Help patients battle insomnia — safely

By Jennifer Laliberté

The lifetime prevalence of intermittent periods of sleep disturbance is reaching 30%. And fully 10-15% of your patients deal with chronic insomnia, according to Dr Malgorzata Rajda from the Sleep Disorders Clinic and Laboratory in Halifax. Of course, fatigue is a subjective and very commonly reported complaint, so it's imperative that you figure out why your patients can't sleep before taking action.

QUESTION PERIOD
Patients with insomnia may have difficulty falling asleep or maintaining sleep; be waking up too early in the morning or getting up repeatedly; or simply report not feeling well rested. "The first thing you have to do is figure out if there's a precipitating factor that's causing sleep difficulties," says Dr MacFarlane. "They may be in pain, dealing with a family issue or the loss of a job — it may very well be something that the physician can help with." Episodes of acute insomnia, lasting up to a few weeks, are often caused by a specific event. Dealing with it will often resolve the sleep issue.

Chronic insomnia occurs several times a week for one month or more and may be caused by several factors acting in combination, and often includes other health problems.

It's important to ask enough questions to identify the underlying cause of insomnia, because a mistake can lead to ineffective or even harmful interventions. "If the patient is waking up repeatedly from pain, you're better off finding a way to control that than prescribing a sleeping aid," points out Dr Rajda.

SUREFIRE SLEEP STOPPERS
She says half of people who have difficulty sleeping have an underlying psychiatric problem, like depression, anxiety or substance abuse. Some prescription drugs, and other sleep disorders like restless leg syndrome or obstructive sleep apnea, can also interfere with getting enough Zs.

You also have to figure out if patients are compensating for sleepless nights by means that are actually counterproductive. "Sleeping in on weekends, napping, drinking excessive caffeine or drinking alcohol before bed — all these things will send a patient into a vicious circle," says Dr MacFarlane. Lying in bed for hours trying to get to sleep is another common no-no, adds Dr Rajda.

GOOD SLEEP HABITS
The need for treatment is determined by the severity of the daytime symptoms, which include fatigue and lack of energy, difficulty concentrating and irritability. "If patients aren't experiencing any daytime consequences, what they need most is reassurance that they're getting the sleep they need," says Dr MacFarlane.

Patients whose insomnia affects their waking hours will often gain lasting relief from behaviour therapy. "Addressing their behaviour during the day and right before bedtime is the most effective approach," says Dr Rajda. For some behavioural modification tips, see "How to be a savvy sleeper," below.

SLEEPING AIDS
Hypnotic medications like benzodiazepine receptor agonists provide more rapid relief. "Patients who have a hard time falling asleep should be given a drug with a short half-life, that will be eliminated faster and prevent daytime drowsiness," recommends Dr Rajda. "If the problem is waking up repeatedly or too early in the morning, a drug with a short half-life taken at bedtime won't help."

Both Drs MacFarlane and Rajda agree that a script for a week or two, followed by a reassessment, is perfectly safe. "I often give a little bit more, just so they can have a few extra pills if they need them," says Dr MacFarlane. "Just knowing that they're in the medicine cabinet is enough to get some patients to sleep."

As a result of the rare but widely reported side effects of certain sleep medications many physicians prescribe older antidepressants, which can induce sleep as a side effect, instead. While prescribing an antidepressant isn't likely to hurt your patient, there's little evidence it'll do any good. "The major benefit is in patients with an established diagnosis of depression," says Dr Rajda.

Antihistamines and other OTC sleeping aids are widely used, especially in the elderly whose sleep patterns change as they age. Dr Rajda says these meds are OK if taken truly infrequently as a rescue medication, but nothing more. "They often produce a rebound daytime effect, and rapidly induce tolerance," she says. "If a patient needs them regularly, they're obviously not working and this needs to be addressed by the physician." Keep in mind that older patients are likely to have comorbid conditions or be taking other meds that interfere with their sleep, so a review of what they're taking is in order. "In my experience, elderly patients respond very well to things like increased activity and exposure to light," adds Dr Rajda.