Episode 220: Approach of Insomnia in Adults

Episode 220: Approach of Insomnia in Adults     ARREAZA: Today we are going to talk about how to approach sleep issues in adults — from the initial assessment all the way through treatment. And I think what is going to surprise a lot of our listeners is the changes in management in recent years, especially what is recommended as first-line therapy. So, let's jump right in. MOIRA: Sleep is one of those topics that touches every specialty, but Primary Care in particular, so I'm excited to dig into this. ARREAZA: Let's start with the big picture–statistics. How common are sleep problems in adults? MOIRA: Incredibly common. Chronic insomnia affects roughly 10% of the general population, and that number has only grown in recent years . During the COVID-19 pandemic, for instance, prevalence rates of insomnia symptoms were reported globally at 20 to 45% (wow). And, importantly, those sleep problems did not simply resolve once infection rates dropped, insomnia symptoms and fatigue have continued even as mood improves in people recovering from COVID-19 infection.  ARREAZA: Incredible that we are in 2026 and still talking about COVID-19. And we clinicians need to understand that insomnia isn't just an annoyance. It has long-term consequences. Also, financially, insomnia causes direct and indirect costs of up to $100 billion each year. MOIRA: Exactly. Insomnia is both a risk factor for, and a symptom of, several psychiatric disorders, and it is a predictor of death by suicide, making it an important target for intervention. It's highly comorbid with medical and psychiatric disorders and is associated with significantly increased healthcare utilization and costs. People with insomnia also perform more poorly on complex cognitive tasks. So, we're talking about a condition that affects cognition, mental health, physical health, and quality of life. ARREAZA: And yet, it still gets overlooked in many clinical encounters. Let’s be honest, dealing with insomnia is not easy on patients… and doctors! MOIRA: That's the paradox. Primary care practitioners are often poorly informed about sleep disorders, which remain underdiagnosed and sub-optimally managed. In one Italian epidemiological survey, insomnia was reported by 64% of over 3,000 patients interviewed under general practitioners, with 20% reporting both nighttime and daytime symptoms. So, the patients are there, we're just not always asking the right questions or knowing what to do when they tell us about their sleep. ARREAZA: Great. Let's talk about assessment. In my experience, we need a full encounter to address sleeping issues. Patients tend to mention insomnia as you start walking out of the room. Let’s say a patient tells us, "Doctor, I can't sleep," how de we approach this? MOIRA: The first step is a comprehensive sleep and health history. Clinical assessment should describe the sleep disturbance and elicit etiological and exacerbating factors. You want to understand the nature of the complaint; is it difficulty to fall asleep, difficulty staying asleep, early morning awakening, or some combination? How long has it been going on? What's the impact on daytime functioning? ARREAZA: That’s why I think it should be addressed in a full encounter, if possible, because understanding the full extent of the problem requires time. We need to think about contributing factors too. MOIRA: Absolutely. Factors such as medications, medical disorders, and psychiatric disorders can all increase the risk for insomnia. You need to screen for comorbid conditions, depression, anxiety, PTSD, and chronic pain. Insomnia is actually both a risk factor for and a symptom of several psychiatric disorders. You also want to rule out other primary sleep disorders. Comorbid insomnia and sleep apnea, for example, is highly prevalent and debilitating. If someone has both insomnia and obstructive sleep apnea, treating only one without addressing the other may lead to suboptimal outcomes. ARREAZA: Now that you mention comorbid conditions, let’s mention nocturia. I feel like it’s very common with my older patients. MOIRA: Great point. Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing the shared mechanisms for these disorders. There's emerging work on integrated cognitive-behavioral treatment programs that address both conditions simultaneously, which is a promising direction. But at minimum, you should be asking about it, because if nocturia is driving the awakenings, you need to address that as part of the treatment plan. _____________________ References: Baglioni, C., Altena, E., Bjorvatn, B., Blom, K., Bothelius, K., Devoto, A., … & Riemann, D. (2019). The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment. Journal of Sleep Research, 29(2). https://doi.org/10.1111/jsr.12967 Becker, P. (2022). Overview of sleep management during COVID-19. Sleep Medicine, 91, 211-218. https://doi.org/10.1016/j.sleep.2021.04.024 Bramoweth, A., Germain, A., Youk, A., Rodriguez, K., & Chinman, M. (2018). A hybrid type I trial to increase Veterans’ access to insomnia care: study protocol for a randomized controlled trial. Trials, 19(1). https://doi.org/10.1186/s13063-017-2437-y Brewster, G., Riegel, B., & Gehrman, P. (2018). Insomnia in the Older Adult. Sleep Medicine Clinics, 13(1), 13-19. https://doi.org/10.1016/j.jsmc.2017.09.002 Conroy, D. and Ebben, M. (2015). Referral Practices for Cognitive Behavioral Therapy for Insomnia: A Survey Study. Behavioural Neurology, 2015, 1-4. https://doi.org/10.1155/2015/819402 Dzierzewski, J., Griffin, S., Ravyts, S., & Rybarczyk, B. (2018). Psychological Interventions for Late-Life Insomnia: Current and Emerging Science. Current Sleep Medicine Reports, 4(4), 268-277. https://doi.org/10.1007/s40675-018-0129-0 Fung, C., Huang, A., Markland, A., Schembri, M., Martin, J., Bliwise, D., … & Vaughan, C. (2024). A multisite feasibility study of integrated cognitive‐behavioral treatment for co‐existing nocturia and chronic insomnia. Journal of the American Geriatrics Society, 73(2), 558-565. https://doi.org/10.1111/jgs.19214 Gardner, D., Turner, J., Magalhaes, S., Rajda, M., & Murphy, A. (2024). Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep. Jama Psychiatry, 81(12), 1187. https://doi.org/10.1001/jamapsychiatry.2024.2731 Garland, S., Vargas, I., Grandner, M., & Perlis, M. (2018). Treating insomnia in patients with comorbid psychiatric disorders: A focused review. Canadian Psychology/Psychologie Canadienne, 59(2), 176-186. https://doi.org/10.1037/cap0000141 Germain, A., Wolfson, M., Brock, M., O’Reilly, B., Hearn, H., Knowles, S., … & Wallace, M. (2023). Digital CBTI hubs as a treatment augmentation strategy in military clinics: study protocol for a pragmatic randomized clinical trial. Trials, 24(1). https://doi.org/10.1186/s13063-023-07686-2 Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!