The assessment and management of insomnia in primary care

Author(s): Karen Falloon, Bruce Arroll, C Raina Elley and Antonio Fernando
Source: BMJ: British Medical Journal , 4 June 2011, Vol. 342, No. 7809 (4 June 2011),
pp. 1251-1255
Published by: BMJ

Stable URL: https://www.jstor.org/stable/23049971

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Forthe full versions of these articles see bmj.com
CLINICAL REVIEW

The assessment
assessment and
and management
managementof
of
insomnia in primary care
Karen Falloon,1 Bruce Arroll,1 C Raina Elley,1 Antonio Fernando^

RESEARCH pp 1247,1248 Insomnia affects about a third of the general population

'Department of General Practice
and Primary Health Care, University
of Auckland, Private Bag 92109,
Auckland 1142. New Zealand
'Department of Psychological
Medicine, University of Auckland
Correspondence to: B Arroll
b.arroli@auckland.ac.nz
Cite this as: BMJ 2011;342:d2899
doi: 10.1136/bmj.d2899
Table 1!
11 Secondary
Secondary causes
causes of
of insomnia
insomnia and
and appropriate
Secondary cause
SOURCES AND SELECTION CRITERIA
according to a recent longitudinal study in the UK1 and cross
As well as using our personal reference collections, we
sectional studies estimate the prevalence in patients attend
searched the Cochrane database (www.cochrane.org).
ing primary care to be between 10% and 50%.2 3 According
Clinical Evidence (http://dinicalevidence.bmj.com), and
Best Practice (http://bestpractice.bmj.com). We also
to the American Sleep Disorders Association International
reviewed guidelines from the National Institute for Health
Classification of Sleep Disorders coding manual, insomnia
and Clinical Excellence, the American Academy of Sleep
refers to "a repeated difficulty with sleep initiation, dura
Medicine, and the International Classification of Sleep
tion, consolidation, or quality that occurs despite adequate
Disorders. We selected systematic reviews and meta
time and opportunity for sleep and results in some form of
analyses and when these were not available we used large
daytime impairment and lasting for at least one month."''
randomised controlled trials.
Although some patients who have this problem may not
report it as such, inadequate sleep has been associated older
withadults.10"" The normal range of sleep is seven to nine
hours per night,13 although some individuals claim they can
reduced physical health3 6 and mental health.7 9 The contin
function on as little as four hours, whereas others need up
ued widespread use of sedative medication to treat insomnia
to 10 hours. This article reviews the causes of insomnia and
raises concern about the potential for long term tolerance
its treatment, focusing on the many non-drug options that
and addiction, particularly where insomnia is the presenting
may be suitable for use by general clinicians. This review is
complaint of missed diagnoses such as depression, or when
based
adverse effects might be a problem—for example, falls in on evidence from randomised trials for interventions
and guidance from the American Academy of sleep medicine
appropriate treatments
treatments guidelines (www.aasmnet.org).
Treatment

Depression Treat depression (forexample, antidepressants, cognitive What is insomnia and who gets it?
behavioural therapy)
Patients with insomnia may report difficulty with falling
Anxiety Treat anxiety (drug or cognitive behavioural therapy)
asleep, trouble staying asleep or frequent waking, wak
Physical health problem (such as pain or Treat pain and other symptoms
dyspnoea) ing too early and being unable to get back to sleep, or still
Obstructive sleep apnoea Continuous positive airways pressure or devices to improve feeling tired after waking up. As many as 40% of patients
airway (such as mandibular advancement splint in mild cases): in primary care will report these symptoms if asked.2
consider referral to a respiratory doctor or sleep physician
Insomnia is either primary, in which case no other con
Excess alcohol Interventions to reduce alcohol intake or promote abstinence
tributing cause is present, or secondary, in which case it
Delayed sleep phase disorder (a circadian Change work hours; melatonin in the evening and light
rhythm disorder) exposure (via sunlight or artificial light box) in the morning
is caused or affected by an underlying condition (table 1).
Illicit drug use Interventions to reduce drug use Patients can have more than one underlying diagnosis.
Parasomnias (restless legs, sleep talking, sleep For restless legs check ferritin, consider non-drug based Depression and anxiety underpin insomnia in as many as
walking, sleep terrors, periodic limb movements, measures or non-ergot dopamine antagonist drugs for severe half of cases and they frequently co-exist.2 Physical health
bruxism (teeth grinding), nightmare disorder, cases; for other parasomnias consider referral
problems are also present in about a third of cases.2 Exces
sleep related eating disorder, sleep sex
sive alcohol consumption and illicit drug use may also be
associated with reports of poor sleep (about 8% and 6%
SUMMARY POINTS
of cases, respectively).2 About 12% of those who report
Insomnia affects a third of people and is a common cause of consultation in primary care
difficulty in sleeping have delayed sleep phase disorder, a
History is the main diagnostic tool circadian rhythm disorder in which the person has trouble
There are many causes of secondary insomnia, which should be sought at presentation
getting to sleep at the time most people do.2 They tend to
Excessive daytime sleepiness should raise questions about obstructive sleep apnoea
go to bed very late and have difficulty in waking up when
Primary insomnia is diagnosed after excluding other causes ofinsomnia. It can be treatedmost others get up. People with insomnia function better
effectively by sleep hygiene techniques, by restricting time in bed, or with behaviouralon weekends when they can sleep late and wake up late.
interventions
Obstructive sleep apnoea is a relatively common cause of
Sedatives should be used as a last resort when other approaches have failed because of
sleep disturbance and can have a profound effect on daily
risks of tolerance and adverse effects
functioning (box 1).

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CLINICAL REVIEW

Box
Box11
11Obstructive
Obstructivesleep
sleep
apnoea
apnoea How is insomnia diagnosed?
Taking a good history is important for diagnosing insomnia
• Affects about 9% of those reporting poor sleep in primary care2
and identifying any underlying causes. Box 2 outlines the
• More common in people who are obese
questions posed and information gained when asking about
• Episodic partial or complete upper airway obstruction is usually associated with oxygen
insomnia.
desaturations in the blood and arousals from sleep
• Symptoms include chronic snoring, insomnia, gasping and breath holding, un-refreshing
sleep, and daytime sleepiness. Be alert to this as a possible diagnosis if the Considering
patient secondary causes
Case finding
reports falling asleep during the day including as a passenger in a car on short trips, in for depression or anxiety using brief questions
waiting rooms, or in lectures may identify an underlying mental illness.18 20 Enquiry about
• Bed partners may report the patient's snoring and gasping14 other secondary causes shown in table 1 is warranted. For
people
• If a patient answers yes to all or most of the following questions they will have a with bipolar disorder, insomnia may herald a manic
significant pre-test probability of obstructive sleep apnoea and will require further
episode. Several tools are available for assessing depression
investigation and/or treatment.4 Do you: experience excessive sleepiness during the
and anxiety, including the patient health questionnaire
day?; experience frequent episodes of breathing pauses? (or gasping for air) during
(PHQ)-9, hospital anxiety and depression scale (HADS-7),
sleep. Or has someone told you that while you are asleep you: stop breathing?; snore very
or PHQ-4.14 20 21 The alcohol use disorders identification test
loudly? Do you: get morning headaches?; have a dry mouth on awakening?
(AUDIT) or CAGE may be used to assess alcohol use22 23 and
• There may be a legal obligation for health professionals to advise professional drivers
the alcohol, smoking and substance involvement screening
and machine operators of falling asleep at work.
test (ASSIST) to assess drug use.24
• The diagnosis can be confirmed with polysomnography or nocturnal pulse oximetry.15
• The initial treatment is for patients to use a continuous positive airways pressure (CPAP)
machine at night16; if this is unsuccessful consider surgical options. Level ASleep diaries
evidence
from meta-analysis supports CPAP.16 General practitioners can make use of sleep diaries in which
patients record their sleep pattern for one to two weeks; how
Sleep requirements may fall with age. A recentever,
review
using them makes the consultation more involved. Sev
summarises the literature on normal and abnormal sleep
eral diary templates are available on the internet (for example,
www.sleepeducation.com/pdf/sleepdiary.pdf).
in older people.17 A mean sleep duration of seven hours Sleep diaries
per night was found among 1000 older adults interviewed
can provide patients with insight into their actual sleep habits.
in a French study.17 Another study found that total sleepreflect sleep trends, such as erratic schedules, or
They often
identify
time decreased on average by 27 minutes per decade from predominant sleep patterns, such as taking a long
midlife to the eighth decade of life. Older peopletime
"spend
to fall asleep, frequent awakenings, early morning awak
more time in bed but have deterioration in both enings,
the qualor a mixture. They can provide a starting point for the
ity and quantity of sleep."17 management of sleep problems in a personalised manner and
can be used to monitor progress of certain treatments.

Tabie
Table21
21"Sleep
"Sleep
hygiene"
hygiene"
instructions
instructions
and rationale
and rationale
Physical examination
Instruction Rationale
Although a physical examination cannot diagnose insomnia,
Caffeine and
Limit use of caffeine to nicotine
1 are stimulants
cup of thatcoffee
can delay sleep onset and
it may be useful to help identify or exclude obvious underly
impair
in the morning (if atsleep all),
quality; people vary in their
avoid ability to metabolise these
alcohol
substances from their
and cigarettes at night, and system; some peopleother
limit use alcohol to help them ing causes of sleep disorder such as obstructive sleep apnoea
substances that can
get to sleep
affect
because it relaxessleep
them, but it may cause awakenings and or a neurological condition such as Parkinson's disease. High
reduce sleep quality later in the sleep period
body mass index (>30) and neck circumference of 40 cm or
Peopleuntil
Avoid going to bed do not fall asleep
you if their are
brain is wide awake, so going to bed
drowsy
greater increase the risk of obstructive sleep apnoea.25 Usu
and ready to sleep
before they are sleepy leads to frustration at not being able to sleep,
which can further delay sleep onset; people's sleep patterns and needs ally the primary care doctor will be aware of other co-morbid
may not match those of their bed partners ities. Blood tests for hyperthyroidism and low ferritin levels,
Napping reduces the "sleep
Avoid nappingduringthe daypressure" that builds up during the day which can cause restless legs, may be warranted. A full blood
to the point where a threshold is reached and we are ready to sleep;
napping may delay the time of readiness for sleep and lead to erratic
count may rule out anaemia.
bedtimes, especially if the person can sleep in to compensate for a
later bedtime (leading to a "domino" effect for the day after); if naps
Polysomnography (overnight sleep study)
have been taken during the day, and the "usual" bedtime is kept, sleep
onset may be delayed, leading to frustration and anxiety, which further
Patients can be referred for polysomnography to confirm
prolongs sleep onset sleep apnoea and limb movement disorders or restless legs
Exercise too close
Regular daily exercise can to a sleep
helpperiod can serve as an arousal stimulus,
improve syndrome. Polysomnography measures brain and muscle
delaying sleep onsetlate in the
sleep, but avoid exercise
activity and assesses oxygen saturation overnight.
evening
Ensure that the bedtime environment is The bed should be comfortable, the temperature not too hot or cold,
comfortable and conducive to sleep the room dark, and noise minimised; discomfort, being too hot or cold, How can insomnia be managed in primary care without
noise, and light can disrupt sleep medication?
Think about computer screens, clocks, Looking at a computer screen in the hours before bed may delay sleep For all patients following the principles of basic sleep hygiene
and co-sleepers onset (the light waves emitted are thought to reduce the production of
may be beneficial (table 2).
melatonin, a hormone that is secreted by the pineal gland to promote
sleep); looking at a clock during awakenings can delay sleep onset
by contributing to frustration at being awake (lit clocks may also Secondary insomnia
contribute arousal stimuli to the brain); if co-sleepers are disturbing
For patients in whom a cause of the insomnia is identi
sleep (by excessive movements or snoring) they probably warrant their
own assessment for sleep disorders fied (secondary insomnia) we recommend beginning with
If not asleep within 15-20 minutes, get The thought behind this idea is that bed needs to be associated with treatment of the underlying condition (see table 1). For all
out of bed and return onlywhen drowsy being asleep not with being awake and having difficulty gettingto sleep patients following the principles of basic sleep hygiene may

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 CLINICAL REVIEW

Box
Box2121
History
History
takingtaking
and information
and information
gained gained

Can you describe your problem with sleeping? Are there any symptoms of obstructive sleep apnoea (ask bed partner too if
possible)?
Does it interfere with your function the next day (for example, feeling
Such as heavy snoring, pauses in breathing, and gasping
unrefreshed in the morning, fatigued, having poor concentration or
irritability)? Information gained
Can you tell me about your bedtime routine starting with the time you get Provides information on obstructive sleep apnoea
into bed?
What other factors may interfere with sleeping?
• Time that you go to bed
Use of stimulants (such as caffeine, alcohol, cigarettes, drugs)
• Time to fall asleep
Other drugs that may interfere with sleep
• Awakenings (number, duration, do you know what causes you to awaken?
Do you have any associated symptoms, such as heartburn, coughing, Important recent life events (such as bereavement)
shortness of breath, pain, anxiety, or full bladder?) Information gained
• Last awakening time in the morning Ideally avoid use of stimulants after 6 pm
• Time of rising from bed Oral decongestants, such as pseudoephedrine; asthma, drugs such as long
• Usual duration of sleep and short acting sympathomimetics; amphetamines; antidepressants, such
• How is your routine different at the weekends or during holidays? Do you as selective serotonin reuptake inhibitors can all cause insomnia, and a trial
have the same bedtime? without them is simple and potentially diagnostic
• Do you do vigorous activity late in the evening? Do you take any naps?
Information gained Ask about frequency, timing, and duration

Some patients think they do not get enough sleep but function well Where are you sleeping when you have the problem? Is the problem
the next day. Technically they do not have insomnia because the persistent when you sleep elsewhere (for example, when on holiday?) Is it
definition of insomnia includes "results in some form of daytime persistent throughout the week and year?
impairment"4 Information gained
Frequent changes in routine and vigorous activity just before bedtime can
Long naps during the day can affect the quality of sleep at night
cause sleep problems If the patient sleeps better when on holiday or at weekends, think of delayed
Physical health problems are a significant cause (43%) of insomnia in sleep phase disorder, especially if he or she goes to bed after midnight
primary care and will require attention2
Do you experience any of the following?
If the time in bed greatly exceeds the time asleep (for example, by a few
Low mood or lack of pleasure in some or most activities or worrying a lot;
hours), the patient may have primary insomnia if no other causes are
nocturnal panic attacks
present. Spending less time in bed can lead to a dramatic improvement in
Restless sleep
sleep quality and may decrease the fragmentation of sleep. Exposure to
computer screens in the hours before bed can delay sleep onset. Leg or body twitching
Leg jerking (consider restless legs syndrome)
How do you feel on awakening?
Shaking fits
Unrefreshed and still sleepy?
Sleep walking or talking
Any symptoms such as headaches or dry mouth?
Waking up in terror
Daytime sleepiness—falling asleep in waiting rooms, as a passenger in a
car, or during lectures Unusual nighttime behaviours

Information gained Information gained

Need to consider obstructive sleep apnoea. Consider asking the patient toPatients who answer yes to the first question may have depression and
fill out the Epworth sleepiness scale,16 which measures levels of daytimeanxiety; consider using the formal inventories for case finding
sleepiness The other symptoms may be related to parasomnias

be beneficial (table 2). In our experience patients may have Primary insomnia
Box3|Parasomnias
Box 31 Parasomnias
(neurological conditions,
conditions, several contributing diagnoses. Addressing some of these About 30% of patients with primary insomnia will improve
rare in primary
primary care)
care) issues may solve other problems. For example, advising with basic sleep hygiene alone (table 2).29
patients to reduce their use of drugs and alcohol along with
Restless legs syndrome
treating pain or breathing difficulty may resolve depression Restriction of time in bed
Sleeptalking
and anxiety as well as improving the insomnia. Recommendations developed and published by the Ameri
Sleepwalking
can Academy of Sleep Medicine in 2006 have concluded from
Sleep terrors
Delayed sleep phase disorder and parasomnias the available evidence that psychological and behavioural
Periodic limb movements
The use of melatonin at night and light boxes in the morn interventions are effective in the treatment of chronic pri
Bruxism (teeth grinding)
ing are helpful; at least two randomised trials have shown a mary insomnia.30 Empirically-supported treatments include:
Nightmare disorder benefit for those with delayed sleep phase disorder.26 27 cognitive behavioural therapy, bedtime restriction (sleep
Sleep related eating For most cases of restless legs, non-drug treatments restriction), stimulus control therapy, relaxation training,
disorder
such as massage, exercise, stretching, and warm baths and paradoxical intention (instructions to remain passively
Sleep sex before bedtime are recommended.28 For more severe cases, awake and avoid any effort to sleep).31
non-ergot dopamine antagonists are recommended, on Cognitive behavioural therapy has been shown to be an
the basis of evidence from randomised controlled trial.28 effective treatment for insomnia in meta-analyses of ran
Advice should be sought for other parasomnias, such as domised trials.32 33 It aims to address the various cognitive
sleep walking and other nocturnal behaviours that are not and behavioural aspects of insomnia using a combination
common in primary care (box 3). of interventions such as behavioural strategies (such as

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CLINICAL REVIEW

Box41
Box 41Bed
Bedtime restriction
time for for
restriction primary insomnia
primary insomnia medication as monotherapy may not result in the quality
of sleep that can be achieved by other methods and may
• Ensure the diagnosis is most likely to be primary insomnia (no other conditions)
not deal with the underlying sleep problem. A randomised
• Advise workers who drive vehicles or operate heavy machinery to consider treatment
during their vacation, because there is a short term risk of sleep deprivation comparison between zopiclone and cognitive behavioural
therapy found better sleep efficiency in the cognitive behav
• Estimate time spent in bed versus time spent asleep, with use of a sleep diary if necessary.
A common scenario is that a patient stays in bed around 8-9 hours but only sleeps iouralfor
therapy
a group, along with fewer awakenings.™6 The
total sleeping
total of 6 hours. Advise the patient to restrict their total time in bed to their estimated time did not differ between the groups.
total
sleep time. We find it best for the patient to get up at the usual (household) timeA and
high go
level of suspicion is warranted if an unknown or
to bed later. For example, if the usual getting up time is 0600, suggest that they
newgo to bed
patient asks for a hypnotic by name because he or she
at 2400 instead of their usual 2200. Advise the patient to do only quiet, relaxing activities
may want the drug for illicit purposes. The discussion about
before bedtime. These activities have to be done outside of bed and not lying down to
sleep medications will depend on whether the clinician or
avoid naps, which can disrupt the routine. We recommend patients keep their bedtime
the patient raises medication as an option. Patients who
allowance for two weeks before making any adjustments. The patient usually reports that
raise the matter must be informed of the benefits of non
the quality of their sleep improves as they feel they are starting to have deep sleep and the
sleep period is consolidated. drug based treatment. They may eventually need drugs, but
After two weeks: optimal practice should include a trial of non-drug based
treatment. If the clinician raises the matter then presumably
• If the patient is sleeping better and functioning well nothing else is needed. Many patients
preferto continue on the bed restriction schedule as they find it very effective the patient has completed a trial of non-drug treatment or
• If they are sleeping better but feel sleep deprived the next day they may wishthe to situation
add 30 is extreme and urgent.
minutes to their time allowed in bed every week and continue doing so until the feelings of
sleep deprivation disappear, while stilt maintaining continuous sleep at nightConcerns about hypnotics
• If they are not sleeping better, they may wish to reduce their time in bed by 30 Hypnotic
minutes drugs
(but(benzodiazepines or "z-drugs" such as zopi
not to less than five hours at night). Ensure that the patient tries each option for at are
clone) least
associated with perceived tolerance, dependence,
two weeks before making another change. If they are not sleeping better on five and hours persyndrome and with "rebound insomnia" on
withdrawal
night you may wish to get some advice from a sleep specialist
cessation.™7"™9 They can also have side effects, and in rare
The bedtime allowance is never set at less than the estimated average time spent asleep or
cases can be associated with unusual sleep behaviours (such
five hours (whichever is longer)
as "sleep driving" or making phone calls, with no remem
brance of the events), especially if taken with alcohol.™8
bedtime restriction, stimulus control therapy, and relaxa
There is also the risk of misuse—hypnotics can enhance the
tion), education (for example, about sleep hygiene),
"high" and
from other drugs™9 and have been used in overdose
cognitive strategies (cognitive therapy). Importantly, it is
attempts. Further problems include drug interactions, issues
around driving under the influence of psychotropics, and
not designed to be administered by a general practitioner
(typically administered in six to eight sessions, as shown
potentialin
risks when prescribing to the elderly (falls, cogni
a randomised controlled trial)34 and thus it remains
tive under
impairment, and fatigue).™10
Despite
used in primary care. Therefore, a simple starting point forthese potential problems, benzodiazepine recep
tor agonists are often prescribed for insomnia.™11 Tolerance
treatment of primary insomnia is to address sleep hygiene
andrestric
and to try a behavioural intervention such as bedtime dependence are common concerns despite the con
tion or stimulus control. tradictory evidence in many clinical studies. A six month
double
Bedtime restriction involves curtailing time spent blind placebo controlled study of eszopiclone in
in bed
to closely match actual time spent asleep (box 4).35 hundreds
Evidenceof patients showed sustained response and no
from a randomised controlled trial suggests that thistolerance.™12
method Benzodiazepines have been consistently shown
is effective for some patients with primary insomnia.™1
to improve sleep latency and increase total sleep time,™11
Restricting time in bed often forms part of cognitive
and behav
they have significantly fewer side effects than sedating
antidepressants
ioural therapy interventions. This is potentially a very simple and sedating antipsychotics.™13 Shorter act
ing benzodiazepines
treatment that can be used in primary care and is useful for (Zolpidem, triazolam) are preferred for
insomnia with delayed sleep latency (long onset of getting
people who spend a lot of time in bed but not sleeping.
to sleep).
Stimulus control refers to a set of instructions designed toMedium acting ones like temazepam and zopi
reassociate the bed and bedroom with sleep and re-establish
clone are preferred for patients who wake in the middle of
Box
Box 51
51Stimulus
Stimuluscontrol
control a regular sleep-wake routine (box 5).™2 the night. Long acting drugs like clonazepam are preferred
instructions
instructions
for patients with insomnia and daytime anxiety. To limit the
(1) Go to bed only when What is the role of medication in primary insomnia? risk of dependence or tolerance, prescribers can tell patients
sleepy Hypnotic drugs are often used to manage insomnia in gen to use benzodiazepines "as needed," with a maximum
(2) Get out of bed if eral practice.w3 Different classes of sleep medications are pre frequency per week (no more than three nights).
unable to sleep after scribed (table 3) or purchased over the counter (for example,
15-20 minutes, returning
sedating antihistamines, melatonin, and natural supple Non-benzodiazepine drugs used as hypnotics
to bed only when sleepy
ments such as valerian), although this approach is not evi Sedating antidepressants and sedating antipsychotics gen
(repeat as necessary)
dence based as a treatment of chronic insomnia.™4 ™5 Recent erally do not result in physical dependence, tolerance, or
(3) Use the bed/bedroom
reviews have shown that pharmacotherapy and psychologi misuse. Because of this, many doctors prefer to prescribe
only for sleep
cal or behavioural interventions result in similar short term these groups of drugs instead of benzodiazepines. This is
(4) Arise at the same time
each day (up to four weeks) improvements, but that psychological despite their common adverse effects including daytime
and behavioural treatments have persisting benefits that can sedation, weight gain, and anticholinergic side effects. Sedat
(5) No naps
also improve with time.™4™5 Furthermore, the use of sleep ing antidepressants are more toxic than benzodiazepines in

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 CLINICAL REVIEW

7 Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and

Table
Table31
31Drugs
Drugscommonly
commonly
usedused
for for
insomnia
insomnia
psychiatric disorders: a longitudinal epidemiological study ofyoung
Usual
adults. Biological Psychiatry 1996;39:411-8.
Drug Class hypnotic dose Half life 8 Ford DE, KamerowDB. Epidemiologic study of sleep disturbances
Temazepam Benzodiazepine 10-20 mg 5-15 hours"16 Sedation, confusion, amnesia, and psychiatric
and psychiatricdisorders.
disorders.An
Anopportunity
opportunity for
for prevention?IAMA
prevention? WM/I

receptoragonist impaired coordination, disinhibition 1989;262:1479-84.

Mallon L,
9 Mallon L, Broman
Broman )E,
)E, Hetta
HettaJ,
I, Mallon
Mallon L,
L, Broman
Broman J-E,
J-E,Hetta
Hetta).
J. High
High
Triazolam Benzodiazepine 0.125-0.25 mg 2-3 hours™16 Same as above
incidence of diabetes in men with sleep complaints or short sleep
receptoragonist
duration: a 12-yearfollow-up study ofa middle-aged population.
Zolpidem Benzodiazepine 5-10 mg 1.5-2.4 hours™11 Same as above Diabetes Care 2005;28:2762-7.
receptoragonist 10 Panneman MJ, Goettsch
GoettschWG,
WG,Kramarz
KramarzP,
P,HeringsRM.
Herings RM.The
Thecosts
costsofof
Zopidone Benzodiazepine 7.5 mg 5-6 hours™" Same as above benzodiazepine-associated hospital-treated fall injuries in the EU: a
receptoragonist Pharmo sudy. Drugs Aging 2003;20:883-9.
11 Campbell SS, Broughton RJ. Rapid decline in body temperature before
Doxepin Sedating . 25-50 mg 8-24 hours™11 Sedation, falls, dizziness, dry mouth
sleep: fluffingthe physiological
physiological pillow?
pillow? ChronobiolInt
Chronobiollnt 1994;11:126-31.
1994;11:126-31.
antidepressant (and other anticholinergic side effects)
12 Curran HV, Collins R, Fletcher S, Kee SC, Woods B, lllife S. Older
headache, nausea, lightheadedness adults and withdrawal from benzodiazepine hypnotics in general
Quetiapine Sedatingantipsychotic 25-200 mg 6 hours™11 Sedation, weight gain, hypotension practice: effectson cognitive function, sleep, mood and quality of life.
Promethazine Sedatingantihistamine 10-20 mg 5-15 hours™16 Sedation, urinary retention, dizziness Psychological Med 2003;33:1223-37.
13 Shapiro CM, Dement WC. Impact and epidemiology of sleep disorders.
BMJ 1993;306:1604-7.
14 Johns MW. A new method for measuring daytime sleepiness: the
bmj.com overdose. There is also less evidence for the efficacy of sedat
Epworth sleepiness scale. Sleep 1991 ;14:540-5.
Previous articles in this ing antidepressants than benzodiazepines in insomnia. Sedat RofaiiLM,Wong
15 RofailLM, WongKH,
KH.UngerG,
Linger G, Marks GB,
GB.Grunstein RR. Comparison
Grunstein RR. Comparison
ing antipsychotics also carry the risk of tardive dyskinesia and between a single-channel nasal airflow device and oximetry forthe
series
diagnosis of obstructive sleep apnea. Sleep 2010;33:1106-14.
weight gain. Sedating antidepressants may be useful if there 16 National Institute for Health and Clinical Excellence. Continuous
O The management of
tennis elbow are anxious or depressive components to the clinical picture. positive airway pressure forthe treatment of obstructive sleep apnoea/
hypopnoea syndrome. NICE, 2008. http://guidance.nice.org.uk/TA139.
Melatonin is a pineal hormone that is naturally secreted
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