Primary Care Management of Sleep Complaints in Adults

Effective Date: November 1, 2004

Recommendations and Topics

Scope

1. Assessment of complaint

2. Insomnia

3. Hypersomnia

4. Parasomnia

Rationale

References

Sponsors

 

Scope

This guideline is for the primary care management of non-respiratory sleep disorders in adults and follows the DSM-IV-TR classification of sleep disorders.1 It does not address the specific management of circadian rhythm disorders (shift work intolerance and delayed sleep phase syndrome) and the relatively rare parasomnia, REM Sleep Behaviour Disorder.

TOP

RECOMMENDATION 1: Assessment of complaint

Assess the sleep complaint by a:

  • history of the sleep complaint
  • sleep diary completed over one week (see insert)
  • history from the bed partner, if appropriate
  • systems review
  • medication and drug history (include over-the-counter medications and recreational drugs)
  • psychiatric history with special attention to the family and personal history of mood and anxiety disorders
  • focused physical exam

RECOMMENDATION 2: Insomnia

If the problem is insomnia (trouble falling asleep or maintaining sleep), assess the degree of daytime impairment.

If daytime impairment is mild to moderate (little or no impairment in social or occupational functioning and complaints of non-restorative sleep, dysphoria, and tiredness after fewer than half the sleeps):

  • ensure that the patient is practicing all the rules of good sleep hygiene – see A Guide for Patients
  • establish a regular rising time
  • commence one of the behavioural interventions below:

Stimulus control re-establishes the association of the bed and bedroom with sleep, rather than with the frustration and anxiety of trying to sleep. The patient should go to bed only when sleepy, and get up at the same time each day regardless of how much he or she slept. The patient should get up, go to another room if unable to fall asleep, or return to sleep, after 15 to 20 minutes (without clock-watching) and return to bed only when drowsy-tired.

Sleep restriction limits the time in bed to the amount of time a patient actually sleeps usually. Estimate the average sleep time from at least three days of a sleep diary. For example, if a patient sleeps an average of six hours a night, the total time in bed is limited to six hours. Ask patients to set their preferred rising time and to retire six hours earlier. They should maintain this bedtime for a few days to induce a mild degree of sleep deprivation – this will help them sleep more efficiently. Then they should go to bed ten minutes earlier every few days until their sleep becomes disrupted. Finally they will set their new bedtime 10 minutes later than the time they went to bed when their sleep became disturbed.

If daytime impairment is severe (significant impairment in social or occupational functioning and complaints of non-restorative sleep, dysphoria, and tiredness after more than half the sleeps):

  • ensure that the patient is practicing all the rules of good sleep hygiene – see A Guide for Patients
  • set a regular rising time
  • commence a short course of hypnotics (14 days or less) but do not extend sleeping hours
  • prior to discontinuing medication (always taper through a half-dose) limit the time in bed to 30 minutes less than the mean total sleep time on medication to induce a modest degree of sleep restriction
  • add 10 minutes to the sleep time every few days until sleep becomes disrupted, then take off 10 minutes to assign the final time in bed

If severe daytime impairment persists after two to three treatment trials refer the patient to an appropriate specialist.

RECOMMENDATION 3: Hypersomnia

If the problem is hypersomnia (excessive sleepiness) and the patient has disruptive snoring and/or witnessed pauses in breathing during sleep, refer to the Assessment and Management of Obstructive Sleep Apnea in Adults.

Otherwise:

  • ensure that the patient is following all the rules of good sleep hygiene-see A Guide for Patients
  • ensure patient is getting sufficient sleep
  • manage any psychiatric disorders (especially depression or bipolar affective illness)

If the problem persists refer the patient to an appropriate specialist with an interest in sleep disorders.

RECOMMENDATION 4: Parasomnia

If the problem is parasomnia (unusual behavioural or physiological events during sleep caused by activation of the autonomic nervous system, motor system, or cognitive processes, e.g., sleep terror, sleepwalking, sleep talking):

Ensure that the sleeper and bed partner are safe.

If mild (talking/shouting only or physical activity limited to occasional restlessness less than three nights per week):

  • ensure practice of good sleep hygiene – see A Guide for Patients
  • prevent sleep deprivation
  • general stress reduction strategies (time management, exercise, counselling, etc.)
  • avoid excessive alcohol intake and recreational drug use.

If moderate to severe (activity places patient and/or partner at risk more than three times per week and/or daytime impairment):

  • commence trial of benzodiazepine; clonazepam (0.25-1.5 mg hs) is commonly used but all are likely effective (no studies demonstrate superiority of a single agent)
  • effective trials should be continued for a year and slowly tapered with the same safety precautions as for mild parasomnia
  • avoid excessive alcohol intake and recreational drug use.

If the problem persists refer the patient to an appropriate specialist with an interest in sleep disorders.

Rationale

This guideline is a revision of the 1999 protocol for the primary care management of sleep disorders in adults. The original protocol provided an evidence-based approach to the common non-respiratory sleep disorders seen by primary care physicians. The protocol took into consideration comprehensive approaches to sleep disorders and placed a high value on patients regaining normal sleep patterns without long-term use of pharmaceutical agents.

This review is based on a search of computerized data bases of the medical literature and comments received from doctors on the original protocol. The current literature confirms the original approach.

The evidence shows that the best assessment tool for a sleep related clinical condition is a detailed history from the patient (and the bed partner when available) augmented by a sleep diary covering a week of sleep-wake function2,3.

Sleep disorders can often be improved with sleep hygiene (see A Guide for Patients)4. Sleep hygiene refers to a set of rules that are known to improve sleep. Good sleep hygiene requires the simultaneous execution of all the rules but particularly emphasizes the importance of getting up at the same time each day, seven days a week.

The most common sleep complaint is insomnia5. For mild to moderate insomnia a behavioural intervention is preferred over treatment with hypnotics6. Research and clinical experience indicate that restricting the time spent in bed through techniques known as stimulus control and sleep restriction helps consolidate and deepen sleep and often is the only treatment required7,8,9.

Many sleep disorders can be safely and adequately managed in primary care settings with referrals to sleep clinics being required only when there has been an inadequate treatment response or when further expertise is required.

References

  1. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Fourth Edition, Text Revision, Washington, DC, American Psychiatric Association, 2000.
  2. Rungta KN, Fleming JAE. The sleep history. BC Med J 1991;33:337-41.
  3. Rajput V, Bromley SM. Chronic insomnia: a practical review. American Family Physician 1999; 60: 1431-8.
  4. National Heart, Lung and Blood Institute Working Group on insomnia. Insomnia: Assessment and management in primary care. Am Family Physician 1999;59:3029-38.
  5. Chesson A Hartse K, Anderson WM, Davila D, Johnson S et al. Practice parameters for the evaluation of chronic insomnia: An American Academy of sleep medicine report. Sleep 2000; 23: 237-41.
  6. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioural and pharmacological therapies for late-life insomnia: a randomised controlled trial. JAMA 1999:281:991-9.
  7. Bootzin RR, Nicassio PM. Behavioural treatments for insomnia. In Hersen M, Eisler RM, Miller PM (eds). Progress in Behaviour Modification. Vol.6. New York: Academic press:1-45.
  8. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time spent in bed. Sleep 1987;10:45-56.
  9. Robinson L, Janicijevic RD, Hamilton PJ, Fleming JAE. Behavioural techniques in psychophysiological insomnia. BC Med J 1991;33:351-3.

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate
    responses to common
    medical situations
  • recommend actions
    that are sufficient
    and efficient, neither
    excessive nor deficient
  • permit exceptions
    when justified by
    clinical circumstances.

Contact Information
Guidelines and Protocols
Advisory Committee
PO Box 9642
STN PROV GOVT
Victoria BC V8W 9P1
E-mail: 
hlth.guidelines@gov.bc.ca
Web site:
www.BCGuidelines.ca

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.