Many barriers exist to the diagnosis and treatment of insomnia. Insufficient physician training in the recognition and treatment of insomnia combined with ever-decreasing office-visit duration bias against the evaluation of sleep disorders in the primary care setting. Many physicians and patients share a common belief that sleep disorders are self-limited and not important. Since treatment of insomnia often involves the prescription of powerful medications with numerous side effects, many physicians are also reluctant to engage their patients regarding sleep-related problems.
Initial Evaluation of Insomnia
A general medical question combined with routine laboratory testing is an important component of the initial approach to insomnia and is mainly targeted at ruling out other predisposing conditions, such as thyroid, hormonal or metabolic disease that can mimic or precipitate symptoms. Although not required in patients without supporting symptoms, blood work to evaluate thyroid function (TSH), FSH/LH levels in perimenopausal women, underlying anemia or electrolyte imbalances is recommended in at-risk patients. A careful physical exam is also indicated in these patients.
Careful evaluation for other medical conditions that can contribute to insomnia is important. Dementia, neuropathy, movement disorders (such as Parkinson’s disease), epilepsy, migraine and chronic headache syndromes and neuromuscular diseases like multiple sclerosis have high rates of antecedent insomnia. Inadequately controlled asthma and chronic obstructive lung disease can also result in recurrent nighttime awakenings. Angina and decompensated heart failure can be associated with difficulty maintaining sleep.
Gastrointestinal disorders, such as gastroesophageal reflux disease (GERD) and inflammatory bowel conditions, may trigger insomnia. Urologic disorders, such as incontinence, benign prostatic hypertrophy (BPH) and chronic cystitis, may disrupt sleep by causing recurrent arousals and frequent nighttime urination. Both pregnancy and menopause are associated with poor sleep. Allergies, sinus disease and chronic ear, nose and throat conditions can seriously impact sleep.
Other Medications, Depression and Substance Abuse
Screening for alcohol and drug dependency is important. Although alcohol use is known to enhance the onset of sleep, sleep maintenance, sleep continuity, frequent arousals and early-morning awakenings are strongly associated with alcohol dependency. Questionnaires like the Beck Depression Inventory can also be helpful because underlying depression is strongly associated with insomnia.
An important priority is evaluating for other coexisting sleep disorders, which may underlie the insomnia symptoms. Sleep conditions like obstructive sleep apnea, parasomnias like sleepwalking or sleep talking, periodic limb movement disorders or restless legs syndrome can produce insomnia. While sleep testing is not routinely recommended for patients with insomnia, those with specific symptoms, such as disruptive snoring, merit further evaluation.
Finally, a careful inventory of both prescription and over-the-counter medications is advised. Details related to sleep habits, caffeine intake, exercise frequency and timing, bedroom environment and bedtime rituals should be elicited. Sleep diaries that facilitate patient self-reporting of sleep and other factors related to insomnia may be helpful to identify trends and prescribe interventions. Many smartphone applications allow for sleep tracking and commercial activity monitors can be helpful, but their accuracy and reliability for predicting sleep quality and depth is poor. Early referral to a board certified sleep medicine specialist is recommended in complex cases.