Insomnia: Inability to Sleep (FL INITIAL Autonomous Practice-Pharmacology)

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.

The American Occupational Therapy Association (2020) identifies rest and sleep as an occupation that supports healthy participation in other occupations. The act of taking rest, participating in routines that allow for comfortable rest, establishing consistent sleep patterns, and creating an environment conducive to good sleep are just a few examples of occupations that can impact the quality of sleep (American Occupational Therapy Association, 2020).

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 list 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 (Centers for Disease Control [CDC], 2017).

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 respiration. 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.

Many factors can lead to insomnia. Causative factors include medical or psychiatric diseases, 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):

• Medical illness – Arthritis, cancer, lung disease, heart failure, stroke, gastroesophageal reflux disease, benign prostatic hypertrophy, acute illness (e.g., bronchitis, sinusitis), 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 (primarily 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.
• Occupational imbalance - Overworking, too many responsibilities

Certain factors increase the risk of developing insomnia. Healthcare professionals who can identify those at high risk for insomnia are better able to care for them. Below is a listing of characteristics to help predict who may suffer from insomnia (Dopheide, 2020; National Institute of Health [NIH], 2021):

• 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 (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 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. This may impact participation in the classroom for children and adolescents. It also affects work as insomnia increases work absenteeism, reduces job performance, and increases the risk of errors at work (Bonnet & Arand, 2021). Sleep issues in the elderly translate to increased risk of social isolation, falls, cognitive impairments, mortality and morbidity (Leland et al., 2014).

Poor sleep also affects health, as those who suffer from insomnia are more likely to suffer from poor general health, have increased healthcare costs, and are more likely to catch a viral illness (NIH, 2019).

Many health problems are directly related to sleep disturbance. When evaluating clients, the provider needs to consider that sleep disturbances and chronic diseases are linked, and both need to be addressed.

Insomnia can result from a combination of personal, environmental, and occupation-related factors (Ho & Siu, 2022). Careful consideration of each of those factors as a part of routine occupational therapy evaluation is therefore imperative. Some assessments specifically focus on the quality of sleep, and they are listed below.

• Pittsburg Sleep Quality Index
• Epworth Sleepiness Scale
• Insomnia Severity Index
• Insomnia Symptom Questionnaire
• Functional Outcomes of Sleep Questionnaire
• Sleep Diary

If insomnia is going to be treated successfully, it needs to be understood by both the 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, patients must be asked about their sleep.

One tool used, 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 provider 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):

• What is the patient doing the day they are being evaluated? Are they working, at school, on a day off, going out for a night on the town, etc.?
• When did they consume alcohol, caffeinated products, or use nicotine?
• 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 lay down, when they fell asleep, and when they woke up.
• Record notes about the night, including how restful the sleep was. Was there any wakening in the middle of the night, any unusual disturbances, or were there any pain or other symptoms during sleep?
• The provider or the bed partner should evaluate the patient for snoring, apnea, or excessive 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 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 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 a 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.

Five classes of prescription sleep medications are available for the treatment of insomnia. These include (Neubauer, 2021):

• Benzodiazepines
• Nonbenzodiazepines
• Antidepressant (Doxepin®)
• Melatonin agonists
• Orexin receptor antagonists

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:

• Nervousness
• Nausea
• Vomiting
• Headache
• Coordination problems

Estazolam has a longer half-life and is more likely to be associated with next-day drowsiness. It is also associated with (Neubauer, 2021):

• Malaise
• Headache
• Constipation
• Dizziness
• Coordination problems

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®).

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 for those with obstructive sleep apnea (OSA) or those with severe chronic obstructive lung disease (COPD). Common side effects of Ramelteon include (Neubauer, 2021):

• Fatigue
• Headache
• Nausea
• Dizziness

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 to promote 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 referred her to an occupational therapist. The OT reviewed her routine and daily activity patterns. The OT offered strategies to manage stress. She now goes for walks 2-3 times a week and limits caffeine intake after noon. The OT also helped Helen select three sleep hygiene techniques that she would like to implement in preparation for good sleep. At the two-week follow-up session, she reported more restful sleep and a better mood. She will continue to work with OT to identify ways to manage her day and routine to improve the quality of sleep.

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 worked with his OT to establish a consistent sleep schedule. He also agreed to reduce the time spent playing video games after 8 pm to limit exposure to blue light and improve quality of sleep.

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.

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