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Insomnia: Inability to Sleep

1.00 Contact Hour:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Raymond M. Lengel (ARNP)

Purpose/Goals

This course will improve the nurse's ability to define, assess and manage insomnia.

Objectives

  1. Define insomnia
  2. Summarize common causes of insomnia
  3. Discuss the impact of insomnia on quality of lifea
  4. Review the steps in a nursing assessment of a patients with insomnia
  5. List four non-pharmacological methods to improve sleep
  6. Discuss the role of pharmacological therapy in the treatment of insomnia

Introduction

The Center for Disease Control defines insomnia as an inability to fall or stay asleep that can result in functional impairment throughout the day (Center for Disease Control, 2008). Insomnia may be associated with irritability, reduced concentration or poor functioning.

Insomnia is classified as primary or secondary insomnia. Secondary insomnia is the most common type of insomnia and is believed to affect more than 80% of people who suffer from insomnia (National Institute of Neurological Disorders and Stroke National Institutes of Health, 2007). Primary insomnia is insomnia that is not due to an underlying medical problem, whereas secondary insomnia is insomnia related to another cause such as a medication, medical problem or substance.

Another way to classify insomnia is by its duration. Acute insomnia is defined as insomnia less than 4 weeks. Chronic insomnia is defined as insomnia of greater than 4 weeks. For insomnia to be present it must present greater than 3 nights each week.

Insomnia affects about 60 million Americans each year (National Institute of Neurological Disorders and Stroke National Institutes of Health, 2007). Sleep disorders cost about 16 million dollars in direct health care costs each year (Reeve, K & Bailes B, 2010). Insomnia increases with age and is more common in women than men (National Heart, Lung and Blood Institute, 2007). A recent analysis showed that slightly less than 50% of people who had insomnia suffered for over three years and about 75% of those with insomnia had symptoms of insomnia for one year (Morin, C. M., Belanger, L., LeBlanc, M., Ivers, H., Savard J., Espie, C. A., Merette, C., Baillargeon, L. & Gregoire JP., 2009).

Age and Sleep

Having an understanding about how much sleep one needs is important in understanding insomnia. Below is a listing of what the average person needs for sleep in a 24-hour period. It must be understood that some people can function fine on less sleep than others (Center for Disease Control, 2008).

  • Adults need between 7-9 hours of sleep
  • Adolescents need between 8.5 and 9.5 hours
  • Children 5 to 12 years-old need 9-11 hours
  • Children 3 to 5 years-old need 11-13 hours
  • Children 1 to 3 years-old need 12-14 hours

Different ages have different sleep patterns. At about age 14 there is a shift in the circadian rhythm. Teenager's internal clock shifts to make them want to stay up late and sleep in. There is a physiological reason that high-school students have trouble sleeping.

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 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 in regard to sleep. The older adult is more likely to suffer from sleep disturbances from jet lag or from shift work.

Older adults are more likely to suffer from health problems associated with sleep such as restless leg syndrome, snoring or sleep apnea.

States of Sleep

Sleep is made up of two stages which include 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 four stages (one to four). Stage one is the lightest stage and stage 4 is the deepest stage. 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. This is the stage that 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.

The following case studies set forth the problem. As you read the course, consider the issues of the case. At the end of the course, the nurse practitioners conclusions and solutions are discussed.

Case Study 1

Helen is a 72 year-old retired female who presents to her nurse practitioner with the complaint of not being able to sleep for the last eight months. Her past medical history includes hypertension, depression and arthritis. Her current medications include hydrochlorothiazide, acetaminophen and bupropion.

She complains of inability to sleep for the past eight months, but the insomnia has increased in severity over the past few months. She wakes frequently at night, at least 4 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 3 months, social withdrawal, increased irritability, poor concentration and headaches. She also reports an increase in stress as she is helping take care of her grandkids and has been increasing her coffee intake to "give her the energy to care for the kids".

Her physical exam is unremarkable except for her body mass index being elevated at 29. Lab work was unremarkable.

Case Study 2

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.

Causes of Insomnia

Many factors can lead to insomnia. Causative factors include: medical or psychiatric disease, medications and environmental issues. Below is a listing of common causes of insomnia.

  • Medical illness - arthritis, cancer, lung disease, heart failure, stroke, gastroesophageal reflux disease, benign prostatic hypertrophy, acute illness (bronchitis), obstructive sleep apnea and obesity
  • Psychiatric illness - depression and anxiety
  • Psychological stress - money problems, divorce, change in family dynamics, death or new employment
  • Medications - corticosteroids (especially oral), bupropion, decongestants, hormones, alcohol, diuretics, theophylline and albuterol
  • Substances - caffeine, alcohol and nicotine
  • Environmental issues - poor sleep environment, shift work, too much light in the bedroom

Who is at Risk?

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 with insomnia.

  • Women have insomnia more than men
  • Increasing age is associated with insomnia
  • Individuals who suffer from depression or anxiety
  • Individuals who suffer from illnesses or on medications listed above
  • Smokers
  • Those who frequently drink alcohol
  • Shift workers
  • Individuals who have high stress levels (stressful job, going through a divorce, bankruptcy or the death of a loved one)
  • Low income
  • Individuals who travel long distances
  • Race is not linked to insomnia

Insomnia and Quality of Life

Insomnia negatively impacts quality of life. Poor sleep affects life in a number of 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.

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.

Many health problems are directly related to the sleep disturbance. Nurses need to consider that the sleep disturbance and chronic disease are linked. When insomnia is related to another disease, both conditions need to be addressed.

Nursing Assessment

If insomnia is going to be treated successfully it needs to be understood by both patient and 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 7 out of 10 people who have sleep problems do not report it to the health care provider (Reeve, K & Bailes, B, 2010). Because of this, it is important that nurses ask each patient about sleep.

One tool that can be used by nurses, 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 at: http://www.sleepeducation.com/pdf/sleepdiary.pdf.

Some of the key facts that need to be evaluated include:

  • What is the patient doing the day they are being evaluating? Are they working, at school, a day off, went out for a night on the town, etc?
  • When did they consume alcohol, caffeinated products or smoke?
  • Monitor what was done a few hours before bed? Did they exercise? Did they watch TV (what shows)?
  • Map out the sleep schedule including when they laid down, when they fell asleep and when they woke up.
  • Record any notes about the night including how restful the sleep was, was there any wakening in the middle of the night, were there any unusual disturbances or was there any pain or other symptoms during sleep?
  • Have the nurse or the bed partner evaluate for any snoring, apnea or excusive movement during sleep?
  • Evaluate how the patient felt the next day? Were they tired, did they fall asleep? How was the energy level? Was there excessive irritability? Was there poor concentration?
  • Evaluate the sleep environment. Is the room dark and quiet? What is the condition of the bed?

In addition to evaluating sleep a complete medical and social work up should be included. This includes evaluating for any of the medical problems that are known to be 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 are a contributing factor to sleep disturbances. Another common cause of sleep disturbance is gastroesophageal reflux disease 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 lives. 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 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.

Body weight should be evaluated. Those who are obese or have a neck circumference more than 18 inches are at higher risk of obstructive sleep apnea. Enlarged tonsils or an enlarged tongue is also an indication of sleep apnea.

Some cases of insomnia may require further diagnostic testing. If an underlying chronic disease is suspected than 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. This is a recording of 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.

Treatment

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 properly managed 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. This includes going to bed 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 sort of relaxation before bed will improve sleep. This may include activities such are meditation, stress management, taking a hot shower or prayer.

Practicing healthy habits will improve sleep. Incorporating an exercise program will improve insomnia. The exercise should be carried out earlier in the day. Vigorous exercise before bed is associated with difficulty falling asleep.

tress management is another important technique to improve sleep. 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 worry time during the day. This involves spending 10-15 minutes at a specific time every day to worry about things. This way 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 an adequate sleep environment is helpful to assure 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 adequate darkness.

The bed should be used for only sleep and sex. Do not use the bed for reading or watching TV.
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.

Exercise, eating, using caffeine, drinking large quantities of liquid and alcohol should not occur before bed. Exercise increase the sympathetic nervous system and makes it more difficult to sleep if done to close to bed. 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.

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 be used to 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 night time sleep.

Health Care Provider Interventions

Many cases of insomnia can be managed with the above interventions. This may take a lot of work and patients often would rather take a medication then have to take on all the tasks necessary to improve 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. There are many interventions that can be implemented and they take repetitive encouragement.

Another strategy is to refer a patient to a therapist to help them not only implement some of the strategies listed above, but help them talk through some of the issues that are interfering with sleep. This often takes the form of cognitive behavioral therapy (CBT).

CBT works just as well as medications used to manage sleep. Effects of CBT may be noticed for up to two years - which is longer than the benefits of medications (National Institute of Neurological Disorders and Stroke National Institutes of Health, 2007).

CBT can be used for a variety of mental health conditions, but for insomnia it works best when there are 4-8 sessions for 30 minutes each. Being familiar with a good local therapist is important. Outcomes are improved with a practitioner who is highly trained (Reeve, K & Bailes B, 2010).

Pharmacological Management

When all medical co-morbidities have been properly 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 agent, 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.

The majority of agents used in the management of sleep are indicated for short term use, although many people use them for months to years.

Medications used in the management of insomnia range from over-the-counter medications to prescription medications indicated for sleep to medications not indicated 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, confusion and urinary retention. Side effects are more problematic in the older adult.

A recent analysis showed that sound machines are more effective than over-the counter medicines in the management of insomnia (Consumer Reports, 2008).

Prescription Medications

Three classes of sleep medications are available for the treatment of insomnia. These include: benzodiazepines, nonbenzodiazepines and melatonin receptors.

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. This class typically has a longer half-life and is 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.

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 good for sleep onset insomnia. Like other sleep agents it may be associated with next day drowsiness. Other side effects include: nervousness, nausea, vomiting, headache and coordination problems.

Estazolam has a longer half-life and is more likely to be associated with next day drowsiness. It is also associated with malaise, headache, constipation, dizziness and coordination problems.

Caution should be used in those who have a history of drug or alcohol abuse, those with untreated obstructive sleep apnea and in 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 the older adult. If the drug has been used for an extended period of time, it must be tapered slowly. Abrupt withdrawal may lead to rebound insomnia, nausea, vomiting, anxiety and memory impairment.

More commonly the nonbenzodiazepine class is used for treatment of insomnia. Medications in this class include: Zaleplon (Sonata), Eszopiclone (Lunesta) and Zolpidem (Ambien).

Drug Half-life Notes
Eszopiclone (Lunesta) 6 hours Is 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 Ambien helps with getting to sleep and Ambien CR helps with both getting to sleep and staying asleep. It has been associated with sleep walking and doing night time activities with no memory of doing them in the morning. Less tolerance is noted with Ambien CR. Other side effects include: daytime drowsiness, abnormal dreams, headache, dizziness and lack of coordination. Side effects are more common at higher doses.
Zaleplon (Sonata) .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.

Melatonin receptor agonists are a newer class of medications used in the management of insomnia. Ramelteon (Rozerem) works through a unique mechanism and is not linked to dependence. Its absorption is decreased after a high fat meal. It is not recommended in those with obstructive sleep apnea or those with severe chronic obstructive lung disease. Common side effects of ramelteon include: fatigue, headache, nausea and dizziness. It is most likely the safest drug to use for long-term use.

Alternative products

Many patients will chose alternative products in place of prescription or over-the counter products in the management of sleep disturbances. Melatonin and valerian root are commonly used for insomnia and may help in its management (Reeve, K & Bailes B, 2010).

Melatonin is not effective for most cases of insomnia, but it may work in those who suffer from jet lag, shift workers and those with circadian rhythm disturbances.

Valerian root has limited data to show its effectiveness in those with sleep disturbances, but is associated with sedation during the day in those who take it at night.

Other mediations

Some drugs 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: doxepin, trazodone, mirtazapine and amitriptyline.

Case Study Conclusion

Helen is suffering from co-morbid depression and insomnia. It is important to focus on both conditions in an effort 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 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 to enhance her sleep. She was scheduled for a follow up in two weeks to evaluate the efficacy of this intervention. If no improvement is noted than the addition of an agent for insomnia will be considered.

Case study two conclusions

John was disappointed with his doctor's decision to not give him a long-term prescription of 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 was able to reduce 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 to not eat a large meal before bed and restart his exercise program. He also implemented many of the non-pharmacological interventions outlined above.

Removal the albuterol and pseudoephedrine from his medical treatment plan resulted in a significant improvement in his insomnia. John was unwilling 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 that he implemented significantly improved his sleep.

Conclusion

Insomnia is a widespread problem that can and should be managed by the nursing profession. 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 the insomnia, helping the patient implement lifestyle changes to manage insomnia and lastly assist the patient to work with their doctor to use any medications used in the management of insomnia.

References

Center for Disease Control. (2008). Sleep and Sleep Disorders. Retrieved February 16, 2010 from (Visit Source).

Consumer Reports. (2008). The Trouble with Drugs. Retrieved March 3, 2010 from (Visit Source).

Foldvary-Schaefer, N. (2009). The Cleveland Clinic Guide to Sleep Disorders. New York: Kaplan Publishing.

Jacobs, G. D. (2005). National Institutes of Health State-of-the Science Statement on Chronic Insomnia in Adults. Retrieved February 17, 2010 from (Visit Source).

Kelso, C. M. & Gentilli, A. (2009). Primary Insomnia. Retrieved March 1, 2010 from (Visit Source).

Morin, C. M., Belanger, L., LeBlanc, M., Ivers, H., Savard J., Espie, C. A., Merette, C., Baillargeon, L. & Gregoire JP. (2009). The natural history of insomnia: a population-based 3-year longitudinal study. Achieves of Internal Medicine. 169(5), 447-53.

National Institute of Neurological Disorders and Stroke National Institutes of Health. (2007). Brain Basics: Understanding Sleep NIH Publication No.06-3440-c. Retrieved February 16, 2010 from (Visit Source).

Reeve, K. & Bailes, B. (2010). Insomnia in Adults: Etiology and Management. The Journal for Nurse Practitioners. 6(1), 53 - 60.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, Medical Surgical


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