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
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
Suspicion for
Obstructive sleep apnea: Sleep study
Parkinsonism: Neurology
Refractory insomnia: Refer to sleep specialist
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