Difference between revisions of "Insomnia"

(References)
(Differential Diagnosis)
 
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==Differential Diagnosis==   
 
==Differential Diagnosis==   
* [[Alcohol Abuse]]
+
* [[Alcohol Abuse]], [[alcohol withdrawal|alcohol]], [[benzodiazepine withdrawal|benzo]], or [[opioid withdrawal]]
 
* [[Depression]]/[[anxiety]]
 
* [[Depression]]/[[anxiety]]
*[[Bipolar disorder]]
+
*[[Bipolar disorder]], [[schizophrenia]]
 +
*[[Hepatic encephalopathy]]
 +
*[[TBI]]
 +
*[[Acute mountain sickness]]
 +
*[[Delirium]]
 +
*[[Hyperphosphatemia]]
 +
*Medications (many!)
 +
*Excess [[caffeine]]
 
* Sleep-disruptive environmental circumstances
 
* Sleep-disruptive environmental circumstances
 
* Restless legs syndrome  
 
* Restless legs syndrome  

Latest revision as of 03:29, 3 October 2019

Background

  • Daytime dysfunction due to difficulty initiating sleep or lack of good sleep.
  • A common emergency department complaint among patients in recovery from a substance use disorder or a psychiatric disorder
    • Most substances of abuse affect sleep during active use, acute withdrawal, and with sustained abstinence
  • Specific medications for insomnia should be avoided in patients with history of substance abuse.

Clinical Features

  • Difficulty falling asleep and staying asleep
  • Impaired daytime function (must also be reported for a diagnosis of an insomnia disorder)
  • Simultaneous psychiatric, medications/substances, are usually present

Differential Diagnosis

Evaluation

  • A personal medical history considering any medical conditions, any medications being taken, and any stressful life events/changes that could be causing insomnia
  • Screen for mood disorders, PTSD, substance use disorders
  • A sleep history and review of sleep and wake diaries can be helpful in determining the cause

Management

  • Sleep hygiene education, relaxation, and stimulus control
  • Zaleplon for sleep onset insomnia, Zolpidem (Ambien) or Eszopiclone for sleep maintenance insomnia[1]
  • Trazodone, gabapentin, and melatonin/melatonin agonists
    • Benzodiazepines should be avoided (due to risks of overdose when mixed with alcohol or other substances)

Disposition

  • Discharge home unless patient acutely psychotic
  • Follow up with primary care doctor
  • Consider outpatient polysomnography-sleep study

See Also

External Links

References

  1. Bonnet, MH and DL Arand. Treatment of insomnia in adults. In: UpToDate, Benca, R (Ed), UpToDate, Waltham, MA, 2017. ([1])