Nonpharmacologic Management of Chronic Insomnia

 


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Am Fam Physician. 2015 Dec 15;92(12):1058-1064.

  Patient information: See related handout on chronic insomnia, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Insomnia affects 10% to 30% of the population with a total cost of $92.5 to $107.5 billion annually. Short-term, chronic, and other types of insomnia are the three major categories according to the International Classification of Sleep Disorders, 3rd ed. The criteria for diagnosis are difficulty falling asleep, difficulty staying asleep, or early awakening despite the opportunity for sleep; symptoms must be associated with impaired daytime functioning and occur at least three times per week for at least one month. Factors associated with the onset of insomnia include a personal or family history of insomnia, easy arousability, poor self-reported health, and chronic pain. Insomnia is more common in women, especially following menopause and during late pregnancy, and in older adults. A comprehensive sleep history can confirm the diagnosis. Psychiatric and medical problems, medication use, and substance abuse should be ruled out as contributing factors. Treatment of comorbid conditions alone may not resolve insomnia. Patients with movement disorders (e.g., restless legs syndrome, periodic limb movement disorder), circadian rhythm disorders, or breathing disorders (e.g., obstructive sleep apnea) must be identified and treated appropriately. Chronic insomnia is associated with cognitive difficulties, anxiety and depression, poor work performance, decreased quality of life, and increased risk of cardiovascular disease and all-cause mortality. Insomnia can be treated with nonpharmacologic and pharmacologic therapies. Nonpharmacologic therapies include sleep hygiene, cognitive behavior therapy, relaxation therapy, multicomponent therapy, and paradoxical intention. Referral to a sleep specialist may be considered for refractory cases.

The International Classification of Sleep Disorders, 3rd ed., (ICSD-3) defines insomnia as difficulty falling asleep, difficulty staying asleep, or early awakening despite the opportunity for sleep that is associated with impaired daytime functioning and occurs at least three times per week for at least one month.1  The full ICSD-3 criteria are included in Table 1.1,2 Short-term, chronic, and other types of insomnia are the three major categories according to the ICSD-3. Insomnia can be acute (lasting up to three months) or chronic (lasting at least three months). Based on the severity of the disorder, all the criteria do not have to be met to begin therapy.1

WHAT IS NEW ON THIS TOPIC: INSOMNIA TREATMENT

Although the combination of stimulus control and sleep restriction therapy leads to a similar treatment response compared with either therapy alone, multicomponent therapy is associated with higher remission rates (absence of insomnia posttreatment).

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Sleep hygiene is recommended as an initial intervention for all adults with insomnia.

C

26

Cognitive behavior therapy for insomnia is recommended for first-line treatment of primary insomnia in older adults.

C

9, 16, 26

Moderate-intensity exercise, tai chi, and low-impact aerobic exercise (not within 4 hours of bedtime) improve sleep quality in older adults.

C

16, 26, 37, 38

Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies whenever possible.

C

16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Sleep hygiene is recommended as an initial intervention for all adults with insomnia.

C

26

Cognitive behavior therapy for insomnia is recommended for first-line treatment of primary insomnia in older adults.

C

9, 16, 26

Moderate-intensity exercise, tai chi, and low-impact aerobic exercise (not within 4 hours of bedtime) improve sleep quality in older adults.

C

16, 26, 37, 38

Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies whenever possible.

C

16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

BEST PRACTICES IN SLEEP MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive behavior therapy, and reserve medication for adjunctive treatment when necessary.

American Academy of Sleep Medicine

Do not use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.

American Geriatrics Society


Source: For more information on the Choosing

The Authors

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DAVID L. MANESS, DO, MSS, FAAFP, is a professor in and chair of the Department of Family Medicine at the University of Tennessee Health Science Center, Memphis....

MUNEEZA KHAN, MD, FAAFP, is an assistant professor and program director in the St. Francis Family Medicine Residency Program at the University of Tennessee Health Science Center.

Address correspondence to David L. Maness, DO, MSS, University of Tennessee Health Science Center, 1301 Primacy Pkwy., Memphis, TN 38119 (e-mail: dmaness@uthsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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