Sleep Disturbance and Insomnia

Introduction | Classification | Epworth Sleepiness Scale (ESS) | Causes of Insomnia | Management | Pharmacological Options | When to Refer | References

Introduction

Sleep disturbance and insomnia are common conditions that affect the quality of life and overall health. Insomnia is characterised by difficulty in falling asleep, staying asleep, or waking up too early, leading to daytime impairment. It can be a primary condition or secondary to other medical, psychiatric, or environmental factors.

Classification

Insomnia can be classified based on its duration and underlying causes:

• Acute Insomnia: Short-term insomnia lasting less than three months, often triggered by stress, illness, or environmental changes.
• Chronic Insomnia: Insomnia occurring at least three times a week for three months or longer, often associated with underlying health conditions or chronic stress.
• Primary Insomnia: Insomnia not directly attributable to another health condition or substance use.
• Secondary Insomnia: Insomnia caused by an underlying condition, such as depression, anxiety, pain, or medications.

Epworth Sleepiness Scale (ESS)

The Epworth Sleepiness Scale (ESS) is a simple and validated tool used to assess the level of daytime sleepiness, which can help identify sleep disorders such as insomnia, sleep apnoea, or narcolepsy:

• ESS Scoring: The ESS consists of eight questions that ask about the likelihood of dozing off in various situations, such as watching TV, sitting quietly in a public place, or after lunch. Each item is scored from 0 (no chance of dozing) to 3 (high chance of dozing), with a total score ranging from 0 to 24.
• Interpretation: A score of 0-10 is considered normal, 11-14 indicates mild sleepiness, 15-18 suggests moderate sleepiness, and 19-24 indicates severe sleepiness, warranting further investigation.

Causes of Insomnia

Several factors can contribute to the development of insomnia:

• Stress and Anxiety: Worries about work, school, health, finances, or family can keep the mind active at night, making it difficult to sleep.
• Depression: Insomnia is a common symptom of depression, where individuals may have trouble falling asleep or waking up early and being unable to return to sleep.
• Poor Sleep Hygiene: Irregular sleep schedules, stimulating activities before bedtime, and an uncomfortable sleep environment can all contribute to insomnia.
• Medical Conditions: Chronic pain, asthma, gastroesophageal reflux disease (GERD), and neurological disorders can disrupt sleep.
• Medications: Certain medications, including corticosteroids, beta-blockers, and antidepressants, can cause or exacerbate insomnia.
• Substance Use: Caffeine, nicotine, alcohol, and recreational drugs can interfere with sleep patterns.

Management

The management of insomnia involves a combination of behavioural therapies, sleep hygiene practices, and pharmacological treatments when necessary:

Behavioural Therapies

• Cognitive Behavioural Therapy for Insomnia (CBT-I): The first-line treatment for chronic insomnia. CBT-I focuses on changing thoughts and behaviours that contribute to sleep problems. It includes techniques such as stimulus control, sleep restriction, and relaxation training.
• Sleep Hygiene Education: Encouraging regular sleep and wake times, creating a comfortable sleep environment, avoiding caffeine and alcohol before bedtime, and establishing a relaxing pre-sleep routine.
• Mindfulness and Relaxation Techniques: Practices such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and improve sleep quality.

Pharmacological Options

When behavioural therapies are insufficient or not feasible, pharmacological treatments may be considered:

• Promethazine 10mg: An antihistamine with sedative properties, used short-term for sleep disturbances. Promethazine can help with sleep onset but may cause drowsiness the next day.
• Zopiclone: A non-benzodiazepine hypnotic that is effective for short-term management of insomnia. It helps with sleep onset and maintenance but is typically prescribed for no longer than 2-4 weeks due to the risk of dependence and withdrawal symptoms.
• Melatonin: A hormone that regulates the sleep-wake cycle. Melatonin supplements are often used for sleep disturbances related to circadian rhythm disorders or jet lag. It is considered safe for short-term use and can be particularly beneficial for older adults with insomnia.

When to Refer

Referral to a sleep specialist or secondary care is recommended in the following situations:

• Persistent Insomnia: If insomnia persists despite initial management, especially if it significantly impacts daily functioning or quality of life.
• Suspected Sleep Disorder: If there are symptoms suggestive of other sleep disorders, such as obstructive sleep apnoea (e.g., loud snoring, witnessed apnoeas, daytime sleepiness), referral for further evaluation is necessary.
• Complex Cases: If the insomnia is associated with significant psychiatric or medical comorbidities, specialist input may be required.

References

1. National Institute for Health and Care Excellence (2024) Insomnia Management in Primary Care. Available at: https://www.nice.org.uk/guidance/ng87 (Accessed: 26 August 2024).
2. British National Formulary (2024) Management of Insomnia and Sleep Disorders. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).
3. Epworth Sleepiness Scale (1991) A Method for Measuring Daytime Sleepiness. Available at: https://epworthsleepinessscale.com/ (Accessed: 26 August 2024).

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