Healthcare providers (HCPs) caring for women of any age will find that a substantial proportion of them have difficulty falling and/or staying asleep. When insomnia interferes with their daily life and causes distress, they may seek professional help. This article provides background information about sleep, and offers HCPs useful and up-to-date information regarding the evaluation of patients presenting with sleep problems and the wide variety of treatments that are available.
The American Academy of Sleep Medicine (AASM) defines insomnia as a complaint of trouble initiating/ maintaining sleep that is associated with daytime consequences and that is not attributable to environmental circumstances or an inadequate opportunity to sleep.1 According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), insomnia is characterized by difficulty initiating and/or maintaining sleep and/or waking earlier than desired, occurring at least 3 nights per week for at least 3 months, and causing dissatisfaction with sleep.2 Unlike in days past, when insomnia was classified as a condition secondary to another diagnosis, it is now considered an entity of its own.
The DSM-V lists insomnia among 10 other sleep–wake disorders.2 Healthcare providers (HCPs) may need to rule out other sleep–wake disorders (e.g., obstructive sleep apnea, circadian rhythm sleep–wake disorder, restless leg syndrome [RLS]) before making a definitive diagnosis of insomnia in a given patient.
Prevalence and adverse consequences
Among adults in the United States, about 30% have symptoms of insomnia on occasion and 6%-10% have chronic insomnia meeting DSM-V criteria, including the all-important element of dissatisfaction with one’s sleep.3,4 Insomnia is more common in women than in men, in older adults than in younger adults, and in persons affected by co-morbid physical or mental health conditions than in persons in the general population.1,4
Chronic insomnia, defined as insomnia lasting longer than 3 months, has many adverse effects on daily functioning, health, and quality of life.1 It is linked to increased rates of work absenteeism and occupational and motor vehicle accidents, and it has been identified as a major risk factor for developing psychiatric disorders, especially mood disorders; for relapse among persons with depression or alcoholism; for adverse effects in persons with chronic health conditions; and for development of hypertension and cardiovascular disease.1
Background information about sleep
The typical adult falls asleep within 30 minutes of going to bed. If she awakens in the middle of the night, it generally takes 30 minutes or less for her to fall back to sleep. A full night’s sleep lasts 7-8 hours. Her sleep efficiency—the amount of time asleep relative to the amount of time spent in bed—is about 85%.
The sleep-wake cycle
Wakefulness and sleep are under the control of highly complex neural circuitry consisting of neuronal populations, neurotransmitters, and pathways that form orchestrated wake- or sleep-promoting networks.5 Neurotransmitters involved in wakefulness include dopamine, norepinephrine, serotonin, acetylcholine, histamine, and orexin,6 the lattermost of which was identified in 1998 and has been found to play a critical role in maintaining wakefulness.7 Neurotransmitters involved in sleep promotion include adenosine, GABA, melatonin, and galanin.6 The role of these neurotransmitters is particularly relevant in that the medications used to treat insomnia either activate sleep-promoting neurotransmitters or suppress wakefulness-promoting neurotransmitters.
Effect of life stage on sleep
Life stages in women, including pregnancy, menopause, and older age, can have major effects on sleep quality, duration, and efficiency.
Increased rhinorrhea, low back discomfort, need for an altered sleep position, fetal movements, heartburn, RLS-type symptoms, and shortness of breath can disturb sleep during pregnancy.8,9
According to The North American Menopause Society, sleep disturbances occur mainly in women bothered by nighttime hot flashes, although a firm cause-and-effect relationship has not been established.10 Other contributors to insomnia during this life stage include general aging effects, stress, negative mood, and hormonal changes.10
Alterations in sleep architecture that occur as a part of normal aging, including a decrease in total sleep time and increases in arousals and awakenings secondary to lighter and more fragmented sleep, contribute to sleep problems such as insomnia in older persons.11 Other factors contributing to insomnia in older adults include co-morbid physical and mental health conditions and the medications used to treat them, changes in lifestyle and schedule, and altered circadian rhythm. Insomnia in older adults is typically characterized by difficulty sleeping through the night or waking up too early, as opposed to difficulty falling asleep.4
Unless HCPs specifically ask a patient about her sleep habits during a wellwoman visit or a patient broaches the topic herself—perhaps as she is about to leave the exam room— they may not learn about any sleep problems she is having. But a sleep problem such as insomnia, especially if chronic and distressful, merits a workup and treatment in many cases.
Even in a busy office setting, HCPs can start with a two-question screen: Do you experience difficulty sleeping? If so, do you have difficulty falling or staying asleep? To elicit more information, HCPs can then ask: Are you dissatisfied with your sleep? Do you suffer daytime fatigue? Affirmative answers to any or all of these questions suggest a diagnosis of insomnia, and may determine the type of treatment needed.
Another screening option is the BEARS Sleep Assessment Tool.12 Initial letters of the acronym stand for Bedtime problems (e.g., Does the patient have difficulty falling asleep?); Excessive daytime drowsiness; Awakenings during the night (e.g., Is the patient making frequent trips to the bathroom? Is she being interrupted by a crying baby or a sick child?); Regularity and duration of sleep; and Sleep-disordered breathing (e.g., Does the patient have obstructive sleep apnea?).
Workup: Taking a targeted history
For a patient whose screening responses suggest she may have a sleep disorder, HCPs should ask these questions (if not posed during initial screening): Do you suffer from daytime fatigue? Do you snore or have episodes where you stop breathing when you sleep (based on the report of someone sharing your bedroom or your bed)? How many hours are you in bed each night? How many hours do you sleep each night? Do you feel refreshed upon awakening and throughout the next day? Do you have restless leg symptoms? Do you ever sleepwalk or have vivid dreams?
In addition, HCPs should ask the patient about alcohol or illicit drug use, which can have profound effects on sleep. HCPs should also consider aspects of her current health that may be affecting her sleep; common offenders include overactive bladder, chronic pain, mental health disorders, fibromyalgia, hyperthyroidism, perimenopause, and RLS. In patients complaining of RLS-type symptoms, HCPs should consider checking a ferritin level. RLS can be associated with iron-deficiency anemia and ferritin levels below 50 ng/mL.13
If a patient does have ongoing health problems, HCPs should inquire about the over-the-counter (OTC) and prescription medications she is using to treat them. Commonly used medications that can disturb sleep include selective serotonin reuptake inhibitors, dopamine agonists, amphetamines, anticonvulsants, decongestants, corticosteroids, beta agonists, theophylline, antihypertensives, diuretics, and appetite suppressants.14 In addition, HCPs should ask the patient which treatments, including alcohol, marijuana, OTC preparations, and prescription drugs, she has tried to help her sleep.
Some patients may have sleepstate misperception; they believe that they are awake much of the night but are actually asleep for a normal period of time. They think that it takes them an abnormally long time to fall asleep (even though it does not) and/or they underestimate how long they remain asleep. To identify this misperception, or to better understand the nature of any patient’s sleep problem, HCPs can recommend a home sleep study.
Home sleep study
This study, conducted primarily to check for obstructive sleep apnea (OSA) with a small, portable monitor, measures oxygen saturation, heart rate, airflow, and movement in the chest and abdomen, and records time spent snoring and sleep position. The AASM recommends its use for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms indicating an increased risk of OSA.15 HCPs can incorporate the use of home sleep studies into their own practices.16
Sleep apnea affects 6%-17% of the general population—and not just men, obese persons, or older persons, although these are the strongest risk factors.17 One sign of OSA with which HCPs may not be aware is recurrent uvulitis. A patient who presents with frequent sore throats not ascribed to other causes and a beefy-looking uvula may in fact have OSA.18 Of note, a home sleep study does not replace polysomnography performed in a sleep laboratory. The latter is preferred if HCPs suspect that a patient has severe OSA or another type of sleep abnormality or disorder that needs to be identified.
Non-medication approaches to therapy
For a patient who meets criteria for insomnia and who wants to improve her sleep, the first step is to treat any co-morbid condition(s) that may be causing or contributing to her insomnia. At the same time, HCPs should consider the medications that the patient is already taking, including OTC/prescription medications and alcohol, to determine whether any of them may be causing or exacerbating her problem.
The next step is to evaluate the patient’s sleep hygiene and, if less than optimal, advise her to make changes. Good sleep hygiene entails19:
- being consistent—that is, going to bed at the same time each night and getting up at the same time each morning, including on weekends;
- making sure one’s bedroom environment is quiet, dark, cool, and relaxing;
- removing electronic devices from the bedroom;
- avoiding large meals, caffeine, and alcohol before bedtime;
- getting some exercise on most days; and
- receiving daily exposure to sunlight (if possible) and keeping lights on until bedtime.
If making improvements in sleep hygiene proves inadequate, a patient can try a course of psychotherapy such as cognitive-behavioral therapy for insomnia (CBT-I). CBT-I addresses sleep-disruptive beliefs, maladaptive habits, and physiologic factors and incorporates elements of cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation.4,20 A systematic review and meta-analysis demonstrated that CBT-I is effective for adults with chronic insomnia.20 Two possible downsides of CBT-I, as delivered by an HCP, are that it may be difficult to access and it may be expensive. As an alternative, online CBT-I options are available and have been reported to be effective.21,22
Non-medication approaches may be particularly useful for pregnant women with insomnia because many, if not most, medications used to treat insomnia can have a potentially adverse impact on the developing fetus. A recent study of pregnant women with insomnia showed that CBT-I was preferred over drug therapy or acupuncture.8 CBT-I is also recommended as first-line treatment in healthy midlife women with insomnia and moderately bothersome vasomotor symptoms.23
Nonprescription medication options
For patients still experiencing troublesome insomnia after non-medication interventions have been tried, several OTC medications are available. Although not included in the Table, the most common nonprescription “medication” used to treat insomnia is alcohol.24 An alcoholic drink may facilitate sleep onset, but it can also cause insomnia, manifested by multiple nighttime awakenings, increased urination, and difficulty falling back to sleep.
Melatonin, valerian root, and diphenhydramine are three nonprescription medications commonly used to treat insomnia. The Table provides information about their mechanisms of action, indication(s), dosing (in most cases, women and older patients should receive only the lowest dose), appropriateness of use in pregnancy/lactation, and precautions. The Table also includes recommendations from the AASM and from the American Geriatrics Society (AGS), specifically with regard to the AGS Beers Criteria, which lists medications that can cause side effects in older adults related to the physiologic changes of aging.25
Prescription medication options
Three general categories of prescription medication options for treatment of insomnia are the benzodiazepine (BZ) hypnotics, non-BZ hypnotics, and miscellaneous hypnotics. The Table provides the same categories of information for these prescription medications as for the nonprescription medications. Again, in most cases, women and older adults should receive only the lowest dose of a given medication.
Five BZ receptor agonists, all Schedule IV drugs, have been approved by the FDA for short-term treatment of insomnia.26 Two drugs in this class—temazepam and triazolam— are listed in the Table; the others, which are similar to temazepam and triazolam, are estazolam, quazepam, and flurazepam. Their mechanism of action entails binding to a modulatory site on the GABAA receptor and enhancing GABA activity.27
The prescribing information for drugs in this class includes a boxed warning about administering them concurrently with an opioid, which could result in profound sedation, respiratory depression, coma, and even death. BZ hypnotics can cause complex sleep behaviors (e.g., sleep-driving, having sex or eating while asleep and having no memory of it afterward).28,29 Based on the Beers Criteria, these agents should be avoided in older adults.25 Patients who take BZ hypnotics for a prolonged period (despite the fact that they are indicated only for short-term use) and who wish to discontinue them should taper them gradually, as opposed to stopping them abruptly, to avoid withdrawal symptoms.
These Schedule IV drugs, eszopiclone, zaleplon, and zolpidem (Table), are known as the “Z” drugs because their generic name or their predecessor’s generic name starts with “Z” (eszopiclone is the active stereoisomer of zopiclone, which is available in Japan, Brazil, and some European countries). Or perhaps these drugs are so nicknamed because they help people get their zzz’s.
Non-BZ hypnotics act through the BZ binding sites associated with GABAA receptors.30 Their effects may be slowed if they are ingested with or shortly after a meal.31-34 They should be taken only if patients can be assured of getting a full night’s sleep.31-34 Based on the Beers Criteria, these drugs should be avoided in older adults.25 Doses should be as low as possible in patients with mild to moderate hepatic impairment; in those with severe hepatic impairment, these drugs should be used at the lowest possible dose, with great caution, or avoided.31-34
Other concerns regarding the “Z” drugs include short-term effects such as complex sleep behaviors, next-day sedation, and long-term effects such as amnesia, dementia, and rebound insomnia after the drug is stopped.31-34 If these drugs are to be halted after prolonged use, they should be slowly tapered to avoid withdrawal symptoms.31-34
These agents include ramelteon, a prescription-strength melatonin agonist; three antidepressants; and suvorexant, which inhibits the action of orexin, a neurotransmitter involved in wakefulness (Table).35-40
Patients and HCPs should not expect to find an effective solution for insomnia in one visit. Patients receiving any type of medication for insomnia should return for follow-up after 4-8 weeks for evaluation of efficacy, safety, and the need for ongoing treatment. The American College of Physicians guidelines suggest that patients who require medication for longer than 4-5 weeks be assessed regularly for the need to continue it.4
Insomnia affects millions of individuals in the U.S. Because many patients with insomnia do not mention their sleep problem at HCP visits, they should be screened for insomnia on a regular basis. Numerous treatment options, both nonpharmacologic and pharmacologic, exist. In most cases, HCPs should proceed in step-wise fashion, starting with behavioral approaches and advancing to OTC or prescription medication; the choice of medication depends on a patient’s age, health status, particular form of insomnia (problem with sleep onset, sleep maintenance, or both), and other considerations (e.g., a need to avoid drugs with addictive potential). Regardless of therapeutic choice, HCPs should follow patients with insomnia on a regular basis to ensure that treatment is effective, well tolerated, and still needed.
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