...perchance to dream

Insomnia is a common complaint in primary care; it can cause:

• excessive daytime sleepiness
• irritability
• depression
• memory problems^1-5

Although prescription sleeping pills are very heavily advertised to both doctors and consumers, their risk-benefit ratio can be problematic for many patients.

By contrast, some simple behavioral interventions can be surprisingly effective.

Before reaching for the prescription pad:

Underlying issues may require treatment other than sedation.^6,7 Begin with a concise history of:

• medical problems;
• psychiatric symptoms;
• social/family issues;
• prescribed and OTC drug regimen;
• substance use (including caffeine, tobacco, and recreational drugs).

Define and manage underlying causes:

For example:

• If the patient can't sleep because of pain (as from osteoarthritis), treat the pain;
• If the patient can't sleep because of depression, address the depression;
• If the patient can't sleep because of trouble breathing (as from congestive heart failure, COPD, or asthma), manage the respiratory condition.

Occasionally, symptoms of insomnia may be caused by sleep apnea. This should be suspected if the patient has any of the following:

• nocturnal gasping, choking, or apneic spells;
• prominent snoring;
• extreme daytime somnolence;
• falling asleep inappropriately during the day.

Interviewing the bed partner may help in getting the complete history.

Sleep apnea can be a serious problem; if it is suspected, refer the patient for an overnight sleep study. Referral may also be indicated for patients who have evidence of "restless legs syndrome" or other movement disorder.

If no underlying causes are found, define symptoms with a sleep history:

Tools to collect additional data from the patient include:

Prescribe behavioral changes before drugs

Some simple interventions can lead to more normal sleep habits without resorting to medications.⁸ These are summarized in a patient education leaflet that can also be found on this website in the "Medication information for patients" section:

• consume no caffeine, alcohol, and nicotine after midday;
• use the bedroom only for sleep (and sex) - not for other activities;
• avoid daytime naps;
• get some exercise each day, but not right before bedtime;
• establish a relaxing bedtime routine (that may include bathing, reading, or a small snack);
• maintain a quiet, dark environment in the bedroom;
• get up at the same time each day; and
go to sleep only when tired.

Other good sources of information for patients can be found at http://healthysleep.med.harvard.edu/portal/, and http://www.sleepeducation.com/hygiene.aspx

If a prescription is needed

Meta-analyses of the clinical trial literature have found no significant differences in sleep outcomes among any of the benzodiazepines (BZDs) (such as flurazepam (Dalmane and generics) or BZD-agonists (such as zolpidem (Ambien and generics), eszopiclone (Lunesta), and zaleplon (Sonata and generics).^2,9,10 However, the BZD-agonists have a slightly better safety profile than BZDs.

These drugs produce changes in sleep patterns that are often modest, compared with placebo:

*A "number needed to harm" of X means that for every X patients treated, one will have a significant side effect.

Common side effects of prescription sleeping pills include:

• next-day drowsiness
• confusion
• gait instability
• dizziness
• headache

Substantial evidence links the use of both BZDs and BZD-agonists to an increase in the risk of hip fracture, which is why use in the elderly should be used with caution.¹¹

Comparative effectiveness and safety

For those with resistant insomnia, a trial of medication therapy is reasonable, while the patient continues behavioral interventions.

Treatment approach for insomnia, if a drug is requires

Prescription sleep meds do not necessarily need to be used on an every-night basis. Intermittent dosing of BZD-agonists works just as well as every-night dosing.¹² Based on long-term studies conducted primarily in non-elderly people, BZD-agonists dosed nightly or as needed can remain effective (without tolerance) in long-term use (6-12 months). However, continued use confers ongoing risk of side effects, especially in older patients. As with any medication, regularly reassess potential harms and benefits.¹³

Summary of the efficacy, safety, cost, and value of the therapies for insomnia

 *Most behavioral interventions are inexpensive to implement, but formal cognitive behavioral therapy programs can be expensive and limited in availability.

Other medications

Many other prescription and OTC drugs have sedating effects, and are widely used to treat insomnia. These include antihistamines, antipsychotics, antidepressants, valerian, and alcohol. Their efficacy is not well supported by evidence, and some may cause serious adverse effects, especially in older patients.

...pleasant dreams

First, diagnose the problem: look for treatable underlying causes. If no underlying condition is diagnosed, some simple behavioral changes can help address insomnia in many patients. Reserve drug treatment for patients who do not respond to behavioral approaches. use the lowest effective dose, and prescribe affordable generics. BZD-agonists work as well on an intermittent rather than an every-night basis. ongoing use confers ongoing risk of side effects especially in older patients.

References

1. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. May 2009;57(5):761-789. 2. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations and management of chronic insomnia in adults. Evid Rep Technol Assess (Summ). Jun 2005(125):1-10. 3. Buysse DJ. Chronic insomnia. Am J Psychiatry. Jun 2008;165(6):678-686. 4. Franzen PL, Buysse DJ. Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues Clin Neurosci. 2008;10(4):473-481. 5. Wilson JF. In the clinic. Insomnia. Ann Intern Med. Jan 1 2008;148(1):ITC13-11-ITC13-16. 6. Toward Optimized Practice. Guideline for Adult Insomnia: Assessment to Diagnosis 2010. Available at: http://www.topalbertadoctors.org/informed_practice/cpgs/adult_insomnia.html. 7. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. Oct 15 2008;4(5):487-504. 8. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. Nov 1 2006;29(11):1415-1419. 9. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. Sep 2007;22(9):1335-1350. 10. Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, 3rd, Kupfer DJ. Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. JAMA. Dec 24-31 1997;278(24):2170-2177. 11. Zint K, Haefeli WE, Glynn RJ, Mogun H, Avorn J, Sturmer T. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepi Drug Safety. Oct 2010 online. 12. Hajak G, Cluydts R, Declerck A et al. Continuous versus non-nightly use of zolpidem in chronic insomnia: results of a large-scale, double-blind, randomized, outpatient study. Int Clin Psychopharmacol 2002;17:9-17. 13. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev 2009;13(3):205-214.

These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient's clinical condition.