Insomnia is characterized by difficulty in falling asleep or disturbance in sleep cycle leading to clinical effects of lack of sleep. Sleep disturbance could be a symptom of underlying medical or psychological conditions and hence a thorough assessment is needed before starting treatment for insomnia. Initial suggestions should be based on improving sleep hygiene.
Medications (depending on underlying factors):
- For acute insomnia associated with identifiable stressful events (family illness, death etc.) – Tab. Zolfresh 5 (Zolpidem 5 mg) – one tablet at night (immediately prior to bedtime) for no more than 3 weeks. This is associated with severe side-effects.
- For acute insomnia associated with change in sleep wake cycle (night shifts, night travel etc.) – Tab. Meloset 3 (Melatonin 3 mg) – Half tablet at night (30 minutes before bedtime). Gradually increase till maximum dose of 5 mg per night.
- Chronic insomnia in elderly patients or with difficulty in falling asleep – Tab. Meloset 3 (Melatonin 3 mg) – Half tablet at night (30 minutes before bedtime). Gradually increase till maximum dose of 5 mg per night.
- Tab. Nortimer 10 (Nortryptilline 10 mg) – 1 tablet at bedtime for chronic insomnia associated with depression or with frequent broken sleep.
General advice to improve sleep hygiene:
- Ensure good exercise routine – at least 6 hours before bedtime. It may take up to 2 months before this helps sleep cycle.
- Avoid heavy meal or exercise at least 90 minutes before bedtime.
- Avoid high level mental activities before bedtime.
- Avoid stimulating drinks such as caffeine based, carbonated drinks before bedtime.
- Have light bedtime snack or drink such as warm milk, non-caffeine drinks
- Do not carry out any mental activities in bed (reading, watching TV).
- Practice mental relaxation techniques – meditation, massage, breathing techniques.
- Reduce distractions whilst sleeping – ensure bedroom is quiet, dark and keep temperature comfortable.
- Create fixed sleep timetable – Fix time to go to bed, time in bed and wake up time.
- Early morning light exercise to promote prompt waking up routine.
Investigations:
Investigations are based on patient assessment to rule out underlying medical conditions:
- Thyroid function test – sleep disturbance is common in hypothyroidism
- HbA1c and diabetic screening – sleep disturbance is common due to hypoglycaemia or polyuria
- Renal and Liver function tests – to rule out uraemia, hepatic encephalopathy and dose adjustment
- Nt Pro BNP (N-terminal Pro B-type Natriuretic Peptide), ECG and Cardiac 2D echo – to rule out congestive cardiac failure
- Sleep studies – to rule out sleep apnoea.
Referral:
Consider referring patient to neurologist for organic causes. Consider referral to psychologist or psychiatrist if mental health disorder is suspected.