Insomnia

Elderly female with h/o HTN, heart failure, OSA, COPD, diabetic neuropathy, Parkinson disease, anxiety, depression, ADHD, PTSD, and chronic pain presents with poor sleep for greater than three months. Reports difficulty falling asleep and staying asleep resulting in daytime impairment. ROS positive for creeping, crawling, and itching sensation in legs that is most prominent in the evening and improves with movement. Employed as a night-shift worker. Endorses daily use of caffeine, alcohol, and tobacco. Prescribed medications include metoprolol, prednisone, escitalopram (SSRI), methylphenidate. Recently started OTC pseudoephedrine for nasal congestion. Masked facies, HTN, obesity, JVD, LE edema, end-expiratory wheeze, unilateral resting tremor, cogwheel rigidity, decreased sensation to monofilament, and shuffling gait on exam.

  • Labs

    • Obtain CBC to evaluate for anemia

    • Consider CMP, HbA1c, BNP, urine drug screen

  • Comorbid conditions

    • HTN: Optimize antihypertensive regimen

    • Heart failure with signs of fluid overload: Adjust diuretic regimen

    • Monofilament exam positive for diabetic neuropathy: Start amitriptyline 25 mg and increase to 50 mg after 1 week

    • Restless leg syndrome: Start pramipexole IR 0.125 mg 2 hours before bedtime and increase to 0.25 mg after 3 days

    • Anxiety/depression: Administer GAD-7 and PHQ-9 and treat accordingly

  • Insomnia medications

    • Sleep onset

      • Melatonin 5 to 10 mg two hours before sleep

      • Ramelteon 8 mg one hour before sleep

    • Sleep maintenance: Doxepin 6 mg three hours before sleep (recommended for comorbid depression and geriatric patients)

    • Sleep onset and maintenance: Eszopiclone 1 mg before sleep for two weeks (MDD 3 mg qd)

  • Consults

  • Counseling

    • Pt advised to practice good sleep hygiene

      • Adopt a regular sleep schedule, sleep > 8 hours per night, and limit daytime naps to < 1 hour

      • Reduce caffeine, alcohol, tobacco, and other stimulant consumption

      • No exercise < 1 hour before bed

      • Eliminate excessive light and electronics in the bedroom

    • Pt advised to avoid OTC antihistamines

Notes

  • Acute vs. Chronic

    • Acute insomnia lasts < 3 months and generally has an identifiable stressor

    • Chronic insomnia lasts > 3 months

      • May be related to sub-optimally treated, underlying medication condition

      • May require medical treatment

  • Insomnia risk factors

    • Female sex

    • Night shift work

    • Medical conditions

      • Cardiovascular: HTN, heart failure

      • Respiratory: Obstructive sleep apnea (OSA)

      • Neurologic: Diabetic neuropathy, Parkinson disease (masked facies, unilateral resting tremor, cogwheel rigidity, shuffling gait)

      • Psychiatric (common): Anxiety, depression, PTSD, shift-work disorder

      • Other: Chronic pain, restless leg syndrome

    • Medications

      • OTC nasal decongestants, e.g. pseudoephedrine

      • Beta-blockers, e.g. metoprolol for heart failure

      • Glucocorticoids, e.g. prednisone for COPD

      • Antidepressants: SSRIs and SNRIs

      • Stimulants, e.g. methylphenidate

      • Vices: Caffeine, alcohol, tobacco

  • Medications not recommended for insomnia

    • Do not use antihistamines, benzodiazepines, mirtazapine, trazodone

    • Anticonvulsants and antipsychotics may have limited use