# 101 Insomnia: Patient Assessment

FAST FACTS AND CONCEPTS #101
 

Author(s): Michael Miller and Robert Arnold MD

Background   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 focuses on the assessment of insomnia; it is the first of a series of three Fast Facts about insomnia (see #104, 105).

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 (see Fast Fact #217).
  • Conditioned Insomnia: learned or psychological insomnia. An acute event such as a significant life stress, pain, or illness 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 rapid-eye-movement sleep.

Sleep History   Obtain a focused sleep history from the patient and bed partner. If needed, the patient should be asked to record their daily sleep patterns in a sleep log for one week; see http://www.webmd.com/sleep-disorders/guide/how-to-use-a-sleep-diary.

  • Sleep hygiene: Has the patient altered their bedtime routine (e.g. change in bedtime, use of sleep aids, lying on bed watching TV prior to sleep)? 
  • Sleep chronology: Evaluate the onset, pattern and duration of sleep and 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 causes 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: Fears about dying may cause a patient to be afraid of falling asleep or to not want to turn off the lights; this is especially common in patients with dyspnea. This is in contradistinction to more typical insomnia where the patient is bothered by the lack of sleep.

 

References

  1. Ohayon MM. Epidemiology of Insomnia: what we know and what we still need to learn. Sleep Medicine Rev. 2002; 6(2):97-111.
  2. Chokroverty, S. Evaluation and treatment of insomnia. In: Basow DS. UpToDate. Waltham, MA: UpToDate; 2003.
  3. Schenck C, Mahowald M, Salk R. Assessment and management of insomnia. JAMA. 2003; 289(19):2475-2463.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in November 2003. Re-copy-edited in April 2009; sleep log website updated.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Miller M, Arnold R. Insomnia: Patient Assessment. Fast Facts and Concepts. November 2003; 101. Available at: http://www.eperc.mcw.edu/fastfact/ff_101.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a 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.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-Pain Symptoms and Syndromes