🩺 Insomnia

Insomnia is defined as persistent difficulty with sleep initiation, duration, or quality, despite adequate opportunity for sleep, resulting in daytime impairment. It is a highly prevalent complaint in UK general practice. Chronic insomnia is defined as symptoms occurring at least three times a week for at least three months. Management prioritises non-pharmacological interventions, specifically Sleep Hygiene education and CBT-I, which is the first-line treatment for chronic cases. Pharmacological options are reserved for short-term distress or acute crises.

A thorough sleep history is required: time of sleep onset, frequency of nocturnal awakenings, and 'early morning wakening'. Use a sleep diary to track patterns over 2 weeks. Screen for 'sleep hygiene' factors such as caffeine intake, alcohol use, evening screen time, and an irregular sleep-wake cycle. Inquire about daytime consequences like fatigue, poor concentration, and irritability. It is essential to screen for symptoms of OSA (snoring, witnessed apnoeas) and Restless Legs Syndrome (urge to move legs, worse at night).

Examination is often unremarkable but should focus on identifying underlying causes. Check BMI and neck circumference if OSA is suspected. Assess for signs of chronic systemic illness (heart failure, COPD) that may impair sleep. The Mental State Examination (MSE) is essential to identify comorbid mood or anxiety disorders. Observations like blood pressure may be relevant if the patient is using stimulant medications or has untreated sleep apnoea.

Obstructive Sleep Apnoea (OSA), Restless Legs Syndrome, Anxiety/Depression, Poor sleep hygiene, Circadian rhythm disorders (e.g., shift work disorder), Medication side effects (e.g., SSRIs, beta-blockers).

Sudden onset of severe insomnia in an older person (can be a sign of depression or occult malignancy). Witnessed apnoeic episodes or heavy snoring (suggesting OSA). Night sweats or unexplained weight loss. Rapid onset of psychosis or neurological symptoms. Restless legs causing significant distress. Serious daytime somnolence impacting safety (e.g., driving).

Insomnia is primarily a clinical diagnosis. Blood tests (FBC, TFTs, HbA1c, Iron studies) can be used to rule out medical contributors like anaemia, hyperthyroidism, diabetes, or iron deficiency (linked to Restless Legs). Formal sleep studies (polysomnography) are NOT indicated for primary insomnia but are required if OSA, narcolepsy, or periodic limb movement disorder is suspected. Questionnaires like the Epworth Sleepiness Scale can help quantify daytime somnolence.

Insomnia is often a symptom of an underlying condition rather than a primary diagnosis; always look for depression, anxiety, or obstructive sleep apnoea (OSA). For long-term management, Cognitive Behavioural Therapy for Insomnia (CBT-I) is more effective and sustainable than pharmacological therapy. Avoid the 'prescribing cycle' of benzodiazepines or Z-drugs for more than 2-4 weeks due to the high risk of dependence and tolerance. In the elderly, sedative medications significantly increase the risk of falls and fractures.

Relevant to the 'Primary Care' and 'Mental Health' MLA topics. Be aware of the NICE recommendations that 'Z-drugs' (zopiclone, zolpidem) and benzodiazepines should be limited to short-term use (max 2-4 weeks) for severe, disabling insomnia only. Recognise that melatonin is primarily used for patients aged 55 and over for short-term management.