Insomnia
CFPC Key Features
In patients presenting with sleep complaints take a careful history to distinguish insomnia from specific psychiatric diagnoses or other sleep-related diagnoses (e.g., sleep apnea, periodic limb movements, restless legs syndrome, sleepwalking, sleep talking).
When assessing patients with sleep complaints:
Obtain a collateral history from the bed partner or parents, if possible and appropriate
Assess the contribution of drugs (prescription, over-the-counter, recreational), caffeine, and alcohol
In all patients with insomnia:
Provide appropriate advice about sleep hygiene (e.g., limiting caffeine, naps, and screen time, following regular sleep schedule, limiting bedroom activities to sleep and sex)
Offer other non-pharmacological options, such as cognitive behavioural therapy
When initiating sleep medications:
Educate the patient about risks and discuss these medications’ time-limited effects
Use hypnotic medications judiciously (e.g., prescribe only when disordered sleep has a severe impact on function, and only with a clear indication)
Negotiate a reduction and cessation plan with the patient
When a patient with a long-term history of using sleep medication presents for renewal of their prescription reassess, educate, and discuss tapering and alternative therapies.
General Overview
Definition: Difficulty initiating sleep, maintaining sleep or non-restorative/non-refreshing sleep, causing clinically significant distress or impairments in function
Acute: <3 months duration
Often sudden onset and associated with stress or disrupted sleep schedule
Chronic: >3 months for > nights/week, impairs daytime function
Both acute and chronic can be subdivided into initial (sleep-onset), middle (sleep-maintenance) or late (sleep-offset) insomnia
DDx
💡 The term "secondary insomnia" (i.e., insomnia stemming from another condition) may be avoided since it is often not possible to draw firm conclusions about the direction of causality between insomnia and comorbidities. Successful treatment requires attention to both insomnia and comorbidities.
Psychiatric
Anxiety**
Substance use (especially EtOH, caffeine, nicotine, stimulants)
Post-traumatic stress disorder
Medical
Hyperthyroidism
Diabetes
Medication (CNS stimulants/depressants, bronchodilators, antidepressants, beta antagonists, glucocorticoids)
Sleep Disorders
Hypersomnolence disorder
Narcolepsy
Circadian rhythm sleep-wake disorders
Delayed sleep-wake phase disorder (sleep normally if go to bed later and wake up later)
Common in adolescents
Advanced sleep-wake phase disorder (sleep normally if go to bed earlier and wake up earlier)
Non-REM Sleep Arousal Disorders
Sleep terrors
Sleep walking
Obstructive Sleep Apnea**
History
Sleep habits
Sleep latency (time to fall asleep), sleep efficacy (sleeping vs. time in bed), duration, disturbance
Activities (exercise, exposure to light/screens)
Stressors
Depression/anxiety screening
Impact on life/function
Alcohol
Drugs
Medications (including over-the-counter, herbal)
Caffeine
Collateral from bed-partner or household members
Investigations
Sleep clinic if suspect OSA or limb movement (or does not respond to treatment), or
Nocturnal polysomnography for sleep apnea or periodic limb movements of sleep
Consider TSH, fasting glucose
Consider Ferritin, Mg, renal function, B12 (restless leg syndrome)
Treatment
💡 Goal is improved continuity and quality of sleep (not 8 hours of sleep)
Non-Pharmacological Summary
Discuss sleep hygiene, determine patient's commitment to improve sleep
Sleep diary
Strict and constant routine of going to bed and getting up
Strengthen appropriate thoughts about sleep
Sleep needs to be allowed to occur, which can be very difficult for people trying desperately to enter that state
Consider stimulus control, and relaxation therapy (meditation)
Sleep restriction, avoid day-time napping
Sleep Hygiene
No caffeine/alcohol within 6h of bedtime
Alcohol helps with sleep initiation but impairs sleep maintenance
No nicotine (including replacement) close to bedtime
No excessive liquids or heavy evening meal before bedtime
Moderate physical activity, avoid heavy exercise within 3h of bedtime
Minimize noise and light
Temperature (avoid too warm)
Avoid watching/checking clock
Stimulus control
Re-associate bed/bedroom with sleep
Go to different room if sleep onset >15 minutes
Wake-up at same time each day despite how little sleep
Sleep Consolidation (Restriction therapy)
Sleep prescription to improve sleep efficacy (minimize bed time)
Avoid napping
Prescribe minimum sleep time (eg. 7h) + 30 minutes bedtime
Monitor by sleep logs
Once sleeping for >90% of time in bed for two weeks consecutively, and slowly increase bed time
Relaxation therapy
Stress management, relaxation techniques (breathing, light exercise, stretching, yoga)
CBT-I (Cognitive Behavioural Therapy for Insomnia)
Address inappropriate beliefs and attitudes that perpetuate insomnia
Unrealistic sleep expectations (eg. must have 9h of sleep)
Misconceptions about causes of insomnia (eg. chemical imbalance)
Amplifying consequences (eg. cannot function after sleeping poorly)
Performance anxiety, loss of control
Pharmacotherapy
Medications
General Principles:
Generally pharmacotherapy has high risks
Fatigue
Cognitive effects (memory impairment)
Fall, motor vehicle accident, fracture, mortality
Minimal benefits
Increased total sleep time by 25 minutes
Decrease sleep latency by 10 minutes
Consider pharmacotherapy only when disordered sleep has a severe impact on function, and only with a clear indication
Discuss goals/expectations, safety concerns, side effects
Beware of increased risks of adverse events in elderly patients especially with benzodiazepines and benzo-like/“Z” drugs (e.g., zopiclone, zolpidem)
Only prescribe as an adjunct (not alternative) to non-pharmacological measures
Ideally prescribe at lowest effective dose for short-term <7 days
Long-term use may be considered in severe insomnia resistant to CBT-I, but must be regularly re-assessed at each visit
Consider discussing reduction and cessation plan, and alternative therapies for patients on chronic pharmacotherapy for insomnia
Beware risk of rebound insomnia when deprescribing
Preferred agents:
Histamine receptor antagonists
Doxepin 6mg PO qHS
Doxepin 10mg (generic) may be cheaper
Minimal side effects and minimal risk of tolerance
Preferred in elderly
Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines)
Zopiclone 3.75-7mg PO qHS
Short half-life
Side effect: Metallic taste, daytime sleepiness
Risk of tolerance/dependence
Zolpidem 5-10 mg SL qHS
Caution in elderly
Risk of tolerance/dependence
Temazepam 15-30mg PO qHS
Intermediate half-life (higher risk of daytime sleepiness)
Avoid in elderly
Risk of tolerance/dependence
Variable evidence for natural sources (and variable quality control if OTC):
Melatonin 0.3-5mg (consider 0.1-0.5mg physiologic doses)
Preferred in pediatric population, especially if comorbid ADHD or ASD
Often first-line as high safety profile, low price, and ease of availability
L'Tryptophan 500mg-2000mg
Valerian 400-900mg
Other agents (generally not recommended unless also treating comorbidity):
Antidepressants: e.g., mirtazapine, amitriptyline, nortriptyline
Antipsychotics: e.g., quetiapine, (Seroquel), methotrimeprazine (Nozinan)
Muscle relaxants: e.g., cyclobenzaprine
Avoid off-label antihistamines (e.g., dimenhydrinate, diphenhydramine, doxylamine).
Follow-up
First visit
Assess and treat comorbidity
Sleep hygiene and behavioural interventions/CBT
Consider sleep diary
Consider investigation/pharmacotherapy based on patient
F/U 2-4 weeks
Evaluate sleep efficiency, daytime symptoms
Reinforce behavioural interventions/CBT
Review pharmacotherapy
F/U 3 months
If limited progress, referral to sleep medicine program or psychologist
References:
AASM 2017. http://www.aasmnet.org/Resources/clinicalguidelines/130217.pdf
AAFP 2017. https://www.aafp.org/afp/2017/0701/p29.html
CPS 2018. https://www.cps.ca/documents/position/melatonin-sleep-disorders-children-adolescents
CEP 2017. https://cep.health/clinical-products/insomnia-management-of-chronic-insomnia-tool/
Accelerating Change Transformation Team 2015. https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/Adult-Insomnia-CPG.pdf

