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Insomnia

Definition
Insomnia is a sleep disorder characterized by persistent symptoms of trouble falling asleep, staying asleep, or waking up too early in the morning accompanied by at least one symptom of impaired daytime function (not getting enough sleep or daytime sleepiness).
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Pathophysiology
Insomnia is caused by a hyperarousal state primarily due to physiologic or neurophysiologic factors.
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Disease course
Insomnia is characterized by difficulty sleeping, frequent nocturnal awakening, prolonged periods of wakefulness during sleep period, and poor quality sleep. Insomnia impacts physical functioning, role limitation due to physical and emotional health problems, body pain, general health perceptions, vitality, social functioning, and mental health.
2
Prognosis and risk of recurrence
Persistent insomnia has been associated with an increased risk of all-cause mortality (HR 1.58, 95% CI 1.02-2.45), while intermittent insomnia has not been associated with an increased risk.
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Key sources
The following summarized guidelines for the evaluation and management of insomnia are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024; 2017), the European Sleep Research Society (ESRS/EIN 2023), the European Society of Medical Oncology (ESMO 2023), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021), the United States Department of Defense (DoD/VA 2020; 2016), the Amyotrophic Lateral Sclerosis Society of Canada (ALSSC 2020), the British Association for Psychopharmacology (BAP 2019; 2018), the Canadian Neurological Sciences Federation (CNSF 2019), the American Academy of Sleep Medicine (AASM 2018; 2017), the College of Family Physicians of Canada (CFPC 2018), the Society of Critical Care Medicine (SCCM 2018), the Huntington's Disease Expert Group (HD-EG 2018), the Living Concussion Guidelines (LCG 2017), the American College of Physicians (ACP 2016), the American Academy of Neurology (AAN 2016), the European Neurological Society (ENS/EFNS 2013), the European Federation of Neurological Societies (EFNS 2012), and the American Psychiatric Association (APA 2007).
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Guidelines

1.Diagnostic investigations

History and physical examination
As per ESRS 2023 guidelines:
Elicit general and sleep history in patients with insomnia, including:
Situation
Guidance
Sleep history
History of sleep complaints and daytime functioning
Information from bed partner/caregivers (snoring, breathing pauses/apneas, periodic limb movements during sleep, nocturnal restlessness, strange behaviors)
Work time/circadian factors (shift and night work, phase advance, delay)
Sleep-wake pattern, including daytime sleep (sleep diary, sleep questionnaires)
Comorbidities
Past and present disorders, including somatic, neurological, and mental disorders
Social factors
Personality factors, work and partnership situations, and interpersonal conflicts
Substance use
Medications, alcohol, caffeine, nicotine, and illegal drugs
A
Perform a physical examination if clinically needed.
A
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  • Actigraphy

  • Polysomnography

  • Screening for obstructive sleep apnea

  • Additional testing

2.Medical management

General principles
As per AAFP 2024 guidelines:
Offer medications for the treatment of insomnia, but discourage their long-term use (> 3 months).
A
Avoid benzodiazepines and nonbenzodiazepine hypnotics if possible because of significant long- and short-term safety concerns.
D

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  • Benzodiazepines

  • Nonbenzodiazepines (prescribing)

  • Nonbenzodiazepines (deprescribing)

  • Melatonin receptor agonists (melatonin)

  • Melatonin receptor agonists (ramelteon)

  • Orexin receptor antagonists

  • Antidepressants

  • Antipsychotics (prescribing)

  • Antipsychotics (deprescribing)

  • Anticonvulsants

  • Antihistamines

3.Nonpharmacologic interventions

Cognitive behavioral therapy for insomnia: as per AAFP 2024 guidelines, offer CBT-I as first-line therapy in patients with chronic insomnia, as it improves sleep quality, insomnia severity, daytime fatigue, total sleep time, and beliefs and attitudes about sleep.
B

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  • Mindfulness-based interventions

  • Light therapy

  • Alternative and complementary medicine

4.Specific circumstances

Pediatric patients: offer behavioral strategies as first-line therapy in pediatric patients with disturbed sleep.
A
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  • Pregnant patients

  • Menopausal patients

  • Elderly patients

  • Critically ill patients

  • Patients with restless legs syndrome

  • Patients with periodic leg movements of sleep

  • Patients with intellectual disability

  • Patients with dementia

  • Patients with cancer (evaluation)

  • Patients with cancer (psychotherapy)

  • Patients with cancer (pharmacotherapy)

  • Patients with cancer (other therapies)

  • Patients with Parkinson's disease (evaluation)

  • Patients with Parkinson's disease (management)

  • Patients with Huntington's disease

  • Patients with ALS

  • Patients with multiple sclerosis

  • Patients with mild traumatic brain injury (evaluation)

  • Patients with mild traumatic brain injury (management)

  • Patients with autism spectrum disorder

5.Patient education

Sleep hygiene education: avoid advising sleep hygiene education as a standalone treatment for chronic insomnia disorder.
D