Insomnia diagnosis and treatment across the lifespan

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doi:doi: 10.12788/jfp.0545

Applied Evidence

Insomnia diagnosis and treatment across the lifespan

J Fam Pract. 2023 January;72(1):18-28 | doi: 10.12788/jfp.0545

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References

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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

Technology use prior to bedtime is prevalent and associated with sleep and circadian rhythm disturbances.

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

Continue to: Inquire about sleep initiation...