Diagnosis and Management of Clinical Conditions That Disturb Sleep
Core concepts
Here the primary disorder is elsewhere and sleep is the casualty: insomnia disorder, psychiatric illness (depression, anxiety, PTSD), chronic pain, nocturia, GERD, asthma/COPD, heart failure, thyroid disease, menopause, pregnancy, medications and substances (stimulants, steroids, beta-blockers, SSRIs, alcohol, caffeine, cannabis), and primary insomnia comorbid with medical disease. The candidate must distinguish insomnia disorder (difficulty initiating/maintaining sleep or early awakening with daytime impairment ≥3 nights/week for ≥3 months) from short-term insomnia and from sleep deprivation.
Management anchors
First-line for chronic insomnia is cognitive behavioral therapy for insomnia (CBT-I): stimulus control, sleep restriction, relaxation, cognitive restructuring, and sleep hygiene. Pharmacotherapy is adjunctive and time-limited; avoid benzodiazepines in older adults and in OSA, and recognize that sedating antidepressants (trazodone, low-dose doxepin) are used off-label. Treat the underlying medical or psychiatric condition, review the medication list, and screen for depression and anxiety. In pregnancy, prefer behavioral approaches; in older adults, address nocturia, pain, and polypharmacy.
Traps
Questions reward identifying a secondary cause rather than reflexively prescribing a hypnotic. Watch for caffeine and alcohol as hidden culprits, and for beta-blockers, steroids, and decongestants causing insomnia. Do not miss depression presenting as early-morning awakening, or anxiety presenting as sleep-onset latency. Avoid the trap of diagnosing insomnia in a patient with insufficient opportunity to sleep (shift work, newborn) - that is sleep deprivation, not insomnia.
Rule of thumb
Before adding a sleep medication, ask two questions: what else is waking the patient (pain, nocturia, reflux, dyspnea, mood), and what in the medication cabinet or cup is doing it?