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Managing Adult Insomnia Confidently
Managing Adult Insomnia Confidently
ABSTRACT
Insomnia is a significant health problem often ineffectively managed in primary care.
Patients should be briefly screened for sleep issues at every visit. Insomnia management
focuses on patient education in nonpharmacologic treatments including sleep hygiene,
sleep restriction, stimulus control, relaxation techniques, mindfulness practices, and
cognitive therapies. Hypnotics should be used appropriately and sparingly. No single
treatment is fully effective; each patient will require a unique blend of treatments for
maximal effectiveness. Nurse practitioners should work closely with patients to find
the best mix of modalities for them.
718 The Journal for Nurse Practitioners - JNP Volume 14, Issue 10, November/December 2018
counterproductive to rest and sleep, resulting be vigilant for behavioral or medical sources of sleep
in insomnia. disturbance because addressing this source will
improve sleep.
SCREENING AND CLINICAL PRESENTATION Several conditions and medications are associated
Screening with sleep disturbance; these include obstructive sleep
Primary care providers should briefly screen for sleep apnea, nocturia, restless legs syndrome, congestive
issues at every patient encounter during the general heart failure, asthma, gastroesophageal reflux disease,
health questionnaire because most adults will expe- chronic pain, anxiety, and depression, as well as the
rience sleeping problems at some point in their use of corticosteroids, antidepressants, anticonvul-
lives.3,4 Screening can be accomplished by asking the sants, bronchodilators, antihistamines, thyroid sup-
following simple question: “How are you plementation, oral contraceptives, nicotine, and
sleeping?”4(p68) Frequent screening provides the alcohol.2,3 In diagnostic evaluation, it is essential that
opportunity for earlier identification of sleep providers consider all organic causes of insomnia
disturbance and timely diagnosis and treatment symptoms and provide a thorough evaluation for any
of insomnia. conditions they suspect could be contributing to
sleep disturbance.2,3 Disturbance in sleep caused by
Clinical Presentation another condition or behavior is not true clinical
Patients with insomnia do not typically present with insomnia. It is helpful to remember that problems
the chief complaint of sleep issues. Rather, it is during falling asleep are often issues of poor sleep hygiene or
patient interview that sleep problems are identified. medication or substance use, whereas early
Insomnia presents with problems initiating or main- awakenings typically have psychological origins, such
taining sleep with associated daytime dysfunction.3 as depression or clinical anxiety. It is also important to
Issues with sleep initiation include not being able to work with the patient to identify current sources of
fall asleep at bedtime or lying awake for several hours stress because high stress levels can cause sleep issues
in bed unable to sleep.2 Patients may also complain of because of nighttime hyperarousal (Table 1).2,3
problems maintaining sleep, such as waking up
several times during the night or waking up early and Diagnosis
not being able to go back to sleep.4 Finally, patients The Diagnostic and Statistical Manual of Mental Disorders
often report daytime symptoms, such as excessive (Fifth Edition) provides a clear list of criteria for
fatigue, irritability, difficulty focusing at work or on a insomnia diagnosis that is easily accessible for NPs.
specific task, or not feeling refreshed after waking Diagnostic criteria are as follows:
from a night of sleep.3,4 Any of these complaints 1. Patient reports dissatisfaction with current sleep
should be investigated for a cause and could be a quality or quantity, including issues of initiating
symptom of insomnia.5 or maintaining sleep
2. Sleep issues cause significant daytime dysfunc-
DIAGNOSTIC EVALUATION tion or distress, either in professional life or
Patient Interview relationships, and disrupt behaviors or
When evaluating for insomnia, it is essential to take a emotional state
thorough sleep history, focusing on the frequency 3. Sleep issues occur at least 3 times a week for at
and timing of sleep issues, bedtime routine, and least 3 months
nighttime environment.2 NPs must also take a 4. Sleep issues occur despite adequate available
detailed medical, psychiatric, and substance use opportunity for sleep
history, including all current medications, herbal or 5. There is no other identifiable organic cause of
alternative therapies, tobacco, illicit drugs, and sleep issues5
alcohol use, to rule out other organic causes of sleep When making a diagnosis of insomnia, it is
disturbance.2,3 During this process, providers should essential to rule out other medical, behavioral, or
720 The Journal for Nurse Practitioners - JNP Volume 14, Issue 10, November/December 2018
as television or smartphone use.3,7 Caffeine directly in bed to the time spent sleeping.11 Contrary to
causes sleep disturbance when consumed within 6 popular belief, staying in bed longer does not result in
hours of bedtime.8 Bedtime smartphone use is higher-quality sleep. Decreasing the overall time
associated with sleep problems, including worse sleep spent in bed produces mild sleep deprivation in
quality, difficulty falling asleep, and increased daytime patients by allowing for less sleep opportunity (or
fatigue, and, thus, should be avoided before bed.9 time spent in bed trying to sleep, but, in insomnia,
NPs should feel confident in teaching sleep hygiene often spent lying awake in bed).10 Mild sleep
to their patients, as well as identifying when violating deprivation in a scheduled manner resets and
these behaviors are contributing factors to insomnia stimulates the body’s endogenous sleep drive, thus
symptoms during sleep diary review (Table 2). improving sleep.11
CBT-I. CBT-I is a highly effective treatment As a provider, sleep restriction is conducted by
strategy for insomnia. However, it is infrequently writing a “sleep prescription.”11(pe509) Upon
used in primary care because providers report inad- review of the patient’s 2-week sleep diary,
equate office time or training in conducting general providers calculate an average time spent sleeping
cognitive behavioral therapy or specifics for insomnia and an average time spent awake in bed. The sleep
management.10,11 Patients are often not referred to a prescription is written by adding the average time
psychologist’s office for CBT-I unless their insomnia spent sleeping plus 50% of the average awake time
is severe, which leaves most patients suffering from in bed.11 It is important to note that sleep
insomnia without the helpful strategies of CBT-I. prescription time cannot be less than 5 hours per
The specific components of CBT-I are simple, easy night to ensure sleep deprivation is not severe.11
to teach to patients, and highly effective, even when Over time, as the patient begins to sleep more, the
administered by nonpsychiatric professionals.10 Each sleep prescription increases. It is recommended that
of these strategies are thoroughly discussed, with the if the patient sleeps for at least 80% of the sleep
goal that NPs will feel confident in using these prescription time for a week, the sleep prescription
nonpharmacologic management strategies to treat is increased by 20 minutes for the next week. If
insomnia in primary care. 80% of the sleep prescription is not met, the sleep
Sleep restriction. One of the most effective com- prescription is kept the same, and patients are
ponents of CBT-I is sleep restriction.2,6 The goal of encouraged to continue with sleep restriction
sleep restriction is to limit the amount of time spent training.11 Although it can take time, sleep
restriction is a central behavioral component of
Table 2. Sleep Hygiene Education3,7 CBT-I and is highly effective in increasing sleep
time and quality (Table 3).3,6,10
Guidelines
Stimulus control. Stimulus control is a mainstay
Regular sleep routine and bedtime
behavioral component of CBT-I and applies the
Keep bedroom cool, dark, and comfortable
principles of classical conditioning to promote
Use earplugs, white noise machines, or eyeshades as sleep.6,10 The goal of stimulus control is to strengthen
desired
associations between sleep-promoting stimuli
Limit daytime naps (bedtime and the bed) with sleep and to weaken
Exercise during the day, but not 3 hours before bed associations of negative thoughts or problem
Avoid alcohol before bed behaviors with sleep.2 Poor sleep practices, such as
watching television in bed, going to bed when not
Avoid stimulants before bed, such as caffeine and
nicotine tired, and spending too much awake time in bed,
have decreased the mind’s association of sleep with
Avoid stressful or cognitively stimulating activities
before bed sleep stimuli, and, as a result, the bed is no longer a
cue for sleep.2,10 Stimulus control is designed to
Avoid rich, heavy food before bed
repair this cognitive association.
722 The Journal for Nurse Practitioners - JNP Volume 14, Issue 10, November/December 2018
Cognitive therapies are typical psychological However, they can be sedating and addictive and, if
treatments that providers most often associate with used, should only be used for a short duration with
CBT-I. These therapies can take more office time quick, scheduled weaning.14 Selective melatonin
because problematic thought patterns can be difficult receptor agonists are newer hypnotic agents, such as
to identify. If unable to provide cognitive therapy, ramelteon and tasimelteon.3,4 These medications are
patients should be referred to appropriate psychiatric most effective in treating insomnia associated with
services or sleep centers.2,6 NPs can also consider the circadian rhythm issues and shift work because these
use of Web-based cognitive therapy programs, which help to regulate melatonin production to stabilize the
are increasingly popular. However, cognitive therapy sleep-wake cycle.14 Finally, sedating antidepressants,
is not considered a necessity in current such as trazodone, mirtazapine, and doxepin, are
recommendations for treating insomnia.6 Thus, if often used to treat insomnia that presents with
time or provider training limits providing cognitive concurrent mild depressive symptoms (see
therapy in the office, using a combination of the Supplementary Table 4, available online at http://
aforementioned 4 strategies is considered www.npjournal.org).3,10
comprehensive, even without the cognitive The goals of pharmacologic management are the
component. This is termed multicomponent therapy and same as nonpharmacologic management—to improve
is the current recommendation for the sleep and daytime functioning.3 Although the use of
nonpharmacologic management of insomnia.6(p1417) medications is effective, it must be managed closely to
prevent inappropriate use and habit formation and
Pharmacologic Management should not last for longer than 3 to 6 months.14
Although nonpharmacologic management strategies Hypnotics should be also used sparingly in older
are recommended as the primary treatment for adults.14 Hepatic and renal clearance rates are reduced
insomnia, there are cases in which patients benefit in elderly patients, which can lead to higher drug levels
greatly from short-term use of sleep-assisting medi- in the body. Thus, sedating medications can have more
cations or hypnotics. Patients often report trying powerful and lasting effects and should be limited in
over-the-counter sleep aids without success before older adults when possible.
seeking medical care; common choices include
melatonin, Benadryl, and Tylenol PM (McNeil FOLLOW-UP, REFERRAL, AND CONTINUING
Consumer Healthcare, Fort Washington, Pennsyl- EDUCATION
vania).3 These medications are not recommended to Insomnia can be persistent and should be followed
treat insomnia because of anticholinergic side effects closely. Upon diagnosis after sleep diary review, NPs
such as constipation, blurry vision, urinary retention, should begin patient education in nonpharmacologic
sedation, and confusion.3 The exception is management strategies discussed in the previous sec-
melatonin, a hormone supplement that can support a tions.2,3,6 It is recommended that nonpharmacologic
healthy circadian rhythm. However, melatonin is treatments are given 4 to 6 weeks to improve
considered a dietary supplement, and, thus, it can be insomnia symptoms before starting hypnotic
difficult to regulate the strength and formulation medications.14 Nonpharmacologic strategies may not
without pharmaceutical oversight. quickly eradicate all insomnia symptoms, but patients
Several hypnotics are available for treating should report improving sleep quantity and quality. It
insomnia. Nonbenzodiazepine receptor agonists are is also important to ensure patients are implementing
the primary recommendation for insomnia; these strategies correctly and regularly to be effective. If
include zolpidem, zaleplon, and eszopiclone.3,14 nonpharmacologic management does not improve
These medications are effective in increasing sleep insomnia symptoms at subsequent follow-up visits,
onset and duration without the negative side effects patients may be started on hypnotics.3 Dosage should
of benzodiazepines. Benzodiazepines, such as be started low and increased slowly to avoid sedation,
quazepam, estazolam, and temazepam, have side effects, and misuse and discontinued in a
frequently been used to treat insomnia in the past. scheduled manner.3 Regardless of strategies, patients
724 The Journal for Nurse Practitioners - JNP Volume 14, Issue 10, November/December 2018
Supplementary Table 4. Hypnotic Medication
Prescriptions3,8
Medication Dose
Nonbenzodiazepine
receptor agonists
Selective melatonin
receptor agonists
Ramelteon 8 mg PO qhs
Tasimelteon 20 mg PO qhs
Antidepressants