Disease modifying treatment available:
Time critical diagnosis and management:
Lateralising:
Difficulty initiating or maintaining sleep.
None
| Disorder | Clinical features | Associated features | Investigations | Disease modifying treatment available | Time critical |
|---|---|---|---|---|---|
| Depression |
Epilepsy |
||||
| Obstructive sleep apnoea |
Cognitive impairment Bilateral papilloedema |
||||
| Anti-CASPR2 encephalitis |
Myokymia Seizure Generalised pain Weight loss Cerebellar ataxia Hyperhidrosis Psychosis Amnesia |
Thymoma Anti-LGI1 encephalitis |
|||
| Nocturia | |||||
| Restless leg syndrome | |||||
| Familial fatal insomnia |
Insomnia is associated with an increased risk of depression anxiety and substance abuse.
Insomnia should be differentiated from circadian rhythm disorders.
Insomnia may cause the following:
None
| Laboratory Investigation | Result |
|---|
The management of insomnia can be considered in several steps:
1) Identification and treatment of any underlying cause
2) Encouraging good sleep hygiene
3) Regular exercise (but not late at night)
4) Medications
CBT is the most cost-effective treatment for chronic insomnia.
Medications to treat insomnia are primarily GABA A receptor agonists. Stimulation of these receptors produces a sedative effect. Additional effects include muscle relaxation, anti-epileptic effects, anxiolytics, memory impairment, behavioural disturbance and ataxia. If the half life of these medications is too long a 'hangover' effect with impaired function upon waking is observed. If the half life is too short rebound insomnia can develop. These drugs have significant potential for physiological dependence and a street value. Z-drugs targeting a specific GABAA receptor subtype are better tolerated. These medications have no role in the management of chronic insomnia.
Long acting melatonin is available for the treatment of insomnia in adults over the age of 55. A dual orexin receptor antagonist (daridorexant) are now also available.
Anti-depressant medications are sometimes used to help treat co-existent depression. The evidence basis for this is not great and all are used off license in the UK. The most commonly used anti-depressants for this purpose are trazodone, doxepin and mirtazapine.
None