Evaluating Insomnia

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Evaluating Insomnia - #38

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Learn underlying basic science and practical clinical management of insomnia evaluation.

Assessment

The following evaluation tools are useful for evaluating sleep disturbances:

  • Sleep Questionnaire / History

    • Ask about pre-sleep conditions, sleep-wake patterns, sleep-related symptoms, daytime consequences (see figures 1)

  • At-home sleep log
    • Document for ≥ 2 weeks, continue tracking during treatment
  • Psychological screening tests
    • Check for comorbid psychiatric conditions (e.g., anxiety, depression).
  • Bed partner interviews
  • Polysomnography recommended if a breathing or movement disorder is suspected, the diagnosis is uncertain, failed treatment, or violent sleeping habits6

Click on Figure 1 Below to Enlarge

PDF of Figure 1

When using this diagram, the clinician should be aware that the presence of one diagnosis does not exclude other diagnoses in the same or another tier, as multiple diagnoses may coexist. Acute Adjustment Insomnia, not a chronic insomnia, is included in the chronic insomnia algorithm in order to highlight that the clinician should be aware that extrinsic stressors may trigger, perpetuate, or exacerbate the chronic insomnia.

 

Figure 1: Insomnia Evaluation Algorithm

Context

Evaluation of sleep disturbances in a geriatric patient

Action

List evaluation strategies for insomnia which may be useful for geriatric patients

Definition

Insomnia: Difficulty with sleep which may include: prolonged sleep onset latency, frequent nocturnal awakenings, prolonged periods of wakefulness during the sleep period, or frequent transient arousals .

Incidence / Prevalence

Geriatric patients commonly experience sleeping disturbances. Although sources differ, up to 60% of geriatric patients report problems with sleeping at least a few nights per week, with 6-15% meeting diagnostic criteria for insomnia(1, 2). Higher rates of insomnia are seen in women, especially after the onset of menopause1. Despite the increased prevalence of insomnia in geriatric patients, insomnia is not normal aging(3). Sleep disturbances in geriatric patients are associated with decreased quality of life, daytime fatigue or low energy, cognitive decline, and mood dysphoria1. The increased prevalence of insomnia in the geriatric population is likely multifactorial in etiology. Comorbid medical, psychiatric, or neurologic illnesses leave patients more susceptible to sleep disturbances, due to the nature of the illness as well as the medications to treat the illness.

Underlying Sciences

Polysomnography (PSG), a type of diagnostic sleep test, has shown that older patients experience less total nighttime sleep, spend more time in bed, have more nighttime awakenings,, and take longer to fall asleep4. Physiologically, patients show increased activation of the autonomic nervous system, as indicated by increases in heart rate, blood pressure, metabolic rate, body temperature, activity of the hypothalamic-pituitary-adrenal axis, and norepinephrine secretion . This activation may explain why patients with insomnia typically have higher frequency brain waves while sleeping, a factor which may predispose them to awaking during sleep. Additionally, with age, the circadian rhythm becomes less synchronized; possibly affected by variation in bedtime, medications and dosing administration times, mealtimes and other changes in routine (e.g., timing of “lights-out/on” in long-term care facilities).(4)

Objectives

Identify strategies for evaluation of insomnia in a geriatric patient.
 

Keywords/Tags

Review of Systems (ROS)

Psychiatric

Geriatric Topics

Aging Principles
Cognitive, Affective & Behavioral Health

ACGME Compentencies

Medical Knowledge
Patient Care

References

  1. Kierlin L, Olmstead R, Yokomizo M, Nicassio P, Irwin MR. Diagnostic and Statistic Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults. Sleep Medicine. 2012; 13:958-960.
  2. McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. American Journal of Managed Care. 2009; 15(1):S14-S23.
  3. Galimi R. Insomnia in the elderly: an update and future challenges. Gerontology. 2010; 58:231-247.
  4. Morin CM, Benca R. Chronic Insomnia. Lancet. 2012; 379:1129-1141.
  5. Figure 1 from: Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep Medicine. 2008; 4(5):487-504.
This GFF ___ my competence in geriatrics.

Authors

Gretchen Wagner, Kathryn Denson, MD, Larry Hook, MD, Elizabeth Nilsson, MD, Dmitriy Shmaryan, MD

Author Affiliation

Medical College of Wisconsin

Copyright

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