Insomnia diagnosis and treatment across the lifespan
Insomnia impairs quality of life and is associated with an increased risk for physical and mental health problems and substance misuse. Here’s how you can help.
PRACTICE RECOMMENDATIONS
› Use a standard validated screening tool for the diagnosis of insomnia in all age groups. A
› Employ nonpharmacologic interventions as first-line treatment for insomnia in all populations. A
› Utilize sleep hygiene or cognitive behavioral therapy for insomnia in adolescents and all adults. A
› Initiate independent cognitive or behavioral therapies with younger children. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Pregnant women. Sleep disorders in pregnancy are common and influenced by multiple factors. A meta-analysis found that 57% to 74% of women in various trimesters of pregnancy reported subthreshold symptoms of insomnia16; however, changes in sleep duration and sleep quality during pregnancy may be related to hormonal, physiologic, metabolic, psychological, and posture mechanisms.17,18
Sleep quality also worsens as pregnancy progresses.16 Insomnia coupled with poor sleep quality has been shown to increase the risk for postpartum depression, premature delivery, prolonged labor, and cesarean delivery, as well as preeclampsia, gestational hypertension, stillbirth, and large-for-gestational-age infants.19,20
Older adults. Insomnia is a common complaint in the geriatric population and is associated with significant morbidity, as well as higher rates of depression and suicidality.21 Circadian rhythms change and sleep cycles advance as people age, leading to a decrease in total sleep time, earlier sleep onset, earlier awakenings,and increased frequency of waking after sleep onset.21,22 Advanced age, polypharmacy, and high medical comorbidity increase insomnia prevalence.23
Studies have shown that older adults who sleep fewer than 5 hours per night have an increased risk for diabetes and metabolic syndrome.21 Sleep loss also has been linked to increased rates of hypertension, coronary artery disease, myocardial infarction, and possibly stroke.21,22 Poor sleep has been associated with increased rates of cortical atrophy in community-dwelling older adults.21 Daytime drowsiness increases fall risk.22 Older adults with self-reported decreased physical function also had increased rates of insomnia and increased rates of daytime sleepiness.22
Making the diagnosis: What to ask, tools to use
Clinical evaluation is most helpful for diagnosing insomnia.24 A complete work-up includes physical examination, review of medications and supplements, evaluation of a 2-week sleep diary (kept by the patient, parent, or caregiver), and assessment using a validated sleep-quality rating scale.24 Be sure to obtain a complete health history, including medical events, substance use, and psychiatric history.24
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