≥ 92% of participants will report an increase in knowledge regarding assessing and managing insomnia.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will report an increase in knowledge regarding assessing and managing insomnia.
After completing this activity, the learner will be able to:
Insomnia involves difficulties initiating sleep, difficulties with sleep maintenance, and subsequent daytime impairment in function (Mah & Pitre, 2021). Insomnia may be associated with irritability, reduced concentration, or poor functioning.
Insomnia is classified by its duration, with acute insomnia defined as insomnia that lasts days to weeks, and chronic insomnia is defined as insomnia of greater than three months. For insomnia to be present, it must occur greater than three nights each week (National Institute of Health [NIH], 2022).
In the United States, insomnia costs more than 100 billion dollars annually (Reynolds & Ebben, 2017). Insomnia accounts for over 9.4 million office visits per year. Up to 40 percent of adults report insomnia symptoms every year, and at any given time, there is a 9.5 percent prevalence of short-term insomnia in the United States. Of the short-term cases of insomnia, approximately 20 percent transition to chronic insomnia. Insomnia is a persistent problem in those affected, with 40-70 percent of individuals suffering as long as four years (Dopheide, 2020).
Having an understanding of how much sleep one needs is essential in understanding insomnia. Below is a listing of what the average person needs for sleep in 24 hours. It must be understood that some people can function fine on less sleep than others (Center for Disease Control [CDC], 2017).
|Adults (over 65 years old):||7-8 hours|
|Adults:||7 or more hours|
|Children 6 to 12 years old:||9-12 hours|
|Children 3 to 5 years old:||10-13 hours|
|Children 1 to 2 years old:||11-14 hours|
|Infants 4 to 12 months:||12-16 hours|
Different ages have different sleep patterns. At about age 14, there is a shift in the current circadian rhythm. Teenagers' internal clock shifts to make them want to stay up late and sleep into the later morning hours. Therefore, there is a physiological reason that high-school students have trouble sleeping (CDC, 2017).
Older age is also associated with changes in sleep. Older individuals sleep a similar amount of time, but they often have trouble staying asleep for one long sleep session. Those over 65 years-old wake more frequently at night and have a difficult time falling back asleep. Older adults spend less time in the deeper stages of sleep. Aging comes along with more difficulty adapting to changes regarding sleep. The older adult is more likely to suffer from sleep disturbances from jet lag or shift work. Older adults are more likely to suffer from sleep-related health problems such as restless leg syndrome, snoring, or sleep apnea (NIH, 2021).
Sleep comprises two stages: rapid eye movement sleep (REM) and non-rapid eye movement (NREM) sleep. When asleep, the majority of time is spent in NREM sleep, which is broken down into three stages. Stage one is the lightest and stage 3 is the deepest. In stage one, the person is drowsy with the eyes closed but can be easily woken. The stages get progressively deeper.
REM sleep has one stage in which dreams occur and it is associated with eye movements, increased brain activity, and increased respirations. The body cycles through the stages 5-6 times each night (NIH, 2019).
As you read through the course, consider the issues of the following cases. At the end of the course, conclusions and solutions are discussed.
Helen is a 72-year-old retired female who presents to her nurse practitioner with the complaint of not sleeping well for several months. Her past medical history includes hypertension, depression, and arthritis. Her current medications include hydrochlorothiazide, acetaminophen and ibuprofen.
She complains of not sleeping well for the past eight months, but the insomnia has increased in severity over the past few months. She frequently wakes at night, at least four nights a week. She also complains of difficulty falling asleep. She reports that she often feels extremely tired during the day and at times needs to take a nap.
Her review of systems is positive for a ten-pound weight gain over the past three months, social withdrawal, increased irritability, poor concentration, and headaches. She also reports increased stress as she is helping take care of her grandkids and has been increasing her coffee intake to have “the energy to care for the kids."
Her physical exam is unremarkable except for her body mass index (BMI) being elevated at 29. Lab work is unremarkable.
John is a 34-year-old male who is a shift worker at the local factory. His past medical history is remarkable for asthma and allergies. His current medications include an albuterol inhaler which he takes three times a day and over-the-counter loratadine-D for his allergies that he takes once a day.
His job has been recently more stressful, with his boss encouraging him and his co-workers to work through their lunch break to get more work done. He comes home from work extremely hungry and eats a large meal, and then goes to bed. His extended work hours have reduced his exercise time.
Many factors can lead to insomnia. Causative factors include medical or psychiatric disease, medications, and environmental issues (Chun et al., 2021). Below is a listing of common causes of insomnia (Dopheide, 2020; National Institute of Health [NIH], 2019):
Certain factors increase the risk of developing insomnia. Nurses who can identify those at high risk for insomnia are better able to care for them. Below is a listing of characteristics to help the nurse predict who may suffer from insomnia (Dopheide, 2020; National Institute of Health [NIH], 2021):
Insomnia negatively impacts the quality of life. Poor sleep affects life in many ways. Insomnia affects mental function. Those with insomnia may suffer from reduced concentration and poor memory. It also affects work as insomnia increases work absenteeism, reduces job performance, and increases the risk for errors at work (Bonnet & Arand, 2021).
Poor sleep also affects health as those who suffer from insomnia are more likely to suffer from poor general health, have increased health care costs, and are more likely to catch a viral illness (NIH, 2019).
Many health problems are directly related to the sleep disturbance. When nurses are evaluating patients, they need to consider that sleep disturbances and chronic diseases are linked. When insomnia is related to another disease, both conditions need to be addressed.
If insomnia is going to be treated successfully, it needs to be understood by both patient and the nurse. Insomnia can result from different causes and present in different ways. It is, therefore, critical to fully assess the patient with insomnia.
Insomnia is a disease that is underreported. As many as two out of three adults are affected by insomnia (Bonnet & Arand, 2021). Because of this, nurses must ask each patient about their sleep.
One tool nurses use, especially in the primary care setting, is questionnaires to evaluate sleep quality. Two popular ones are the Pittsburg Sleep Quality Index and the Epworth Sleepiness Scale.
Tracking sleep is the first part of the sleep assessment. Tracking sleep can be accomplished in a variety of ways. Having the patient maintain a sleep diary provides helpful information for the nurse to assess sleep patterns. A two-week sleep diary can be downloaded here.
Some of the key facts that need to be evaluated include (NIH, 2022):
In addition to evaluating sleep, a complete medical and social workup should be done, including evaluating for any medical problems associated with insomnia.
Uncontrolled medical or psychiatric diseases contribute to insomnia. Is there any pain? Pain can significantly reduce the quality of sleep. If pain is present, the underlying cause should be determined and managed. Evaluation of any respiratory conditions should be carried out as lung diseases contribute to sleep disturbances. Another common cause of sleep disturbance is gastroesophageal reflux disease (GERD), and specific questions to evaluate for this should be asked.
A review of medications should also be included because many medications are linked to insomnia.
A major cause of insomnia is stress. Evaluating the patient's life may give insight into the cause of insomnia. Each patient should be asked about any stress in their life. Some areas to probe include: stress at work, a new job, stress at home, a changed personal relationship (divorce, marriage, a child going off to college, etc.), or the death of a friend or family member.
After a complete interview with the patient and an evaluation of the sleep habits, the next step is a complete physical exam. The physical exam is meant to pick up any conditions that may be contributing to insomnia.
Bodyweight should be evaluated. Those who are obese or have a large neck circumference are at higher risk of obstructive sleep apnea (OSA) (Bonnet & Arand, 2021). Enlarged tonsils or an enlarged tongue is also an indication of sleep apnea.
Some cases of insomnia may require further diagnostic testing (Bonnet & Arand, 2021). If an underlying chronic disease is suspected, then evaluation for that condition should ensue. A popular method to evaluate the patient with insomnia is evaluating the patient in a sleep lab. One test often done is a polysomnogram which records the physiological variables of sleep. It usually includes an electroencephalogram (EEG), electromyogram (EMG), electrocardiogram (ECG), respiratory assessment, oxygen saturation, and limb movement assessment. Sometimes esophageal pH is monitored to assess for acid in the esophagus.
This assessment can evaluate for the presence of underlying factors that contribute to insomnia. Some conditions that may be picked up include obstructive sleep apnea, restless leg syndrome, gastroesophageal reflux disease, and seizures (Bonnet & Arand, 2021).
The first step in the treatment of insomnia is to manage any underlying medical problems. Most cases of insomnia are secondary insomnia, so the majority of cases of insomnia will never be managed appropriately if the underlying cause is not identified and treated.
At the same time that underlying conditions are being evaluated and worked up, the patient should be taught non-pharmacological interventions to improve sleep. Non-pharmacological interventions are critical to the management of insomnia as pharmacological options are associated with many side effects.
Nurses need to teach patients about steps they can take to improve the quality and quantity of their sleep. Those with insomnia need to develop a regular sleep routine, including going to bed at the same time every day and waking up at the same time.
Maintaining a consistent routine before bed will help set the mood for sleep. Ideally, incorporating some relaxation before bed will improve sleep, including meditation, stress management, taking a hot shower, or prayer.
Practicing healthy habits will improve sleep. Incorporating an exercise program will help to improve insomnia. The exercise should be carried out earlier in the day. Vigorous exercise before bed is associated with difficulty falling asleep (Kline et al., 2021).
Activities practiced before bed can have an impact on sleep. Blue light, which is emitted by electronics, may interfere with sleep. There is evidence that blue light suppresses melatonin secretion (a hormone made by the pineal gland that helps regulate sleep and wake cycles), thereby interfering with sleep (Dopheide, 2020). Nurses should encourage patients not to look at bright screens of electronic devices two to three hours before bed. If you must look at electronic devices at night, consider blue-light blocking glasses or install an app that filters blue wavelengths.
Stress management is another essential technique to improve sleep (Dopheide, 2020). Those who manage stress are better able to quiet their mind at night. One technique that can be tried is to tell patients to set a worrying time during the day, which involves spending 10-15 minutes at a specific time every day to worry about things. When the patient's mind tries to worry at night, they can remind themselves that they are to worry at a specific time tomorrow.
Setting up a good sleep environment is helpful to ensure adequate sleep. Make sure that the room is dark. Investing in adequate shades and curtains and turning off any lights will help individuals get to sleep. The use of a sleep mask may be needed to get sufficient darkness. The bed should be used for only sleep and sex. Do not use the bed for reading, watching TV, or other activities. The room should be quiet. Earplugs or white noise machines may help with sleep. The bed should be comfortable. A good mattress and pillows can aid in sleep. Those with back pain can sometimes benefit from a pillow under the knees. A comfortable sleep environment includes a comfortable temperature.
Do not nap. Naps during the day disturb the sleep-wake cycle and may make insomnia worse (Dopheide, 2020).
Exercise, eating, using caffeine, and drinking large quantities of liquid and alcohol should not occur before bed. Exercise increases the sympathetic nervous system and makes sleeping more difficult if done too close to bed (Kline et al., 2021). Eating before bed, especially a big meal, increases the risk of gastroesophageal reflux. Drinking, especially a lot of fluid, increases the risk of getting up in the middle of the night to use the bathroom. Caffeine is a stimulant and reduces the ability to sleep. Alcohol, while sedating, actually reduces the quality of sleep and results in early morning awakening (Dopheide, 2020).
Encourage patients to be careful what they do when they wake up in the middle of the night. Ideally, they should not open their eyes when they wake up in the middle of the night. If they do open their eyes, do not look at the clock. The more one does when they wake up, the more work the mind has to do and the more this drives the patient awake.
Placing a nightlight in the bathroom can reduce the need to turn on the bright overhead lights when awakening in the middle of the night. Bright light exposure in the middle of the night drives the patient out of a state of sleep.
Spend a little time outside every day. Bright light during the day is associated with improved nighttime sleep.
Many cases of insomnia can be managed with the above interventions. Non-pharmacological interventions require more effort than medications, and patients often would rather take medication than have to take on all the tasks necessary to improve the quality of sleep.
When the patient returns to the office to discuss what else can be done, the first step a nurse must take is to review and coach the patient again about non-pharmacological interventions. Many interventions can be implemented, and they take repetitive encouragement.
Another strategy is to refer a patient to a therapist to help them implement some of the strategies listed above and help them talk through some of the issues interfering with sleep. Cognitive-behavioral therapy (CBT) is the type of therapy that this entails.
CBT works just as well as medications used to manage sleep (Martin, 2021). Treatment is most effective when given over 4-8 sessions and is done in person or remotely. Effects of CBT may be noticed for up to two years - which is longer than the benefits of medications (Martin, 2021).
CBT can be used for a variety of mental health conditions, including insomnia. CBT for insomnia includes sleep education, sessions that focus on stimulus control and sleep restriction, cognitive therapy, and sleep hygiene. Being familiar with an excellent local therapist is essential. CBT improves multiple aspects of sleep, including sleep efficiency, wake time after falling asleep, and sleep onset latency (Martin, 2021).
When all medical co-morbidities have been adequately managed and non-pharmacological interventions tried without success, the use of medications to manage insomnia can be implemented.
Even though medications are often tried as a first-line intervention, they should not be considered until all other options have been exhausted. Medications used in the management of insomnia are not without risk and have many side effects. Some of the risks include drowsiness the next day, dependency, impaired memory, hallucinations, and sleepwalking. The older adult is at higher risk for side effects and complications.
Most agents used in managing sleep are indicated for short-term use, although many people use them for months to years.
Medications used to manage insomnia range from over-the-counter medications to prescription medications indicated for sleep to medications not indicated specifically for sleep but have sedating properties.
Over-the-counter medications used in the management of insomnia typically contain an antihistamine. The two most popular antihistamines in over-the-counter sleep medications are diphenhydramine (Benadryl) and doxylamine succinate (Unisom).
While these agents are effective in the short-term management of insomnia, tolerance quickly develops to them. In addition, they are laced with side effects, including constipation, dry mouth, blurred vision, next-day drowsiness, confusion, and urinary retention. Urinary retention is more likely in men with an enlarged prostate. Side effects are more problematic in older adults.
Five classes of prescription sleep medications are available for the treatment of insomnia. These include (Neubauer, 2021):
When prescription medication is added to the treatment of insomnia, non-pharmacological interventions should still be promoted.
Benzodiazepines are the oldest class of drugs to help with sleep and have some disadvantages over the nonbenzodiazepine class. Benzodiazepines typically have a longer half-life and are more likely to lead to sedation the next day.
Not all benzodiazepines are FDA approved for insomnia. Alprazolam (Xanax®) and lorazepam (Ativan®) are two popular benzodiazepines, and while often used to induce sleep, are not FDA approved for the treatment of insomnia. A popular benzodiazepine used in the treatment of insomnia is Temazepam (Restoril®). This agent is less effective for sleep onset and commonly leads to daytime drowsiness (Chawla, 2020).
Triazolam (Halcion®) and estazolam (ProSom®) are other agents used for insomnia in the benzodiazepine class. Triazolam has a rapid onset of action and a short half-life, making it suitable for sleep-onset insomnia. Like other sleep agents, it may be associated with next-day drowsiness—other side effects include:
Estazolam has a longer half-life and is more likely to be associated with next-day drowsiness. It is also associated with (Neubauer, 2021):
Benzodiazepines should be used cautiously in those with a history of drug or alcohol abuse, untreated obstructive sleep apnea, and pregnancy. All medications for insomnia must be used cautiously in those with chronic lung disease as they may suppress the respiratory drive. In addition, they may lead to increased confusion in older adults.
If the drug has been used for an extended period, it must be tapered slowly. Abrupt withdrawal may lead to rebound insomnia, nausea, vomiting, anxiety, and memory impairment.
More commonly, nonbenzodiazepine hypnotics are used for the treatment of insomnia. Medications in this class include: Zaleplon (Sonata®), Eszopiclone (Lunesta®) and Zolpidem (Ambien®).
|Eszonpiclone (Lunesta®)||6 hours||Sometimes used long-term as it is indicated for chronic insomnia. Its peak action is in about one hour. Common side effects include next-day drowsiness, an unpleasant taste, dry mouth, headache, and dizziness.|
|Zolpidem (Ambien® and Ambien® CR)||2.5 hours||Zolpidem helps with getting to sleep, and zolpidem controlled-release helps with both getting to sleep and staying asleep. Less tolerance is noted with zolpidem controlled-release. It has been associated with sleepwalking and doing nighttime activities with no memory of doing them in the morning. Side effects, which are more common at higher doses, include daytime drowsiness, abnormal dreams, headache, dizziness, and lack of coordination.|
|Zaleplon (Sonata®)||0.5 to 1 hour||Helpful in sleep initiation due to short half-life. Least likely to be associated with daytime drowsiness. Side effects include headache, malaise, bloody nose, and altered color perception.|
Ramelteon (Rozerem®) is a melatonin receptor agonist used to manage insomnia and works best to get the patient to fall asleep but likely has little effect on sleep maintenance. Ramelteon works through a unique mechanism and is not linked to dependence. It is not recommended in those with obstructive sleep apnea (OSA) or those with severe chronic obstructive lung disease (COPD). Common side effects of Ramelteon include (Neubauer, 2021):
The absorption of Ramelteon is decreased after a high-fat meal. It is one of the safer medications to use for long-term use (Neubauer, 2021).
A newer class of medication is called the “orexin receptor antagonists”. Orexin is a hypothalamic neuropeptide and is instrumental in regulating sleep. These agents work in promoting sleep onset and sleep maintenance. There are two medications in this class, Suvorexant (Belsomra®) and Lemborexant (Dayvigo®). These agents work by inhibiting the OX1R and OX2R receptors to suppress the wake drive.
Suvorexant is dosed at 10-20 mg and Lemborexant is dosed at 5-10 mg. Discontinuation may lead to rebound insomnia. These medications lead to impaired driving the next day and may cause daytime somnolence (Neubauer, 2021; Chawla, 2020).
Many patients will choose alternative products in place of prescription or over-the-counter products to manage sleep disturbances. Melatonin and valerian root are sometimes used for insomnia and may help in its management (Chawla, 2020).
Research on melatonin is limited, but it suggests that it increases total sleep time, reduces sleep latency, and improves circadian rhythms (Chawla, 2020). The American Academy of Sleep Medicine (AASM) is concerned about the medication's limited safety data and does not recommend the medication for chronic insomnia (Sateia et al., 2017).
Valerian root has limited data to show its effectiveness in sleep disturbances but is associated with daytime sedation. The AASM does not recommend valerian root for chronic insomnia (Sateia et al., 2017).
Some medications are used off-label for the treatment of insomnia. The use of sedating anti-depressants helps induce sleep, but they are not FDA approved for insomnia. Some medications often prescribed include mirtazapine, trazodone, and amitriptyline.
Helen is suffering from co-morbid depression and insomnia. It is essential to focus on both conditions to manage her health. Her depression is being treated with bupropion which was started about six months ago with minimal improvement in her mood. In addition, bupropion increases stimulation and may not be the best medication for enhancing sleep.
The nurse practitioner changed her bupropion to paroxetine. The use of mirtazapine was considered, but selective serotonin reuptake inhibitors (SSRIs) are first-line treatments for depression and there was more concern about weight gain with mirtazapine.
Instead of prescribing a sleep agent, the nurse practitioner reviewed multiple strategies for Helen to practice enhancing her sleep. She was scheduled for a follow-up in two weeks to evaluate the efficacy of this intervention. If no improvement is noted, then the addition of an agent for insomnia will be considered.
John was disappointed with his doctor's decision not to give him a long-term prescription for sleeping pills but was willing to try non-pharmacological interventions to improve his insomnia. He started taking a fluticasone inhaler twice a day for his asthma and reduced the frequency of his albuterol inhaler to once or twice a week. He also started taking loratadine (without the decongestant) and started taking budesonide intranasally. The purpose of these changes was to reduce the number of medications he was taking that may have contributed to his insomnia.
He took his doctor's advice not to eat a large meal before bed and restart his exercise program. He also implemented many of the non-pharmacological interventions outlined above.
Removal of the albuterol and pseudoephedrine from his medical treatment plan resulted in a significant improvement in his insomnia. John was unable to change jobs and was stuck in a situation where he would be required to continue with his shift work, but the medication and lifestyle changes he implemented significantly improved his sleep.
Insomnia is a widespread problem. It is a problem that is associated with other medical conditions. If not addressed, it has the potential to exacerbate other health issues. The nurse's role in the management of insomnia includes: Evaluating the condition, identifying possible causes of insomnia, helping the patient implement lifestyle changes to manage insomnia, and lastly assisting the patient in working with their doctor to use non-pharmacological interventions or pharmacological methods of treating the patient’s insomnia.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.