Links

• NPS Sleep diary
• Veteran's MATES
• NPS Position statement on zolpidem and sleep-related behaviour
  

Explore patient concerns with sleep difficulties

Insomnia is a subjective problem with falling or staying asleep, waking up too early or having poor sleep quality, which then results in daytime impairment.[1] Ask patients or carers about their views on normal sleep and the impact of insomnia.[2] Reassure those people without daytime impairment that they may be getting sufficient sleep: address any misperceptions or unrealistic expectations (see page 2).[2–5]

Investigate common causes of insomnia first

Up to 80% of cases are secondary to a comorbidity (Box 1) although the cause can be multifactorial.[1,2] Patients can assist in identifying causes by documenting their sleep–wake patterns and activities in a sleep diary.[3]

Treat by addressing the identified causes

Modify poor sleep practices, optimise management of comorbidities and/or change the use of problematic substances or medicines (Box 1).[3,5] Sleep difficulties caused by acute stressors are usually short-lived and should resolve if the cause is removed or alleviated.[1,2]

Use behavioural and cognitive therapies if no underlying cause is identified (primary insomnia) or if managing underlying causes alone does not improve sleep.[1,5] Ensure that carers are also involved in managing sleep difficulties and advise on how they can help to improve a person’s sleep without hypnotic medicines.

Box 1: Common causes of insomnia[1,2,6–8]

Psychosocial, physical and environmental stressors
E.g. grief, illness, changing time zones, light, noise, hot or cold ambient temperatures, stress (interpersonal, occupational, academic or financial).
Medical conditions
Includes cardiovascular (e.g. angina), endocrine (e.g. thyroid dysfunction), gastrointestinal (e.g. GORD), genitourinary (e.g. incontinence), musculoskeletal (e.g. arthritis), neurological (e.g. chronic pain), respiratory (e.g. COPD), sleep disorders (e.g. sleep apnoea).
Psychiatric disorders
E.g. anxiety disorders, attention deficit disorder, bipolar disorder, dementia, depression, schizophrenia.
Poor sleep practices
E.g. daytime napping, use of bed for activities other than sleep or sex, heavy meals or exercise near bedtime, variable sleep/wake time.
Substance use
E.g. alcohol, caffeine (including in food and energy drinks), nicotine, recreational drugs.
Medicines
Includes antidepressants (e.g. SSRIs), antiepileptics (e.g. phenytoin), beta blockers, CNS stimulants (e.g. methylphenidate), corticosteroids, diuretics, levodopa, sympathomimetics (e.g. salbutamol), thyroid hormones.

Use non-drug therapies to manage insomnia

Advise every patient on good sleep practices, such as regular daytime exercise, keeping a set sleep/wake time and a bedroom environment conducive to sleep (see the Sleep right. Sleep tight leaflet available at §www.nps.org.au/sleep§).[1,2] Use behavioural and cognitive therapies (Box 2) to target specific factors that perpetuate sleep difficulties over time, including in people with secondary insomnia.[1]

Discuss the benefits of non-drug management with patients and carers

Non-drug therapies have comparable efficacy to benzodiazepines and other related drugs, and:

• have longer-lasting effects on sleep
• avoid the potential harms and dependence of hypnotic medicines
• do not disrupt normal sleep patterns.[9–15]

Combining advice on good sleep practices with the therapies in Box 2 (over 4–8 weeks) helps people to fall asleep faster and reduces their time awake after sleep onset by up to 30 minutes more than placebo or no treatment.[9,10,13,16] Improvements can persist for up to 2 years after therapy — hypnotic medicines do not provide this benefit.[9–12]

Treat persisting sleep difficulties with at least one behavioural and cognitive therapy

Use the therapies in Box 2 to manage chronic insomnia (present for > 4 weeks) — advising on good sleep practices alone may not be sufficient.[1,2,9] People with acute insomnia that persists despite addressing poor sleep practices and other factors should also receive these therapies.[2]

Discuss the choice with the patient and/or carer: as a guide, assess the sleep history and/or sleep diary, preferences, and physical and cognitive capacities to engage in therapy.[2,3] If one approach is ineffective or unmanageable, a different therapy or combination can still be helpful.[1]

Start behavioural and cognitive therapies or refer patients to a specialist sleep clinic, sleep physician, psychiatrist or psychologist (see NPS News 67 for how to locate a suitable health professional).[3,17] Self-help materials (e.g. books) are an alternative to face-to-face therapy, but might not be as effective.[18]For more information on behavioural and cognitive therapies for insomnia, refer to the materials in Veterans MATES Therapeutic Brief 18.

Box 2: Behavioural and cognitive therapies for insomnia[1–3,17]

Cognitive therapy
Suitable for people with negative beliefs and attitudes, unrealistic expectations, or who are excessively worried about sleep and the consequences of sleep loss. Techniques identify and change distorted thoughts such as ‘I must sleep at least 8 hours a night or I’ll do myself harm’, ‘If I don’t sleep well I should stay in bed longer and rest’, ‘I won’t cope tomorrow if I’m not asleep soon’.
Stimulus control
Suitable for people who have difficulty falling asleep due to a learned association between the bed or bedroom and sleeplessness, frustration and worry. Technique: patient goes to bed only when tired (using the bed for sleep or sex only) and gets out of bed if unable to fall asleep within a perceived 20 minutes (i.e. without watching the clock); this is repeated each night until a stable sleep–wake schedule is established.
Sleep restriction
Suitable for people who have difficulty staying asleep due to poor sleep drive that causes broken sleep or excessive time spent in bed awake. Technique: patient limits time in bed to the actual total sleep duration per night (setting the wake-up time), gradually increasing as total sleep duration improves and until target is achieved (no less than 5 hours). Monitor for and warn about possible daytime sleepiness with this technique.
Relaxation training
Suitable for patients who cannot ‘wind down’ and sleep at bedtime due to physical tension, overactive mind or worry.Techniques used during the day and night include: Progressive muscle relaxation: patient focuses on and relaxes each muscle group gradually, allowing them to become heavy. Mental imagery: patient takes a few deep breaths, relaxes and imagines something pleasant for as long as possible.

Limit supply of hypnotic medicines when these are required

Avoid prescribing hypnotic medicines whenever possible. A short-acting benzodiazepine (e.g. temazepam) or other related drug (zolpidem or zopiclone) should only be considered if:

• immediate short-term symptom relief is required, and
• sleep difficulties are expected to be short-lived (acute insomnia) and non-drug therapies cannot be implemented readily, or
• chronic insomnia has not responded to non-drug therapies alone.[2–5]

Prescribe only for a short duration

If treatment is required, prescribe for < 2 weeks and ideally intermittently (e.g. 2–5 nights per week).[1,4] Prolonged hypnotic medicine use (for > 4 weeks), especially at high doses, increases the risk of dependence.[4]

Engage patients and carers in limiting use at the time of the initial prescription (Box 3). Check the need for and duration of hypnotic medicines initiated during hospital admission and in aged care facilities: treatment is usually intended to be short-term and should be ceased.

Use zolpidem or zopiclone as cautiously as a benzodiazepine

There is no evidence that zolpidem and zolpiclone differ in their efficacy or safety.[22–24] Zolpidem or zopiclone can cause tolerance, dependence and withdrawal symptoms.[4,8,19,25] Visual hallucinations, psychosis and bizarre behaviours with amnesia (e.g. sleep driving) have been reported with these drugs[25]: see the NPS Position Statement: Zolpidem and sleep-related behaviours.

Limited role for over-the-counter and complementary medicines

There is less evidence for treating insomnia with other drugs and complementary medicines (e.g. melatonin, valerian).[1,4,19] Sedating antihistamines (diphenhydramine, doxylamine) are not recommended because tolerance can develop quickly and adverse effects (e.g. daytime sedation) can be a problem, especially for older people.[6,8,19,26]

Box 3: Discussion points on hypnotic medicines use for patients and carers

Agree up front on a definite duration of therapy outlining: the risk of adverse effects, tolerance and dependence with the medicine that long-term use is rarely necessary and is more difficult to stop the importance of continuing with non-drug therapies.[1,4,6,19]

Discuss a stopping plan — stopping is more likely to be successful when a shared decision has been made with the patient, and there is cooperation from family, carers and staff in aged care facilities.[3,4,20,21] Short-term use for < 2 weeks can usually be stopped abruptly without problem.[4]

Actively pursue discontinuation of long-term use

Systematically discuss cessation of long-term use with each patient at every opportunity. Hypnotic medicines have the potential to cause harm and stopping their use improves alertness, cognition and sleep quality.[3,15] Older people in particular are at greater risk of adverse effects including memory impairment, falls, fractures and motor vehicle accidents.[4,22] Establish the patient’s willingness and goals and agree on a stopping plan (see NPS News 67 [§www.nps.org.au/news_67§] for a guide).

Simple strategies in primary care can motivate patients to stop

Brief intervention in general practice or outpatient settings is at least twice as likely to lead to stopping benzodiazepines as usual care or not raising awareness at all.[27,28] Effective strategies include a letter from a GP outlining the need for discontinuation, a short consultation or meeting and self-help advice.[21,27,28] (A patient leaflet with helpful tips on stopping such medicines and a reduction plan is available at §www.nps.org.au/sleep§).

Gradually taper dosage on an individual basis

Discuss and agree on a tailored dose reduction and titrate to the patient’s severity of withdrawal symptoms (see examples in Box 4).[1,3,4,20] An optimal approach has not been established.[21]

To help patients commit to and achieve their goals:

• allow them to choose on what days they reduce their dose
• maintain regular contact (e.g. weekly) during dose reduction phases
• outline the type, nature and possible duration of withdrawal symptoms
• explain that rebound insomnia is a symptom of stopping and not a sign that treatment should continue
• advise on ways to manage changes in mood, sleep, substance use and withdrawal symptoms (e.g. temporary dose increases).[1,3,20]

Support and encourage further attempts if discontinuation is unsuccessful

Switching to the long-acting benzodiazepine diazepam may result in less withdrawal symptoms if these are problematic with short-acting drugs or high doses (see Box 4) — however, avoid diazepam in older people.[4,20] Using behavioural and cognitive therapies with gradual dose reduction also increases the chance of stopping.[27,28]

Consider referral to a specialist if discontinuation is too difficult in primary care. Reassure patients and carers that further attempts are worthwhile, suggest non-drug therapies that might reduce the need for a hypnotic medicine, and plan for regular medication reviews.[4,6,20]

Box 4: Examples of approaches to gradual dose reduction[4,20,21]

Reduce by a proportion of the starting dose per week (e.g. 10% to 20%) E.g. temazepam 20 mg per night Can reduce by 15–20 mg per week (a rate of 10% to 15%), starting with 2 x 10 mg on three nights plus 1.5 x 10 mg tablets on four nights	First stabilise on an equivalent dose of diazepam for a few days then reduce E.g. temazepam 30 mg per night Switch to diazepam 15 mg daily in divided doses, can then reduce by 10% per day (for inpatients) or slower in an outpatient setting (e.g. by 25% every fortnight).
Tailor further reductions according to the patient’s response. Allow at least several days to stabilise between dose reduction If multiple drugs are used, reduce the dose of each drug one after the other or switch to diazepam by summing dose equivalents.

References

1. Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4:487–504.
2. Sowerby Centre for Health Informatics at Newcastle (SCHIN). NHS Clinical Knowledge Summaries. Clinical topics: Insomnia — Management. (accessed 24 November 2009).
3. Australian Government Department of Veteran's Affairs. Veterans’ MATES Therapeutic Brief 18. Insomnia Management: Effective approaches for a common problem. March 2009. (accessed 11 September 2009).
4. Psychotropic Expert Group. Therapeutic Guidelines: Psychotropic, Version 6. In: eTG complete [CD-ROM]. Melbourne: Therapeutic Guidelines Limited; October 2008.
5. Ramakrishnan K, Scheid DC. Treatment options for insomnia. Am Fam Physician 2007;76:517–26.
6. Tiller JWG. The management of insomnia: an update. Aust Prescr 2003;26:78–81.
7. Woodward MC. Managing insomnia in older people. J Pharm Pract Res 2007;37:236–41.
8. Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med 2006;119:463–9.
9. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 1994;151:1172–80.
10. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev 2009;13:205–14.
11. Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999;281:991–9.
12. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA 2006;295:2851–8.
13. Buscemi N, Vandermeer B, Friesen C, et al. Manifestations and Management of Chronic Insomnia in Adults. Evidence Report/Technology Assessment No. 125. Agency for Healthcare Research and Quality (AHRQ) Publication No. 05-E021-2. Rockville, MD: AHRQ. June 2005. (accessed 6 August 2009).
14. Smit MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5–11.
15. Petit L, Azad N, Byszewski A, et al. Non-pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age Ageing 2003;32:19–25.
16. Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev 2003;(1):CD003161.
17. Harsora P, Kessmann J. Nonpharmacologic management of chronic insomnia. Am Fam Physician 2009;79:125–30.
18. van Straten A, Cuijpers P. Self-help therapy for insomnia: a meta-analysis. Sleep Med Rev 2009;13:61–71.
19. Australian Medicines Handbook, 2010.
20. Khong E, Sim MG, Hulse G. Benzodiazepine dependence. Aust Fam Physician 2004;33:923–6.
21. Lader M, Tylee A, Donoghue J. Withdrawing benzodiazepines in primary care. CNS Drugs 2009;23:19–34.
22. Glass J, Lanctot KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331:1169.
23. Dundar Y, Boland A, Strobl J, et al. Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation. Health Technol Assess 2004;8(24).
24. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007;22:1335–50.
25. Olson L. Hypnotic hazards: adverse effects of zolpidem and other z-drugs. Aust Prescr 2008;31:146–9.
26. Passarella S, Duong M-T. Diagnosis and treatment of insomnia. Am J Health-Syst Pharm 2008;65:927–34.
27. Parr JM, Kavanagh DJ, Cahill L, et al. Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis. Addiction 2009;104:13-24.
28. Voshaar RCO, Couvee JE, van Balkom AJLM, et al. Strategies for discontinuing long-term benzodiazepine use: meta-analysis. Br J Psychiatry 2006;189:213–20.