“A 52-year-old female patient presented with complaints of chronic insomnia and she requested a prescription for the sleeping pills she had seen advertised on TV.”
The question is:
- What is the primary diagnosis for the patient’s insomnia?
- What other information about the patient’s insomnia?
- Questions to help diagnose insomnia related to dangerous diseases?
Insomnia is a very common complaint. About 30% to 50% of adults experience insomnia at some point, and this is a chronic problem in 20% of adults. The incidence rate increases with age (the prevalence increases with age), and is more common in females. About 10% of the population suffers from insomnia with serious consequences such as:
- Daytime sleepiness and fatigue (daytime sleepiness and fatigue)
- Reduced energy (diminished energy)
- Poor concentration (poor concentration)
- Memory loss (memory impairment)
- Irritability (irritability)
- Depression or emotional drop (depressed or anxious mood)
The risk of depression was increased approximately fivefold in patients with insomnia for 1 to 3 years. Therefore, insomnia can be a “foreshadowing” (harbinger) of future mental/psychological diseases (psychiatric illness). Finally, patients with insomnia have an increased risk of occupational accidents (industrial accident) 3-4 times more, traffic accidents increase about 2-3 times, falls and fractures of the pelvis in the elderly.
What is the cause of insomnia?
Insomnia is often caused by psychological or medical disorders, primary sleep disorders (primary sleep disorders) and drug use (medical use). This type of insomnia will be called insomnia with other psychological problems (comorbid insomnia)Insomnia without other comorbidities is called idiopathic or primary (idiopathic or primary insomnia).
History is the most important diagnostic tool to detect underlying disorders (underlying comorbid disorders). There are few useful physical signs (exams), and very few specialized tools needed (specialized studies necessary) like polysomnography (polysomnography) or measure activity (actigraphy).
Common causes (common precipitants) of insomnia is very diverse. Half of insomnia patients will relapse (recurrent)chronic (persistent), or various health problems causing insomnia. Mental disorder (mental disorders) is the most common cause (30%-40%). Of these, depression is common, and nearly 80% of depressed patients will have insomnia.
The most common primary insomnia disorders:
- Restless Legs Syndrome (RLS – Restless Legs Syndrome)
- Cyclic limb movement disorder (PLMD – Periodic Limb Movement Disorder)
- Sleep apnea disorders (Sleep – Related breathing disorders)
Spouses are important information on sleep apnea (sleep apnea) and PLMD by recounting evidence such as loud snoring (heavy snoring)or move arms and legs.
Some drugs have a side effect of causing insomnia, some common “culprits” (culprits) are:
- anticonvulsant drugs (anticonvulsant)
- Antidepressants (antidepressants)
- antihypertensive drugs (antihypertensive)
- cancer medicine (antineoplastic)
- bronchodilator (bronchodilator)
- anticholinergic drugs (anticholinergic)
- hormone therapy (hormonal therapies)
First, review your medical records (medical record) of the patient before asking the patient. Advise the patient to establish a sleep schedule for 2 weeks prior to the formal examination. It provides important information including bedtime (bedtime)wake-up time, daytime nap (daytime naps)number of times and time of waking at night (nocturnal awakening)total sleep time…
Questions to help categorize causes:
Describe your insomnia? (Describe what you mean by “insomnia”)
Is your main problem: (Is you main problem:)
- Go to sleep (Falling asleep?)
- Wake up early (Early awakening ?)
- Or wake up startled (Frequent awakening?)
- Sleep not deep (sleep?)
When did your sleep problems start? (When did your problems with sleep start?)
What do you think causes insomnia? (What do you think started the insomnia?)
Is there a life event that affects your sleep such as the birth of a baby, the death of a loved one, job change, moving house, work pressure, new spouse or lover, financial pressure? (Are there any life events that have affected your sleep (births, deaths, job change, move, work stress, new bed partner, financial stress?)
How many nights a week do you have sleep problems? (How many nights per week do you have problems with sleep?)
Transient insomnia (transient insomnia) Lasts less than 1 week
Acute insomnia (acute or short–term insomnia) lasts 1-3 weeks
Chronic/chronic insomnia (chronic insomnia) lasts more than 3 weeks
Causes of transient and acute insomnia will often be related to new events, including changes in sleep environment, changes in time zones (jet lag)shift/commuting changes, environmental problems (excessive noise – excessive noise or excessive heat), acute illness, use of supportive drugs. Chronic insomnia can be caused by groups of causes: neurological disorders (neurologic disorders), psychological disorders (mental disorders), drug effects, lifestyle problems, and sleep disturbances. Some patients have no specific evidence of sleep disturbance, so this is called sleep state misperception (sleep – state misperception). At this time, the diagnosis must have specialized tools such as polysomnography or actigraphy.
Some differential diagnoses:
• Mental health disorders (Mental health disorders):
– Depressive disorder (Depressive disorders)
– Anxiety disorders (fatigue disorders such as post-traumatic stress – posttraumatic stress disorder)
– Bipolar disorder (Bipolar disorder/Manic depression)
• Medical or neurological disorders (Medical or neurologic disorders):
– Chronic pain (Chronic pain)
– Congestive heart failure (Congestive heart failure)
– Premenopausal (Perimenopause/menopause transition)
– End stage kidney disease (End-stage kidney disease)
– Urinary incontinence (Urinary incontinence)
• Medicine (Medication)
– Side effects of prescription drugs (prescription drugs) and over-the-counter drugs (over-the-counter drugs)
– Using illegal drugs / not going through a doctor (illicit drug use)
– Abuse of alcohol (alcohol abuse)
• Life style
– Watch guard
– Change time zone
• Primary causes of insomnia
– Insomnia without cause (Idiopathic insomnia)
– RLS or PLMD
– circadian rhythm disturbances (circadian rhythm disorders)