on bed watching TV prior to sleep)?

Sleep chronology: onset, pattern and duration; whether the insomnia is transient, intermittent or persistent. A persistent problem usually is a consequence of a medical, neurologic or psychiatric disorder. Ask if the patient has difficulty initiating sleep, staying asleep, or both. Sleep apnea rarely cause disorders in initiating sleep. Nightmares (see Fast Fact #88) cause difficulty staying asleep and may reflect spiritual suffering. Ask about multiple nocturnal or early morning awakenings. Frequent awakening is often due to medicine and early awakening is classically due to depression.Sleep environment -- Are any environmental factors (e.g. noise, light, odors) preventing sleep? This may be particularly important in the hospital or a situation where a patient has moved into an unfamiliar setting (e.g. children 's house).

Physical symptoms: Are there physical symptoms interfering with sleep (e.g. cough, pain, dyspnea)? Symptoms occurring just prior to sleep may reflect primary sleep disorders.
Medical conditions Are there co-morbid medical conditions that are associated with insomnia?

• Worsening of chronic medical conditions (e.g. CHF, COPD)
• New onset or worsening depression and/or anxiety.
• Drugs (e.g. steroids, beta blockers, psychostimulants); Use of alcohol and caffeine, especially in the evening.
• Restless leg syndrome or periodic limb movements in sleep. These patients have highly stereotyped, disagreeable sensations in the legs that occur at rest and relieved by movement. Typical symptoms include crawling, stretching and pulling.

Spiritual concerns (FF #88): Fears about dying may cause a patient to be afraid of falling asleep or to not want to turn off the lights; especially common in patients with dyspnea. This is in contradistinction to more typical insomnia where the patient is bothered by the lack of sleep.

If needed, the patient should be asked to record their daily sleep patterns in a sleep log for one week; see http://www.talkaboutsleep.com/sleepbasics/sleeplog.pdf

References

1. Ohayon MM: Epidemiology of Insomnia: what we know and what we still need to learn. Sleep Medicine Reviews. 6(2):97-111, 2002 Apr
2. Chokroverty, S. Evaluation and treatment of insomnia. http://www.uptodate.com 2003.
   
3. Schenck C, Mahowald M, Salk R. Assessment and management of insomnia. JAMA. 2003 ;289(19):2475-2463.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Miller M and Arnold R. Fast Facts and Concepts #101. Insomnia: Patient Assessment. November 2003. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 11/2003

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-pain symptoms & syndromes; psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders