Insomnia diagnosis and treatment across the lifespan

Inquire about sleep initiation, sleep maintenance, and early awakening, as well as behavioral and environmental factors that may contribute to sleep concerns.^10,18 Consider medical sleep disorders that have overlapping symptoms with insomnia, including obstructive sleep apnea (OSA), restless leg syndrome (RLS), or circadian rhythm sleep-wake disorders. If there are co-occurring chronic medical problems, reassess insomnia symptoms after the other medical diagnoses are controlled.

TABLE 1^25-29 includes a list of validated screening tools for insomnia and where they can be accessed. Recommended screening tools for children and adolescents include daytime sleepiness questionnaires, comprehensive sleep instruments, and self-assessments.^25,30 Although several studies of insomnia in pregnancy have used tools listed in TABLE 1,^25-29 only the Insomnia Severity Index has been validated for use with this population.^26,27 Diagnosis of insomnia in older adults requires a comprehensive sleep history collected from the patient, partners, or caregivers.²¹

Measuring sleep performance

Several aspects of insomnia (defined in ­TABLE 2^31-33) are targeted as outcome measures when treating patients. Sleep-onset latency, total sleep time, and wake-after-sleep onset are all formally measured by polysomnography.^31-33 Use polysomnography when you suspect OSA, narcolepsy, idiopathic hypersomnia, periodic limb movement disorder, RLS, REM behavior disorder (characterized by the loss of normal muscle atonia and dream enactment behavior that is violent in nature³⁴), or parasomnias. Home polysomnography testing is appropriate for adult patients who meet criteria for OSA and have uncomplicated insomnia.³⁵ Self-reporting (use of sleep logs) and actigraphy (measurement by wearable monitoring devices) may be more accessible methods for gathering sleep data from patients. Use of wearable consumer sleep technology such as heart rate monitors with corresponding smartphone applications (eg, Fitbit, Jawbone Up devices, and the Whoop device) are increasing as a means of monitoring sleep as well as delivering insomnia interventions.³⁶

Actigraphy has been shown to produce significantly distinct results from self-­reporting when measuring total sleep time, sleep-onset latency, wake-after-sleep onset, and sleep efficiency in adult and pediatric patients with insomnia.³⁷ Actigraphy yields distinct estimates of sleep patterns when compared to sleep logs, which suggests that while both measures are often correlated, actigraphy has utility in assessing sleep continuity in conjunction with sleep logs in terms of diagnostic and posttreatment ­assessment.³⁷

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