Insomnia is one of the most common sleep disorders, with nearly half of US adults experiencing the disorder at some point in their lives. And yet, despite this prevalence, many patients do not report symptoms of insomnia to their health care provider. 

With the COVID-19 pandemic, people are experiencing high levels of stress and interruptions to their daily schedule that could result in sleep problems. With the right knowledge, nurse practitioners can help their patients suffering from insomnia.

What is Insomnia?

Insomnia is broadly defined as difficulty initiating or maintaining sleep.¹ Lack of adequate or quality sleep can lead to mood disturbances, lack of concentration, and increase risk for overall health problems. Insomnia occurs in approximately 33-50% of the adult population of the United States.² During a time of crisis, such as the COVID-19 pandemic, more people may be feeling worried or overwhelmed leading to problems with sleeping. Primary care NPs are uniquely positioned to guide patients in the management of insomnia, while improving outcomes related to this health issue.

Insomnia has two general categories: primary and secondary. Primary insomnia is insomnia that is not caused by or related to an underlying medical or psychiatric condition. Secondary insomnia is caused by a medical, psychiatric, or environmental condition. 

Insomnia is further classified as acute (less than 4 weeks) or chronic (more than 4 weeks). For lack of sleep to be defined as insomnia it must occur more than 3 nights each week. 

Causes of Insomnia and Impacts to Quality of Life

Untreated insomnia can negatively impact quality of life. Impaired sleep can affect all facets of life. At home or at work, a person may find themselves irritable or accident prone. Workplace productivity may suffer, and overall health may decline. Insomnia can lead to the onset or worsening of medical comorbidities.³ 

The etiology of primary insomnia is not known.⁴ It is diagnosed when other common causes of insomnia are ruled out. While the exact cause remains a mystery, primary insomnia may lead to serious health complications including diabetes, hypertension, heart disease, anxiety, and depression.⁵

Secondary insomnia is a symptom of medical, psychiatric, or environmental conditions that may be undiagnosed, unrecognized, or untreated. Chronic medical concerns such as chronic pain, GERD, obstructive sleep apnea, asthma, obesity, chronic urinary complaints that cause frequency like BPH, thyroid problems, or hormonal issues all can make sleep elusive.

Psychological distress or illness and certain medications can cause sleep problems. Anxiety, depression, and post-traumatic stress may trigger insomnia. Sleep problems may originate with medications such as oral corticosteroids, cold and allergy medications, hormones, and some asthma medications just to name a few.  

Insomnia may also be caused by environmental factors. Is the bedroom conducive for sleep? Does the sleep partner snore? Is the bed comfortable?

When sleep has been elusive many people reach for commonly used substances including caffeine or tobacco to stay awake or alcohol or other sedatives to calm down. All of these substances can contribute to insomnia. 

Formulating a Plan for Insomnia

As many as 7 out of 10 people who have trouble sleeping do not report it to their health care provider.6 Insomnia does not present the same way in everyone. NPs should use routine screening tools and protocols for treatment that can potentially improve outcomes.  

In addition to interviewing the patient, subjective information can be obtained through questionnaires and sleep trackers. The Pittsburgh Sleep Quality Index (PSQI) is a self-administered questionnaire that assesses various aspects of sleep.

Tracking sleep with a sleep diary is also helpful in assessing sleep patterns. Diaries, like the Consensus Sleep Diary (CSD)  are available online. Some patients may use sleep tracker apps on smartphones or smart watches. 

A complete medical and social evaluation should be included. Consider the discussion of most common causes of insomnia above. A medical workup should include ruling out these conditions and if the conditions exist, NPs should help the patient develop a plan for treatment and management.  

Diagnostic testing may be required if an underlying disease is suspected. Most commonly, the patient may be referred for a polysomnogram. A polysomnogram records breathing, oxygen levels, limb movements, heart rate, and brain waves throughout the night. The data may be useful in identifying obstructive sleep apnea, restless leg syndrome,or seizures. 

Non-pharmacological Methods to Improve Sleep

Non-pharmacologic methods are more cost effective and not associated with side effects. Non-pharmacological methods can be as effective as pharmacologic therapies. Many patients benefit from being referred for Cognitive Behavioral Therapy (CBT). Led by a therapist, CBT uses psychological interventions to address behaviors or psychological barriers that may be impeding sleep. CBT is often used in conjunction with some of the sleep hygiene/stimulus control strategies listed below.

1. Set a schedule. Go to bed and wake up at the same time every day.
2. Exercise 20-30 minutes per day, but not in the 2-3 hours before bed. 
3. Avoid caffeine and nicotine late in the day.
4. Avoid drinking alcohol before bed. 
5. Take a hot shower, meditate, or read.
6. Create an environment for sleep. Avoid bright lights, use room darkening curtains.
7. Do not watch TV or use the computer in bed. 
8. Consider ear plugs or white noise machines.
9. Do not nap. Napping can interfere with the circadian rhythm. 
10. Spend a little time outside every day. 
11. Do not lie in bed awake for longer than 15 minutes. Go do something else relaxing and try again when tired.  
12. Consider a nightlight in the bathroom to avoid turning on bright overhead lights.

Role of Pharmacological Therapy 

In some cases, pharmacological therapy is indicated when non-pharmacological methods are ineffective.7 Benzodiazepines such as estazolam, alprazolam and lorazepam have been used for many years for the treatment of insomnia, however, there are some disadvantages. Not all benzodiazepines are FDA approved for the treatment of insomnia. Benzodiazepines are often associated with next day drowsiness. These agents must be used with caution in patients with a history of alcohol or drug abuse, older adults, or persons with chronic respiratory disease. 

Nonbenzodiazepines are more commonly used for insomnia. Zaleplon, eszonpiclone, and zolpidem are the most common agents. Their half-lives and side effect profiles vary. The segment of sleep that is disturbed and existing comorbid conditions should be considered when choosing an agent. 

Melatonin and valerian are over-the-counter agents that are often used for insomnia. There is limited data to demonstrate their effectiveness, however some patients may desire to try a more ‘natural’ approach before a trial of prescription medications.  

Conclusion

NPs can offer guidance for patients with insomnia, especially during the challenging and uncertain COVID-19 pandemic. If 7 out of 10 patients will not bring up sleep concerns with their health care provider, NPs may consider taking a more proactive approach. These are stressful times, but NPs are well positioned to help patients navigate challenging health issues like insomnia.

 

 

References

1. Klingman, K. J., & Sprey, J. (2020). Insomnia disorder diagnosis and treatment patterns in primary care. Journal of the American Association of Nurse Practitioners, 32(2), 145–151. doi:10.1097/JXX.0000000000000232
2. Momin, R. R., & Ketvertis, K. (2020, February 22). Primary Insomnia. Retrieved May 19, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK554516/
3. Brain Basics: Understanding Sleep. (2019, August 13). Retrieved May 19, 2020, from https://www.ninds.nih.gov/Disorders/patient-caregiver-education/Understanding-sleep 
4. Reynolds, S. A., & Ebben, M. R. (2017). The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment: Cognitive Behavioral Therapy for Insomnia. Sleep medicine clinics, 12(1), 39–46. https://doi.org/10.1016/j.jsmc.2016.10.011
5. Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(02), 307–349. https://doi.org/10.5664/jcsm.6470
6.  Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep Medicine, 04(05), 487–504. https://doi.org/10.5664/jcsm.27286
7. Substance Abuse and Mental Health Services Administration. (2016, June). Table 3.36, DSM-IV to DSM-5 Insomnia Disorder Comparison – Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health – NCBI Bookshelf. Retrieved May 18, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t36/