Lack of sleep or disturbance of sleep are very common presenting complaints in general practice.
In hospitals turning down the phone bell and shoeing nurses softly may allow some patients to avoid sleep disturbance after discharge from drug withdrawal and rebound insomnia.
This problem can be subdivided into early, middle and late insomnia.
- Early insomnia
- is the difficulty in getting off to sleep. This can be a problem for patients who have been over-stimulated in the hours preceding sleep.
- Inappropriate activities could include watching television in bed or drinking coffee.
- Middle insomnia
- is defined as a problem where the patient wakes in the night and has difficulty getting back to sleep.
- This is often a problem for patients who are experiencing stress or anxiety. Typically the person wakes and finds that they are ruminating about a particular problem or problems.
- Late insomnia
- can also be called "early morning waking" and is self-explanatory. This may be associated with depression or low mood.
- Treatment for these conditions will depend on the underlying reason for the problem.
Other reasons for insomnia can be more physical causes, such as need for micturition (prostatism, diabetes, excess fluid intake), cough (asthma, acute infection, gastro-oesophageal reflux disease) or chronic pain (arthritis, leg cramps).
Cognitive-behavioural therapy can be usefully employed to help in recalcitrant case.
Medication is rarely beneficial long-term and is usually counter productive as it reduces quality of REM sleep and is usually addictive.
Antihistamine medication has been used as a short-term therapy. It is not a potent treatment. Many insomniacs buy such mild hypnotics from pharmacies.
Avoiding doing (most) interesting things or work in the bedroom, clearing out clutter and ensuring quiet and darkness are part of it, as is cultivation of the correct frame of mind.
There is a risk of mouthing platitudes when the patient has turned up wanting either reassurance that they are normal, or a handful of sleeping tablets. Nevertheless, some advice may be useful to give, and record giving, once or twice. Poor sleep hygiene is a common cause of isolated sleep paralysis which can occur in up to 20% of the population at some time or another.
Sleep apnoea is the absence of breathing when asleep. The commonest cause of this is obstructive sleep apnoea where some people obstruct their airway while sleeping causing apnoea, and resulting in partial wakening. This cycle may be repeated many times in a night, resulting in very poor sleep quality. Sufferers may fall asleep suddenly in the day, for instance while driving.
Study in a sleep lab, diet modification to encourage weight loss, and use of a variety of devices to alter or support the airway, or surgical alteration of the airway, can produce great improvements.
Use in jet lag
Exogenous Melatonin may be effective in attenuating jet-lag, although many of the trials might have used irrational dosing regimes based on how it works in man. So, although it most certainly resets the sleep cycle in vivo, it is not established that Melatonin is actually pharmaceutically effective in jet lag Unknown effectiveness .
Use as hypnotic
Low doses - half a mg - may be more effective than higher doses although this is not the uniform impression among users of it. A story offered to explain this is that the level must decline to zero or very low, in order for rises in it to be effective, and 3 mg may be too much to actually go away in the course of the day. Practically, it may be worth an n-of-1 trial in some insomniacs who seem to have no particular reason not to sleep, and if a suitable low dose preparation appears that also might be worth evaluating. In view of its undemonstrated effectiveness, it should best be used with an effort to evaluate its effect (such as the n-of-one trial or by enrolling the patient in an adequate RCT) rather than casually. It does not induce sleep like a typical hypnotic. Unlikely to be benefical
- Insomnia patient leaflet from "Clinical Knowledge Summaries (which seems to have superseded Prodigy)
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