The management of insomnia depends upon its etiology. If the patient has a medical, neurologic, or sleep disorder, treatment should be directed at the disorder. In particular, adequate pain control can greatly relieve insomnia associated with pain syndromes. In case of a psychiatric disorder, treatment should be directed at the disorder. This may involve medications, psychotherapy, and if possible referral to a psychiatrist, psychologist, or therapist. If the insomnia is related to medication or drug abuse, the offending medication or drug must be withdrawn.

The treatment of psychophysiologic insomnia begins with education about the sleep problem and appropriate sleep hygiene. Before instituting therapy, most patients are asked to maintain a sleep log for 2-4 weeks. In the sleep log, the patient records bed and wake times, how much sleep is obtained, and daytime naps and activities. It gives the physician a clearer picture of the degree of sleep disturbance and allows him or her to better tailor the treatment.

Behavioral therapy now is considered the most appropriate treatment for patients with primary insomnia. The therapies are based on the fact that primary insomnia is associated with physiologic, emotional, and cognitive arousal and conditioning to arousal in bed.

Primary Care Physician's Role

Primary care physicians should be able to diagnose and treat transient or short-term insomnia. Chronic insomnia is often more difficult to treat and when primary or associated with a sleep or psychiatric disorder, referral to an appropriate specialist may be indicated.

Patients should be referred to a sleep specialist in the following cases: If any history suggestive of obstructive sleep apnea or RLS/PLMD and in cases of primary insomnia, particularly if it is psychophysiologic insomnia and of long duration.

Many sleep centers have a staff psychologist who specializes in treating insomnia. The advantages include experience in behavioral techniques and providing sleep education, greater available time for the often-frequent follow-up that is needed, and the ability to ascertain if other psychological factors are present that may need further evaluation by a psychiatrist.

Patients with a history of depression should be referred to a psychiatrist based on the usual referral pattern of the primary care physician.

Insomnia in the elderly poses special concerns. The satisfaction of sleep declines with age. This probably is related to changes in sleep associated with age, such as a decrease in slow wave sleep, increased time awake after sleep onset, and a tendency to go to bed early and rise early. However, aging should not be assumed to be the explanation for insomnia. Multiple factors affect sleep in the elderly, including nocturia, pain syndromes, and many medical disorders (eg, heart failure, COPD, Parkinson disease). Other factors include RLS, PLMD, and sleep apnea (all of which have increased frequency in the elderly), dementia and, frequently, changing situational factors, such as retirement, bereavement, or financial difficulties, leading to anxiety and depression.

As in younger patients, nonpharmacologic treatment should take precedence over pharmacologic treatment. Hypnotics should be prescribed cautiously and in lower doses than for younger patients. Drugs tend to have longer duration of effect due to changes in metabolism and elimination. This can lead to increased incidence of falls and bone fractures at night (if the patient gets up to use the bathroom not fully awake or ataxic) and decrements in daytime alertness and performance (including increased incidence of motor vehicle accidents).