Neurodegenerative conditions (eg Alzheimer’s disease, Parkinson’s disease)īox 2.Alcohol – determine frequency and amount relative to bedtime.Protein, meal/weight replacement shakes.Caffeine – determine frequency and ingestion relative to bedtime given caffeine’s long half-life.Adrenergic agonists (eg salbutamol, dexamphetamine, methylphenidate).
Personality disorders such as narcissistic and borderline.Comorbidities and risk factors associated with insomnia Sleep restriction can be used to increase sleep pressure in lieu of the sedating properties of hypnotics, though this may worsen daytime sleepiness, particularly when combined with medications with a long half-life.īox 1. 11 Consultation by a sleep specialist may be necessary to investigate and treat sleep comorbidities that may co-exist or mimic insomnia (refer to Box 1). 10 Sleep restriction in patients with sleep apnoea should be used judiciously given that it can worsen daytime sleepiness and vigilance. The possibility of manic states precipitated by sleep restriction in patients with bipolar illness has been raised, and one study found CBT-I resulted in mild increases in hypomania. Stand-alone CBT-I is safe and well tolerated by a large number of clinical populations. 7 Improvements in sleep have also been observed in patients prescribed CBT‑I in combination with temazepam 8 and zolpidem 9 however, sleep improvements are better maintained in patients who are not medicated. 6 Unlike hypnotics, improvements in sleep following CBT‑I are maintained after treatment cessation for up to three years. Meta-analysis of randomised controlled trials (RCTs) shows unequivocally that CBT-I reduces sleep onset latency and nocturnal arousals while improving sleep efficiency (ie the length of time asleep relative to the amount of time spent in bed), with effect sizes comparable in magnitude to hypnotics such as benzodiazepines and non-benzodiazepines.
Invariably, CBT-I includes all of these components, delivered over several sessions by a psychologist or trained healthcare professional. 5 However, patients prescribed medications for short-term use require close monitoring for medication dependence, psychiatric status, unproductive sleep-specific coping strategies and maladaptive cognitions, as well as the severity of stressors, as these factors may precipitate and perpetuate insomnia.Ĭognitive behavioural therapy for insomniaĬBT-I refers to a range of evidence-based techniques packaged into a multiple-session treatment that includes behavioural and cognitive strategies (Box 2). Patients presenting with acute symptoms of insomnia may benefit from short-term medication in concert with sleep hygiene education. The Australasian Sleep Association (ASA) 1, American Academy of Sleep Medicine 2, American College of Physicians 3 and European Sleep Research Society 4 all recommend cognitive behavioural therapy for insomnia (CBT-I) as the first-line treatment for patients with insomnia disorder. Both pharmacologic and psychological interventions are indicated for the treatment of insomnia disorder however, selecting the right treatment is dependent on the chronicity of symptoms, with medical and psychiatric factors taken into account.
Insomnia disorder is characterised by inadequate sleep despite adequate sleep opportunity, accompanied by daytime dysfunction.
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