A nonpharmacologic approach to managing insomnia in primary care Kelsey Taylor, PA-C; Nataliya Bilan, PA-C; Nadzeya Tsytsyna, PA-C; Ellen D. Mandel, DMH, MPA, PA-C
© BY JORGE MUNIZ, PA-C / MEDCOMIC.COM
ABSTRACT Insomnia, or inadequate or poor sleep leading to significant distress or impairment in functioning, is a prevalent disorder treated by primary care providers (PCPs). With millions of people across the United States suffering from insomnia, PCPs must understand the disorder’s pathophysiology, perpetuating factors, and treatment, as well as its effect on patient health and the economy. Although PCPs traditionally treat insomnia with pharmaceuticals, behavioral measures are effective and should be used whenever possible. This article reviews clinically relevant principles of diagnosing and treating insomnia, highlighting nonpharmacologic treatments. Keywords: insomnia, sleep, primary care, obstructive sleep apnea, nocturia, chronic pain
Learning objectives Differentiate insomnia from other sleep-wake disorders. Diagnose insomnia using DSM-5 criteria or through the use of validated screening tools. Prescribe an insomnia treatment regimen that uses a behavioral intervention suited to the patient’s particular needs.
nsomnia is a sleep-wake disorder that centers on poor sleep, whether it be the quality or duration of sleep, difficulty falling asleep or staying asleep, or early awakening with the inability to return to sleep.1,2 The prevalence of insomnia disorder varies, based on the Kelsey Taylor practices emergency medicine at NYC Health and Hospital-North Central Bronx in the Bronx, N.Y. Nataliya Bilan practices plastic surgery at Manhattan Eye, Ear, and Throat Hospital in New York City. Nadzeya Tsytsyna practices general surgery at New York University-Langone Hospital in Brooklyn, N.Y. At the time this article was written, Ms. Taylor, Ms. Bilan, and Ms. Tsytsyna were students in the PA program at Pace University-Lenox Hill Hospital in New York City. Ellen D. Mandel is a clinical professor in the Department of PA Studies at Pace University-Lenox Hill Hospital. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI:10.1097/01.JAA.0000525905.52107.20 Copyright © 2017 American Academy of Physician Assistants
definitions of insomnia used. An estimated 5% to 15% of US adults suffer from insomnia disorder as classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), with another 30% to 43% experiencing nighttime insomnia-like symptoms.3 In fact, the average adult sleeps only 6.9 hours a night, just shy of the 7 to 9 hours recommended by the National Sleep Foundation.4 Reduced sleep can lead to associated distress or impairment in functioning as well as daytime symptoms such as fatigue, irritability, difficulties concentrating, disorientation, changes in mood, visual hallucinations, and paranoid thoughts.3,4 SIGNIFICANCE OF INSOMNIA The indirect and direct costs of insomnia are estimated to exceed $100 billion annually.5 Indirect costs are higher than direct costs and are attributed to the daytime effects
A nonpharmacologic approach to managing insomnia in primary care
Key points Providers can identify and diagnose insomnia disorder through DSM-5 and ICSD-3 criteria by obtaining a thorough sleep, medical, substance, and psychiatric history. Consider insomnia disorder in patients who experience daytime symptoms such as fatigue, irritability, difficulties concentrating, or changes in mood. Before prescribing pharmacologic options, consider an integrated behavioral approach, which may yield more long-term improvement in quality and quantity of sleep.
of insomnia. Indirect costs include motor vehicle and workplace accidents, reduced workplace productivity, and increased alcohol abuse costing $77 billion to $92 billion each year.6 The National Highway Traffic Safety Administration estimates that each year, nearly 100,000 policereported crashes, 1,550 deaths, and 71,000 injuries result from driver fatigue.7 Direct costs include PCP visits, prescriptions, and procedures that can be attributed to insomnia directly, or negative health outcomes associated with insomnia.5 For example, hypnotics, typically used to treat insomnia, have associated adverse reactions of early morning hangover, daytime drowsiness, psychomotor impairment, and cognitive impairment, all of which can lead to additional and unnecessary PCP visits.8 Negative health outcomes associated with insomnia include increased risk of death and psychiatric, cardiovascular, and endocrine diseases.9 Patients with insomnia are four times more likely to develop new major depressive disorder over the next 3 to 5 years compared with patients without insomnia.1 Insomnia can increase the chance of a relapse of major depressive disorder; 67% of patients with chronic insomnia and depression relapsed after 1 year despite being treated with an antidepressant, compared with a relapse rate of 10% in patients without insomnia.10 Insomnia also can be linked to increased rates of hypertension, myocardial infarction (MI), obesity, and diabetes. PATHOPHYSIOLOGY The cognitive, cortical and neurologic, and physiologic arousal components of the hyperarousal theory lead to decreased likelihood of sleep, a key component of insomnia.3 Although insomnia is primarily diagnosed based on subjective information, hyperarousal can be supported by objective measures such as increased cortisol, heart rate variability, and increased high-frequency EEG activity during nonrapid eye movement (non-REM) sleep.3 During cognitive arousal, patients are more prone to both generalized and sleep-related worry, and tend to be hypervigilant to their insomnia symptoms.5 During cor-
Comparing sleep-wake disorders1-3
• Insomnia—dissatisfaction with sleep (quality, duration, difficulty falling or staying asleep, awakening too early, inability to return to sleep) despite adequate opportunity and circumstances for sleep. • Sleep deprivation—inadequate opportunity and circumstances for sleep, resulting in similar daytime symptoms as patients with insomnia. • Circadian rhythm sleep disorders—symptoms of difficulty falling asleep or waking too early. Patient goes to bed and wakes at very late times.
tical and neurologic arousal, patients display high frequency electroencephalographic (EEG) activity at or around sleep onset and during non-REM sleep, as well as a smaller wake-sleep difference in regional brain metabolism compared with patients who are considered good sleepers.2 Pathophysiology research, although ongoing, supports the connection between hyperarousal and insomnia.5 According to the hyperarousal theory, during physiologic arousal, patients demonstrate an increase in sympathetic nervous system activation leading to increased BP and heart rate. This process, as well as increased proinflammatory cytokine levels, may explain why insomnia is associated with increased cardiovascular risks such as hypertension and MI.9 In addition, increased hypothalamic-pituitary-adrenal axis stimulation leads to increased levels of cortisol and adrenocorticotropic hormones during the early sleep period.2 Another theory proposes that increased levels of ghrelin (which enhances appetite) and decreased leptin (which reduces appetite) might explain the increased incidence of obesity and diabetes in patients with insomnia.9 Despite progress in understanding the pathophysiology of insomnia, no single model is universally accepted.3 Of the proposed models, hyperarousal (increased physiologic, cognitive, and cortical/neurologic arousal) during sleep and wakefulness is an overarching theme.3,5 IDENTIFYING INSOMNIA PCPs can identify insomnia by using definitions accepted by the DSM-5 as well as the International Classification of Sleep Disorders, 3rd edition (ICSD-3), published by the American Academy of Sleep Medicine (AASM). The DSM-5 criteria differentiate insomnia disorder from other sleepwake disorders (Table 1). When other sleep-wake disorders are excluded and patients do not meet full DSM-5 criteria for insomnia disorder, they are considered to have insomnia symptoms rather than the disorder.11 The DSM-5 diagnostic criteria (Table 2) exclude causal relationships between physical and mental comorbid conditions but allow specifications if insomnia is exacerbated by or associated with a medical or psychological
comorbidity.12 Like the DSM-5, ICSD-3 defines insomnia as difficulty falling asleep or maintaining sleep, accompanied by daytime symptoms that are not attributed to environmental circumstances of inadequate opportunity to sleep.13 AASM states that insomnia is primarily diagnosed through sleep history and detailed medical, substance, and psychiatric history. Polysomnography and daytime multiple sleep latency testing (MSLT) should only be implemented when the clinician suspects sleep apnea or movement disorders.14 For evaluation, AASM suggests self-administered questionnaires, at-home sleep logs, symptom checklists, psychological screening tests, and bed partner interviews.14 Spielmann’s 3-P model of insomnia may be helpful in gathering a thorough history from patients experiencing sleep disturbance.15 This model explores three factors that contribute to the development and course of insomnia symptoms—predisposing, precipitating, and perpetuating factors. Predisposing factors are genetic, physiologic, or psychological qualities that increase vulnerability to sleep disorders. These include female sex, anxiety, and a heightened physiologic stress response.15 Precipitating factors may be concrete events that act as a catalyst for acute insomnia symptoms, including stressful events, acute illness, family stressors, occupational difficulties, or changes in environment.15,16 Perpetuating factors that may exacerbate insomnia symptoms and prevent the patient from returning to TABLE 2.
DSM-5 criteria for insomnia disorder14
• Dissatisfaction with sleep quantity or quality associated with one or more of the following symptoms: ° Difficulty initiating sleep ° Difficulty maintaining sleep (frequent awakenings or difficulty returning to sleep after awakenings) ° Early morning awakenings with inability to return to sleep • The following also may apply: ° The sleep disturbance causes distress or impairs performance in social, occupational, or other important areas of function. ° The sleep difficulty occurs at least 3 nights per week for at least 3 months. • Excluding factors: ° The patient experiences the symptoms despite adequate opportunity for sleep. ° The sleep disturbance cannot be attributed to other physiologic or medical disorders. It cannot be due to the physiologic effects of a substance, and is not better explained by or occurs solely during another sleepwake disorder. ° Coexisting mental disorders or medical conditions do not adequately explain the predominant complaint of insomnia.
normal sleep patterns include anxiety about sleepiness, fear of daytime consequences from lack of sleep, napping, and spending more time in bed.15,16 This model integrates lifestyle factors that may contribute to sleep disturbance and may help identify treatment targets.15 For additional information, validated screening surveys such as the Pittsburgh Sleep Quality Index or Epworth Sleepiness Scale may be used for patients with chief complaints of insomnia or sleep symptoms.4,17,18 These two tools are the most commonly used for evaluating sleep disturbance and daytime sleepiness, respectively.18 ASSOCIATED MEDICAL PROBLEMS Distinguishing primary insomnia from medical conditions that contribute to insomnia can be challenging. Before treating insomnia symptoms (or in conjunction with treating symptoms), identify and manage the underlying disease process that contributes to sleep disturbance. Obstructive sleep apnea Two of the most common sleep disorders, obstructive sleep apnea (OSA) and chronic insomnia, frequently complicate each other’s presentation and exacerbate each other’s severity.19,20 The prevalence of insomnia-like symptoms is 40% to 60% higher in patients with sleep apnea compared with the general population.19 Patients who are overweight and/or obese and who have insomnia symptoms should be screened for OSA. Ask patients about snoring, waking with choking or gasping, morning headaches, and daytime fatigue.1 This is an important treatment target because patients with comorbid OSA and insomnia experience more emotional and physical symptoms and suffer from more psychiatric disorders.20 Using conventional medications to treat insomnia in patients with OSA is challenging because many hypnotic drugs may worsen sleep apnea and contribute to respiratory depression.1 Nocturia One of the most common causes of insomnia in older adults, nocturia reduces sleep quality if patients have difficulty falling asleep after awakenings.21 Nocturia is defined as waking at least once nightly to void, with each void preceded and followed by sleep.21 Nocturia may be a direct cause of sleep disturbance or be linked to awakening due to OSA or other comorbidities that disturb sleep. Providers must determine if patient awakenings are prompted by urinary urgency or if the patient awakes and then needs to urinate. Interventions should target the corresponding initial problem; address voiding symptoms if urinary urgency prompts the nocturia.22 Controlling symptoms of either primary problem will improve sleep in patients with nocturia. GERD Sleep disturbances are significantly higher in patients with gastroesophageal reflux disease (GERD)
A nonpharmacologic approach to managing insomnia in primary care
than those without it.23 Up to half of patients with GERD report that heartburn and other reflux symptoms such as acid regurgitation and chest pain awakens them from sleep, leading to insomnia.23,24 Educate patients about the importance of weight loss, avoiding large meals, remaining upright for 3 hours after a meal, and elevating the head of the bed in an attempt to decrease awakenings. Consider prescribing a proton pump inhibitor (PPI) or histamine H2 receptor antagonist for patients with sleep disturbance due to reflux. Treating nighttime GERD symptoms reduces esophageal acid exposure when patients are recumbent and increases sleep satisfaction.24 Chronic pain Commonly associated with poor sleep quality, chronic pain should be addressed in patients with concurrent insomnia symptoms.25 The prevalence of insomnia in patients who suffer from chronic pain is about 65%.22 These patients have an increased occurrence
CBT-I may decrease depressive symptoms that can concur with insomnia. of insomnia symptoms and report significant sleep disturbance, nonrestorative sleep, more awakenings, and increased time to fall asleep.25,26 Sleep plays a protective role against pain, so lack of sleep seems to be associated with activation of the pain matrix, which may increase the severity and duration of pain symptoms in patients.26 When treating patients with these conditions, remember that opioids alter sleep architecture and contribute to sleep apnea and respiratory depression, which may further exacerbate insomnia complaints in these patients.25 TREATMENT Treatment falls into two main categories: pharmacologic and behavioral interventions. Pharmacologic therapies are only effective for the time that they are implemented; behavioral interventions become a lifestyle practice and their efficacy can be expected to persist in the long term.8 In addition, pharmacologic therapies have several known adverse reactions when used for long periods of time. Therefore, American Geriatrics Society does not recommend hypnotics and benzodiazepines as first-line therapy for insomnia in older adults.27 AASM also recommends psychological and behavioral interventions as initial interventions for patients with insomnia.14 Research indicates that behavioral interventions are likely more cost effective and yield reliable, robust, and long-term benefits in adults of all ages.8 Behavioral interventions include sleep restriction, stimulus control, cognitive therapy, cognitive behavior training for insomnia (CBT-I), sleep hygiene, and relaxation training.
Sleep restriction The most effective component of behavioral therapies, sleep restriction focuses on limiting the amount of time that a patient spends in bed to the actual time spent sleeping. Sleep restriction systematically reduces time in bed to less than what the patient is accustomed to, which leads to faster sleep onset, decreased wakefulness after sleep onset, and higher sleep efficiency.28 Following successful consolidation of sleep time, measured by tracking sleep efficiency, time in bed can gradually be expanded from a minimum of 5 to 5.5 hours to allow for greater sleep opportunity.29 The sleep diary or sleep log is an important tool for assessing baseline sleep patterns, tracking change over time, and setting and adjusting the time spent in bed.30 Patients may find sleep-tracking smartphone applications helpful. Stimulus control This method aims to strengthen the association between the bed and bedroom and sleep, and at the same time weaken the associations that interfere with sleep, such as worrying, working, and watching television. Common instructions that are provided to patients include: • going to bed only when sleepy • using the bed only for rest and sexual activity • going to another room if the patient is unable to go to sleep within 15-20 minutes, and returning to the bedroom only when tired • getting out of bed at the same time every morning regardless of how much the patient slept during the night • not napping. Cognitive therapy The intervention focuses on identifying dysfunctional beliefs, attitudes, and worries about the loss of sleep. Worry contributes to heightened arousal that interferes with sleep, promoting further worry and anxiety, which becomes a difficult cycle to break.29 Once dysfunctional beliefs are identified, the main task is to help the patient challenge these thoughts through guided discovery and to replace them with more adaptive, realistic, and alternative interpretations of their sleep patterns.28 Cognitive behavioral therapy for insomnia CBT-I is the most widely used and studied nonpharmacologic treatment.2 This multicomponent treatment typically combines the components mentioned above and teaches patients skills that can be used in the future.28 CBT-I generally consists of 6 to 10 sessions with a trained therapist that address counterproductive behaviors and cognitive beliefs that perpetuate insomnia.31 CBT-I has been shown to decrease depressive symptoms that can concur with insomnia, as well as improving sleep efficiency and sleep quality.32 Although CBT-I is the mainstay of nonpharmacologic interventions for chronic insomnia, it is not readily available in most clinical settings and is expensive for patients. Therefore, innovative methods such as computerized and online CBT-I, group CBT-I, and CBT-I through telehealth are alternatives. A randomized clinical trial of
303 patients found that nearly 57% of participants in an online CBT-I program achieved insomnia remission.33 Free smartphone applications also increased adherence to CBT-I.30 Sleep hygiene In this method, patients increase behaviors and environmental conditions that promote improved quality or quantity of sleep and reduce or eliminate practices that interfere with sleep.29 Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, evidence is insufficient to indicate that sleep hygiene alone is effective in treating chronic insomnia.14 AASM recommends using sleep hygiene in conjunction with stimulus control, relaxation training, sleep restriction, or cognitive therapy.14 Table 3 reviews sleep hygiene interventions for insomnia. Relaxation training Relaxation decreases waking arousal and facilitates sleep at night. This intervention is effective in reducing physiologic arousal related to insomnia as quantified by heart rate variability, increased metabolic rate, elevated body temperature, and muscle tension.2 Common relaxation techniques include muscle relaxation, diaphragmatic breathing, body scanning, autogenic training, biofeedback, and the use of mindfulness-based therapy for insomnia; the appropriate technique is chosen based on what is easiest for the patient to learn.28 Biofeedback is a form of relaxation that provides sensory feedback (visual or auditory, either mechanically or with computers and amplifiers) to help patients learn how to control physiologic parameters such as galvanic skin response or muscle tension in order to reduce somatic arousal.8 These techniques are practiced during the day, before bedtime, and in the middle of the night if necessary.28 Regardless of the specific relaxation strategy employed, treatment typically involves conducting specific TABLE 3.
• • • • • • • • • • •
Sleep hygiene interventions for insomnia28,29,31,39
Maintain a regular sleep/wake schedule 7 days per week Do not make up for “lost sleep” on the weekends/holidays Avoid naps Keep the bedroom dark, quiet, and at a comfortable temperature Don’t check the time or your phone if you are awake at night Avoid stimulants (coffee, dark chocolate, alcohol, nicotine) Maintain a healthful diet and avoid heavy meals before bedtime Avoid consuming liquids 90 minutes before bedtime, especially if you awaken to use the bathroom Maintain a regular exercise schedule and time exercise for at least 4 to 6 hours before sleep Plan evening activities that promote relaxation (stretching, walking) Avoid bright lghts for 5 to 10 minutes before bedtime (television, phones, computers)
treatment exercises, learning relaxation skills, and regular practice with a trained professional over multiple treatment sessions.8 Exercise Aerobic exercise has been extensively studied and its effects are like those observed after hypnotic medication use.34 Participants who exercised vigorously in the morning had the most favorable sleep outcomes; they were more likely to report good sleep quality and less likely to report nonrefreshing sleep.35 Though regular aerobic exercise improves self-rated sleep measures in patients with insomnia, noticeable improvement in total sleep time may be latent by up to 16 weeks.36 Providers should encourage patients to focus on long-term improvement of sleep thorough exercise, rather than focusing on any individual night of sleep.36
Vigorous morning exercise may improve sleep outcomes. Mindfulness meditation This intervention emphasizes nonjudgmental awareness and attention to the present moment to promote relaxation and mind-body calmness. Examples of mindfulness meditation are mindfulnessbased stress reduction programs that teach meditation through a structured group intervention. Patients who complete mindfulness-based stress reduction programs practice a variety of meditation techniques to fall asleep faster at bedtime, return to sleep sooner if awakened at night, awaken more refreshed, and better cope with occasional episodes of sleeplessness.37 Mindfulness-based therapy for insomnia incorporates mindfulness-based stress reduction into a traditional CBT-I framework.35 In contrast to CBT-I that is primarily aimed at changing thoughts and behaviors to reduce unwanted wakefulness at night, mindfulness-based therapy for insomnia is aimed at shifting metacognitions to reduce sleep-related arousal at night and during the day through mindfulness meditation practice.38 CONCLUSION Identifying and diagnosing insomnia as well as creating a comprehensive treatment plan is paramount in an integrated approach to this sleep disorder. Appropriately identify insomnia through DSM-5 criteria or ICSD-3, which provide straightforward guidelines and exclusions to the diagnosis. The assessment and plan should review associated conditions that may exacerbate insomnia symptoms and contribute to sleep disturbance. Consider nonpharmacologic options before or in conjunction with commonly prescribed sleep aids. This integrated behavioral approach may yield more long-term improvement in
A nonpharmacologic approach to managing insomnia in primary care
quality and quantity of sleep and avoid adverse patient reactions to sleep medications. Treating insomnia with a behavioral approach incorporates beneficial lifestyle habits that may improve patients’ sleep quality as well as associated comorbidities. JAAPA
20. Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http:// cme.aapa.org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of November 2017.
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