Insomnia is identified by problems in falling asleep, staying asleep, or contending with poor sleep quality, despite having the right circumstances for sleep (Kaur et al., 2023). These symptoms lead to daytime dysfunction and are the most prevalent sleep disorder in the United States, affecting approximately one-third of the population (Kaur et al., 2023). Chronic insomnia can have negative impacts on health, overall well-being, and increase daytime sleepiness. Additionally, insomnia is considered a substantial risk factor for various medical conditions such as heart problems, chronic pain syndrome, depression, anxiety, hyperglycemia, weight issues, and asthma (Kaur et al., 2023). It is also more commonly observed in individuals facing psychosocial stressors like disrupted family life, divorce, the loss of a spouse, and alcohol or substance abuse (Kaur et al., 2023).
Three questions and rationale for why you might ask these questions.
- Do you find it challenging to fall asleep, wake up frequently during the night, wake up too early in the morning, or take naps during the day?
2. Can you tell me about your daily sleep routine, specifically the time you go to bed and the time you wake up?
The key to identifying the cause of a patient’s sleep disorder and finding the right treatment lies in asking the appropriate questions. These questions help determine the timing of insomnia, the sleep schedule, and sleep habits (Chawla, 2022).
3. What time of day do you take your antidepressant sertraline?
Certain medications used to treat depression, such as SSRIs like sertraline, can lead to sleep problems (Stahl, 2021). To address this, it is important to consider the timing of taking these medications. By taking them during the day, it may help reduce the likelihood of experiencing insomnia as a side effect (Stahl, 2021).
People in the patient’s life to get feedback from to further assess the patient’s situation.
To gather feedback and evaluate the condition of the patient, it is important with the patient’s consent to engage with individuals who are closely associated with the patient, such as her children, grandchildren, caregivers, and close friends. These individuals may provide valuable information regarding any changes they have observed in the patient that she may not be aware of. Although these changes may be subtle, they can significantly impact the patient’s daily life. By considering their observations, valuable insights can be gained into the patient’s current concerns. To gain further understanding, it may be helpful to ask specific questions such as:
- What differences in behavior have you noticed in the patient and has the patient exhibited any suicidal ideations or self-harming behaviors?
2. Have you noticed any changes in the patient’s mood and how has the patient’s mood been lately?
3. Have you noticed the patient napping during the day, Is the patient more tired or irritable than usual?
By raising these questions, it would draw attention to and uncover changes that the patient might unintentionally omit or fail to observe and indicate signs of the patient’s condition worsening (Chawla, 2022).
What physical exams and diagnostic tests would be suitable
A comprehensive assessment of the patient’s medical history and systems should be conducted, including an evaluation of their family history of insomnia. It is important to inquire about their use of tobacco, caffeinated products, alcohol, and illegal drugs to identify potential factors contributing to their insomnia (Chawla, 2022). The physical examination can provide valuable insights into any underlying medical conditions that may be causing insomnia, aiding in the diagnosis and classification of the condition (Chawla, 2022). Each body system should be assessed to determine or rule out any medical conditions that could be contributing to the patient’s sleep difficulties. For example, the examination of the head and neck can help identify the presence of sleep apnea, while a neurological assessment can exclude restless leg syndrome (Chawla, 2022). Evaluating the affected organ system, such as the lungs, can also provide important information.
When managing chronic insomnia, it is crucial to conduct a thorough evaluation that considers the patient’s sleep-related history, underlying medical or psychiatric conditions, and any medications or other sleep disorders they may have (Kaur et al., 2023). Gathering a detailed sleep history is essential for a proper assessment of insomnia. The clinician should determine whether the sleep disturbances involve difficulty in falling asleep, staying asleep, or both. It is important to screen patients with underlying depression for early morning insomnia (Kaur et al., 2023). Additionally, other sleep-related disorders such as restless leg syndrome, sleep apnea, periodic limb movements, and nocturnal leg cramps should be evaluated during the clinical encounter, as they can contribute to sleep fragmentation (Chawla, 2022). Therefore, the appropriate evaluations when assessing a patient’s complaint of insomnia include a comprehensive assessment of their medical history, evaluation of sleep-related issues, screening for underlying conditions, and assessment of other sleep disorders (Kaur et al., 2023). The following are important assessments for the diagnosis of insomnia:
- The evaluation of underlying medical conditions associated with insomnia can be supported by laboratory tests. The initial workup should include various tests such as thyroid function tests, glycosylated hemoglobin, complete blood count, serum iron studies, liver function tests, and renal function tests (Kaur et al., 2023).
- Self-evaluating questionnaires and assessment scales, such as the Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index, are useful for documenting sleep disturbances and sleep quality (Kaur et al., 2023).
- Sleep logs/diaries are cost-effective ways to assess an individual’s sleep-wake cycle, including factors like alcohol and caffeine consumption, bedtime activities, and daytime napping. However, the reliability and validity of sleep log documentation may be a limitation (Kaur et al., 2023).
- Actigraphy, a wrist-worn device, can capture overall physical activity and sleep patterns but cannot detect irregular limb movements or abnormal breathing patterns in individuals with insomnia (Kaur et al., 2023). In situations where these specific sleep disorders are suspected, polysomnography becomes essential for a comprehensive evaluation (Kaur et al., 2023). Actigraphy, however, provides a convenient and objective means of assessing sleep and wakefulness by monitoring physical activity and exposure to light over extended periods (Chawla, 2022).
- Polysomnography is the preferred method for diagnosing various sleep disorders, but it is not typically indicated for the initial assessment of primary insomnia unless a co-existing sleep disorder is suspected (Kaur et al., 2023). Polysomnography involves an overnight stay at a sleep laboratory to monitor sleep stages and identify sleep disorders, including obstructive sleep apnea (OSA), periodic limb disorder, and REM sleep behavior disorder (Chawla, 2022).
Insomnia does not exhibit any distinct characteristics during physical or mental status examination (Krystal et al., 2019). Nevertheless, the examination can offer insights into other potential diagnoses and coexisting conditions.
List of differential diagnosis
– Primary Diagnosis
- Major depressive disorder (MDD) is characterized by several symptoms, such as a consistently low or depressed mood, reduced interest in enjoyable activities (anhedonia), and disruptions in sleep patterns (Bains & Abdijadid, 2023). MDD tends to be more prevalent among individuals who lack close interpersonal connections or have experienced divorce, separation, or widowhood (Bains & Abdijadid, 2023). Treatment for major depressive disorder encompasses a range of approaches, including medication, psychotherapy, interventions, and adjustments to one’s lifestyle (Bains & Abdijadid, 2023). MDD is the most appropriate diagnosis for the patient because she was depressed over the loss of her husband which she stated has gotten worse and has created the additional issue of insomnia. According to Patel et al. (2018), patients with depression and generalized anxiety disorder have higher rates of insomnia.
– Differential Diagnosis
- Obstructive sleep apnea (OSA): OSA is a sleep disorder characterized by a partial or complete blockage of airflow during sleep (Chawla, 2022). This condition is marked by repeated instances of the upper airway collapsing while asleep that leads to a decrease in oxygen levels in the blood and causes the individual to briefly wake up. Additionally, individuals with OSA may experience nocturia, insomnia, and restless sleep due to frequent awakenings and movement during the night (Chawla, 2022). The relationship between psychiatric conditions and insomnia is bidirectional, with each condition potentially exacerbating the other (Chawla, 2022).
- Restless leg syndrome (RLS): RLS is a condition that affects a significant proportion of adults aged 65 and above that can lead to various sleep disturbances such as difficulty falling asleep, frequent awakenings, and disrupted sleep patterns (Chawla, 2022). The key characteristic of RLS is an irresistible urge to move the legs, accompanied by uncomfortable sensations which the patient did not complain about. This urge intensifies during periods of rest or inactivity, is only temporarily alleviated by movement, and symptoms tend to worsen at night (Chawla, 2022).
Two pharmacologic agents and their dosing, mechanism of action, a rationale choosing one agent over the other, identify any contraindications to use or alterations in dosing for the chosen agent, and include any “check points†and indicate any therapeutic changes.
Insomnia in older patients can be addressed through various pharmacological interventions. These interventions can be categorized into benzodiazepine sedatives, nonbenzodiazepine sedatives, melatonin receptor agonists, antidepressants, and orexin receptor antagonists (Patel et al., 2018). The two medications for consideration for treatment of the patient complaints of insomnia and worsening depression are doxepin and ramelteon. However, the preferred treatment for the patient is doxepin due to its ability to treat both depression and insomnia (Stahl, 2021).
Doxepin 3 mg tablet, take orally once daily at bedtime for insomnia.
- Doxepin is a medication that specifically targets the histamine 1 receptor at low doses, resulting in improved sleep without the side effects associated with other neurotransmitter systems (Patel et al., 2018). It is safe for long-term use and does not lead to dependence (Stahl, 2021). However, patients over the age of 50 should undergo a baseline ECG, except for those taking Silenor (Stahl, 2021). Caution should be exercised when using this medication alongside drugs that may cause bradycardia, hypokalemia, intracardiac conduction slowing, QTc interval prolongation, in patients concerned about weight gain and those with cardiac conditions (Stahl, 2021). Lower doses may be necessary for patients with hepatic impairment. Doxepin is the only TCA approved by the FDA for insomnia (3 to 6 mg/day) and depression (75-150 mg/day) (Stahl, 2021). However, Kaur et al. (2023), indicated dosage range for depression of 25-300 mg daily. Doxepin can decrease wakefulness and promote sleep, providing immediate relief for insomnia, but it may take 2-4 weeks to see therapeutic effects for depression. If it is not effective within 6-8 weeks for depression, a dosage increase, or alternative treatment may be necessary. Patients at risk for electrolyte imbalances should have baseline and periodic serum potassium and magnesium measurements, especially if they are on diuretic therapy (Stahl, 2021). Therefore, caution should be exercised when using TCAs in patients taking drugs that can induce hypokalemia and/or magnesemia, such as diuretics (Stahl, 2021). Close monitoring is necessary for this patient because she is currently on HCTZ, as it can cause electrolyte imbalances. Initiation of Doxepin at the recommended dose is considered safe for this patient since there is no recorded history of MI or QTc prolongation.
Ramelteon 8 mg tablet, take orally once daily at bedtime for insomnia.
- Ramelteon, an FDA-approved treatment for insomnia, has shown significant reduction in sleep latency in older adults without rebound insomnia or withdrawal effects (Patel et al., 2018). It does not lead to dependence, memory disturbances, or nocturnal gait instability in older individuals (Patel et al., 2018). As a melatonin 1 and 2 receptor agonist, it binds selectively to these receptors and has a usual dosage range of 8 mg/day given at bedtime (Kaur et al., 2023). However, due to its low oral bioavailability, absorption may vary among patients, necessitating a range of doses (Stahl, 2021). The medication typically takes effect within an hour. If insomnia persists after 7-10 days, further evaluation for underlying psychiatric or physical conditions is recommended and if the medication is ineffective, dose adjustment or switching to another agent may be considered (Stahl, 2021). In the elderly, no dosage adjustment is necessary, although there may be higher plasma drug concentrations without increased side effects (Stahl, 2021). While ramelteon is suitable for insomnia, the ideal approach is monotherapy that effectively addresses both depression and insomnia in a single medication.
References
Bains, N., & Abdijadid, S. (2023). Major depressive disorder. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK559078/
Chawla, J. (2022). Insomnia clinical presentation: history, physical examination. https://emedicine.medscape.com/article/1187829-clinical
Kaur, H., Spurling, B., & Bollu, P. (2023). Chronic insomnia. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK526136/
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172
Stahl, S. M. (2021). Stahl’s Essential Psychopharmacology: Prescriber’s Guide (7th ed.). Cambridge University Press
