A 61-year-old woman comes to the office due to insomnia. She describes difficulty both falling and staying asleep over the past 6 months. Her insomnia varies and is much worse some days than others. In the mornings, she wakes up half an hour earlier than she would like and rarely feels well rested. The patient has tried several over-the-counter sleep medications, but they make her feel too tired the next day. She is not aware if she snores. The patient drinks a glass of wine several times a week and does not use illicit drugs. She has a history of osteoarthritis and major depression for which she takes ibuprofen and venlafaxine. She has lived alone since her divorce 2 years ago and maintains close relationships with her adult children and grandchildren. The patient is worried about one son who recently lost his job, but she has had no change in mood or appetite. Physical examination is noncontributory.
Which of the following is the most appropriate next step in management of this patient?

Question

A 61-year-old woman comes to the office due to insomnia.  She describes difficulty both falling and staying asleep over the past 6 months.  Her insomnia varies and is much worse some days than others.  In the mornings, she wakes up half an hour earlier than she would like and rarely feels well rested.  The patient has tried several over-the-counter sleep medications, but they make her feel too tired the next day.  She is not aware if she snores.  The patient drinks a glass of wine several times a week and does not use illicit drugs.  She has a history of osteoarthritis and major depression for which she takes ibuprofen and venlafaxine.  She has lived alone since her divorce 2 years ago and maintains close relationships with her adult children and grandchildren.  The patient is worried about one son who recently lost his job, but she has had no change in mood or appetite.  Physical examination is noncontributory.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98c7_2c06_853d_dd8dc1ae5278_MD0002_00 Insomnia is a clinical diagnosis that requires a detailed sleep history that should include time needed to fall asleep, number and duration of awakenings, estimated time in bed and total sleep time, description of the sleep environment, and habits and associated symptoms (eg, snoring, kicking during the night, anxiety, depression). In the absence of clues suggesting another sleep disorder (eg, sleep apnea, periodic limb movements), the first step is to obtain a 2-week sleep diary that provides detailed information regarding the patient's quantity and quality of sleep, bedtime routine, daytime symptoms, use of causative substances, and relationship to environmental factors and psychosocial stressors. This is especially important for patients who describe variability in their sleep pattern and whose report may be affected by recall bias. In addition to confirming insomnia, a sleep diary can identify patterns and contributing factors to assist the physician in making specific sleep-hygiene recommendations (eg, avoiding caffeine or alcohol) and providing targeted behavioral guidance (eg, stimulus control, sleep restriction) or other recommendations (eg, cognitive-behavioral therapy [CBT] for insomnia, psychiatric evaluation). sleep restriction (Choices B and E) The next step is to confirm the patient's insomnia and identify contributing factors that could be altered with behavioral interventions. CBT is considered a first-line treatment of chronic insomnia for patients who do not improve with general behavioral recommendations. Low-dose zolpidem would be appropriate for patients who do not respond to nonpharmacological interventions. (Choice C) Polysomnography would be indicated for further evaluation of suspected sleep apnea, but it is not part of routine evaluation for insomnia. (Choice D) A psychiatric evaluation is appropriate when there is concern that psychiatric illness is the primary cause of the patient's insomnia (eg, untreated anxiety, depressive disorders). It would be premature, however, for this patient who denies significant mood changes. Educational objective: Initial evaluation of patients with chronic insomnia requires a detailed sleep history to clarify sleep patterns and identify contributing factors (eg, substances, psychosocial stressors, environmental issues). A 2-week sleep diary is a useful assessment tool that can help confirm the diagnosis and guide treatment interventions. __________ References: The consensus sleep diary: quantitative criteria for primary insomnia diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/25905662) Nonpharmacologic management of chronic insomnia. (http://www.ncbi.nlm.nih.gov/pubmed/26760592) Psychometric properties of the consensus sleep diary in those with insomnia disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27231885)

A 61-Year-Old Woman Comes to the Office Due to Insomnia