32 Five-minute refresher Insomnia Consultant neurologist Dr Kirstie Anderson presents the diagnostic and management pathway for those who complain of insomnia or poor sleep Sleep history questions 1 Do you snore heavily? Has anyone witnessed prolonged pauses in breathing (apnoeas)? 2 Do you have any unpleasant tingling or discomfort in the legs that makes you need to kick or move? Is it worse in the evenings? Is it helped by moving? 3 What is the timing and dose of any medications, including caffeine, alcohol and nicotine? What about OTC medications that affect sleep, such as caffeine-containing painkillers or sedating antihistamines? 4 ‘Take me through a typical 24 hours’ – describing the sleep/wake pattern over a day and any work shifts. 5 Do you nap during the day – if so when and for how long? 6 Do you have a history of nightmares, acting out dreams or sleepwalking out of the bedroom? If so, at what time of night do these things tend to happen? General advice • Allow at least 11 hours recovery in between the end of one shift at work and the start of the next. • Avoid long working weeks of >60 hours. • Seek flexibility in shifts to accommodate natural larks or owls. • Promote healthy lifestyle advice, particularly eating habits. Common causes of poor sleep Sleep apnoea – 20% perceive a restless, unrefreshing night. Clues include snoring, daytime sleepiness. High-risk groups include those who attend the pain clinic, those with severe mental health problems who may live alone and be unaware of their snoring history and those with CFS/ME. Pulse February 2019 Restless legs syndrome – affects 5-10% of the population with variable severity. Signpost patients to RLS-UK. Gastro-oesophageal reflux – nocturnal cough, pain, laryngospasm. Shift workers – sleeping badly affects women more than men and those over 40. Leads to decreased total sleep time and disrupted circadian rhythm. Assessment in the surgery Epworth sleepiness score – surprisingly, insomnia patients typically have a low ESS, often between 0 and 2. They don’t tend to daytime nap and often misperceive how long they sleep for – only about 10% sleep for less than six hours a night. Sleep diaries – a pattern of spending far more time in bed than asleep is usually seen. The sleep efficiency (sleep time/ time in bed) over seven or 14 days can be calculated. Normal sleep efficiency is typically >85%. Devices such as the Fitbit and Jawbone are not validated to assess sleep – discourage patients from using them to measure sleep. Investigations – check ferritin for restless legs; supplement if below 45. There is little evidence for other routine blood tests if the patient is systemically well. Insomnia disorder • Not explained by another underlying cause of disturbed sleep. • Difficulty falling asleep, or • Difficulty maintaining sleep (typically both). • Subsequent daytime dysfunction. • Occurs on more than three days a week and for at least three months.