Insomnia
Insomnia may be a primary diagnosis or a complaint or symptom secondary to an underlying acute or chronic disorder. Many patients have insomnia but do not tell their doctors, so questions about sleep quality should be asked during health maintenance visits. A careful history of sleep habits, including the time spent in bed or trying to sleep elsewhere, bed mate, noise level, safety, and interruptions, is imperative for diagnosing and treating all sleep disorders.
Differential Diagnosis
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Unnecessary concern about deviation from “normal” sleeping patterns
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Acute, transient insomnia (<4 weeks)
–Situational stress (most common)
–Acute illness or injury
–Medications or drugs (e.g., cocaine)
–Change in sleep environment or hours - Chronic insomnia (>4 weeks)
–Difficulty falling asleep: May be due to poor sleep hygiene, conditioned insomnia (initial acute insomnia progresses to chronic due to maladaptive distorted sleep cognitions), medications (e.g., sedatives, decongestants, oral contraceptive use, antidepressants, bronchodilators), drugs (including over-the-counter and herbal preparations, alcohol, nicotine, illicit drugs), and caffeine (e.g., coffee, soda, medications)
–Difficulty staying asleep: May be due to sleep apnea, medications and drugs (e.g., alcohol), depression, anxiety, dementia, psychosis, mania, post-traumatic stress disorder, and various medical conditions (e.g., COPD, asthma, CHF, angina, GERD, peptic ulcer disease, IBD, BPH, UTI, pregnancy, uremia, diabetes mellitus, hyperthyroidism, menopause, pain, pruritus, seizures)
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RLS
–“Creepy-crawly” unpleasant sensations in
the legs and/or feet
–Temporarily relieved by moving limbs
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Periodic limb movement disorder
–Arms and/or legs jerk during sleep
–May be a primary disorder or secondary to uremia, neuropathy, or iron deficiency
–Often in the elderly
–Often occurs with restless legs syndrome
Narcolepsy
REM-behavior disorder
–Rare, mostly in elderly
–Thrashing or seemingly purposeful
behaviors during sleep
Prion fatal familial insomnia
Workup and Diagnosis
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Sleep and medication/drug history, including bed partner history
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Sleep diary is the most effective specific assessment tool
–Should be recorded each morning
–Include time in bed, time asleep, awakenings, estimate of
sleep quality, associated symptoms (e.g., pain, dyspnea, urinary frequency)
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A focused physical examination to evaluate cardiovascular, pulmonary, and neurologic systems and mental status will improve diagnostic accuracy
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Polysomnography (sleep study) is useful to evaluate sleep apnea, restless legs syndrome, periodic limb movement disorder, and REM-behavior disorder
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“Insomnia” is a self-reported condition; labs or other testing is often unnecessary unless underlying medical conditions are suspected
–ECG, chest X-ray, echocardiogram, pulmonary function
tests if suspect undiagnosed cardiac or pulmonary disease
–EEG if suspect undiagnosed seizure disorder
–TSH and free T4 if suspect thyroid disease
–Iron studies and BUN/creatinine if suspect restless legs
syndrome or periodic limb movement disorder (iron deficiency and renal failure are risk factors for both)
–Consider blood alcohol level, CBC and MCV, LFTs, and toxicology screen if suspect alcohol or illicit drug abuse
Treatment
- Acute transient insomnia: Reassurance, address stressors, treat identifiable underlying causes (e.g., pain), hypnotic agents for up to 7–10 days
- Chronic insomnia
–Improve sleep hygiene (e.g., consistent bed/wake time, sleep environment, medications/drugs, daytime exercise, avoid naps, hot bath near bedtime)
–Treat pain and underlying medical/psychiatric issues
–Behavioral treatments: Relaxation therapy, sleep restriction therapy (curtail time in bed to improve sleep efficiency), stimulus control therapy (bed only for sleep), cognitive therapy (restructure negative thoughts about sleep/daytime functioning)
–Medications are often used but none has demonstrated long-term efficacy nor safety
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Obstructive sleep apnea: Weight loss, CPAP, surgery
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RLS: Dopaminergic agents (e.g., carbidopa/levodopa, pergolide), benzodiazepines, opiates
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Narcolepsy: Modafinil, amphetamines
>
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
Other Book Chapters Related to Sleep symptoms
Read excerpts from these other book chapters related to Sleep symptoms:
Medical Books Excerpts
- INSOMNIA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- INSOMNIA
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Insomnia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Insomnia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Insomnia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Insomnia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Insomnia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- INSOMNIA
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Sleep symptoms
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: INSOMNIA (Differential Diagnosis in Primary Care)
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