Key references discussed in the episode:
- NICE CKS. Scenario: Managing short-term insomnia (less than 3 months duration). May 2022.
- NICE CKS. Scenario: Managing long-term insomnia (more than 3 months duration). May 2022.
- BMJ Best Practice. Insomnia. 15 June 2021.
- PrescQIPP. Appropriate and cost-effective prescribing of short acting hypnotics. February 2017.
Key take-home points:
- There is no standard definition of a normal sleep requirement. This varies with ageing, and from person to person.
- With increasing age, total sleep time decreases.
- The normal time taken to fall asleep is considered to usually be less than 30 minutes.
- Insomnia is a “24-hour disorder” as it impairs daytime well-being and subjective abilities and functioning.
- It is probably best described as a condition of “unsatisfactory sleep, either in terms of sleep onset, sleep maintenance or early waking”.
- It is believed to affect around one-third of the general population in the UK and is between 1.5 and 2 times more prevalent among women.
- People with insomnia are often fatigued or anxious and become more tense and worried as bedtime approaches.
- When assessing insomnia, take a careful history to establish a possible underlying cause. What does the patient mean by “not sleeping”? Examine for possible cause including blood tests – thyroid function tests, iron and HbA1c – and always advise to keep a sleep diary for at least 2 weeks. If obstructive sleep apnoea is possible, consider an overnight sleep study (polysomnography). Do not rush to prescribe; give sleep hygiene advice first.
- About one third of patients with primary insomnia will improve with sleep hygiene advice alone.
- Treatment is only appropriate when insomnia causes significant personal distress or marked impairment.
- Hypnotics should be limited to the lowest effective dose for the shortest time possible, with a maximum 4-week treatment period and avoided where possible among elderly people.
- Prolonged-release melatonin can improve sleep onset and quality in patients aged over 55 with persistent insomnia.