Clinical Practice Guidelines for the Management of Patients with Insomnia in Primary Care.

  1. Introduction
  2. Scope and objectives
  3. Methodology
  4. Epidemiology of insomnia
  5. Concepts, definitions, clinical features and classifications
  6. Diagnosis of insomnia
  7. Treatment of insomnia
  8. Patient information and adherence to treatment
  9. Nursing role
  10. Diagnostic and therapeutic strategies
  11. Dissemination and implementation
  12. Recommendations for future research
  13. Bibliography

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4. Epidemiology of insomnia

Insomnia is the most common sleep disorder and one of those with the greatest health and social significance. The patient with insomnia complains primarily of dissatisfaction with the quality and/or quantity of sleep. This dissatisfaction may stem from the difficulty in falling or staying asleep throughout the night, or the number of times patients wake up during the night.

To understand the epidemiology of insomnia it helps to understand the clinical relevance of this disorder. There are few studies in Spain that have examined the prevalence of insomnia, and there is none that has analysed its incidence. However, data on the prevalence of insomnia in Spain is similar to other western countries.


4.1. Prevalence of insomnia

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The prevalence of insomnia in the general population varies widely, depending on the samples taken across studies. This can be explained by methodological differences, mainly related to the definition used of insomnia.

Epidemiological studies have grouped people in three categories, as proposed in the literature3. The first is the one that includes data for the clinical manifestations of insomnia, such as difficulty in falling and/or maintaining sleep or of non-restorative sleep, irrespective of its duration or consequences. The second group consists of those who take into account consequences during daytime and dissatisfaction with the quantity or quality of sleep, in addition to their declarations on night sleep. The third group meet the diagnostic criteria of insomnia, according to classifications such as the Diagnostic and Statistical Manual of Mental Disorders (the revised third edition, DSM-III-R, the fourth edition, DSM-IV or the revised fourth edition, DSM -IV-TR) and the International Classification of Sleep Disorders (ICSD). See section 5.4.

When the definition also includes the daytime clinical consequences of insomnia and dissatisfaction with the quantity/quality of sleep, the prevalence rate is between 9% -15% and 8% -18%. Finally, if the definition is also based on the classification of DSM-IV, the prevalence of people diagnosed with insomnia reduces to 6%3. These data are presented in graphical form below.

Figure 1. Insomnia in the general population

Graphic 1

Modifi ed Ohayon, Sleep med Rev, 20023

A meta-analysis performed in the US showed that of patients attending PC, more than 50% complained of insomnia only if specifi cally asked about sleeping, 30% visit their GP on their own initiative, and only 5% go to consultation with the main objective of receiving treatment to solve this problem4. A recent study, also in the US, estimates that only 15% of people with sleep problems were diagnosed with sleep disorders. 4% of these patients were diagnosed with Insomnia and only half of them received further treatment for this condition5.

It was also noted that patients with long-term insomnia, according to DSM III-R and DSM IV criteria were between 19% (in 1999) and 26.5% (in 2001), respectively6.

In Spain, sleep disorder prevalence studies in the general population are very limited and show that approximately 23% have some trouble sleeping with 11% reporting having insomnia7. These fi gures are seen in young adults8 and appear to increase with age7,9. Insomnia is the sleep disorder that PC practitioners fi nd more frequently in daily clinical practice10. A PC prevalence study showed 17.4% insomnia according to DSM-III-R, about 27% for complaints of poor sleep and 55.5% had no sleep problems11.

The defi nition of insomnia used in studies infl uences the prevalence fi gures obtained and the sociodemographic features of the insomniac patient. Regardless of the defi nition used, women are more likely than men to suffer from insomnia. Age seems to increase only “complaints” about sleeping (or insomnia)12, as with marital status. People who are separated, divorced or widowed (again, more likely in women) described a higher prevalence13.

Insomnia is more common among people who do not work for pay than among those who do, although this association appears to be an effect of age and sex. There are some studies that associate the prevalence of insomnia with lower income and education levels, but further studies suggest that this may be explained by confusing these categories with others, such as age3.


4.2. Impact of insomnia: associated burden of disease

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The impact of insomnia on health has been studied from the epidemiological point of view, except for its relationship to psychopathology. However, several studies have shown an association of insomnia with a worse overall health status and a self-perception of poor health14,15.

Insomnia is usually associated with daytime fatigue and mood disorders such as irritability, dysphoria, tension, helplessness and depression14,16,17. with one study suggesting that untreated chronic insomnia may be a risk factor in developing major depression18. In addition, patients with insomnia often have somatic complaints, typically gastrointestinal and respiratory, or headaches and non-specific pains14,19.

During the day, patients with chronic insomnia may have problems that affect both their health and social and occupational functioning6,20. They may complain of symptoms on the emotional, behavioural and cognitive level and of an impairment in their social and working lives, with an increase in absenteeism21. Moreover, they are more likely to have accidents. In a survey conducted recently in the United States, 26% of people with insomnia reported that on some occasions they felt drowsy while driving or during working hours. This results in a poorer quality of life: they are impatient, have difficulty concentrating, organising their work or are warned that their productivity is lower than expected5.

Other studies, also conducted in the US, show that patients with insomnia generally have more frequent health service consultations, which represent an increase in both direct and indirect health costs22,23. Diagram 1 shows some of the health effects caused by insomnia, with both personal and social consequences.

Diagram 1. Effects of insomnia on health

Diagram 1

When insomnia becomes chronic, it is associated with increased morbidity19. Insomnia or typical manifestations have been associated in epidemiological studies with respiratory disease (chronic obstructive pulmonary disease-COPD, asthma, chronic bronchitis), rheumatic diseases, cardiovascular diseases (coronary heart disease, hypertension), cerebrovascular conditions (stroke), diabetes and painful diseases, among others19,20.

The effects of tobacco and alcohol are also clear. Smoking is associated with more difficulties in falling and staying asleep and more daytime sleepiness, while alcohol is often used as a self-medication by people with insomnia14,16. About 10% of patients with insomnia consume alcohol several nights a week5.

A relationship that has been repeatedly demonstrated in studies of the general population is that between psychopathological factors and insomnia. It shows that patients with chronic or persistent insomnia are at increased risk of developing other psychiatric disorders, especially depression, anxiety or alcoholism, when compared with patients without insomnia or those who have recovered from this disorder6. The relationship with depression is particularly clear. Firstly, the typical difficulties of insomnia are present in four out of five people with major depressive disorder; while secondly, the persistence of the manifestations of insomnia markedly increase the likelihood of suffering a major depression in a period of one year13,24.

It is unclear whether the fact of having insomnia is associated with increased mortality. According to some authors, sleep problems in the elderly, in particular, are linked to an increased risk of mortality25.

Regarding the impact of insomnia on the Spanish population, it is estimated that in 2006 the Spanish population bore a burden of disease26 equivalent to losing 37,628 years of disabilityadjusted life years (DALY). Since no recorded deaths are caused by this condition, the entire burden is attributable to associated morbidity and disability. This figure accounts for 2.6% of the total disease burden of neuropsychiatric diseases, 0.8% of total non-communicable diseases and 0.7% of the total DALYs lost in Spain. The disease burden of (primary) insomnia is higher in women than men (56% of DALYs for that reason), and is concentrated between those of 15 and 59 years of age (see Table 1 and Figure 2). The overall figures for Spain are similar to those of other neighbouring European countries (Table 2).

Table 1. Burden of disease of (primary) insomnia*, Spain, 2006

Men
Women
Total
DALY
16,669
20,959
37,628
By sex
DALY
44.3 %
55.7 %
100 %
As a percentage of neuropsychiatric conditions
DALY
2.5 %
2.6 %
2.6 %
As a percentage of non-communicable diseases
DALY
0.7 %
1.0 %
0.8 %
As a percentage of all causes
DALY
0.6 %
0.9 %
0.7 %
(*) Código F51 de la CIE-10
DALY: disability-adjusted life years lost.
Source: information prepared and provided by the department of Health reports and Studies, Ministry of Health,
Community of Madrid.

Figure 2. Burden of disease of (primary) insomnia by age group*, Spain, 2006

Graphic 2

(*) Code F51 in the Cie-10
DALY: disability-adjusted life years lost.
YLD: Years of life lost due to disability or poor health.
YLL: Years of life lost due to premature death.
Source: information prepared and provided by the department of Health reports and Studies, Ministry of Health,
Community of Madrid.

Table 2. Disease burden of (primary) insomnia*, Europe-A subregion (WHO), 2004

Men
Women
Total
DALY
155,085
198,419
353,504
By sex
DALY
43.9 %
56.1 %
100 %
As a total of neuropsychiatric conditions
DALY
2.6 %
2.8 %
2.7 %
As the total of non-communicable diseases
DALY
0.7 %
0.9 %
0.8 %
As a percentage of all causes
DALY
0.6 %
0.9 %
0.7 %
(*) Code F51 in the Cie-10
DALY: disability-adjusted life years lost.
Source: WHO. the global burden of disease: 2004 update (2008). information prepared and provided by the department of Health reports and Studies, Ministry of Health, Community of Madrid

The elderly

There are few studies on the prevalence of insomnia in people over 65 years. In international studies, the figures vary between 12% and 40%27. In Spain, studies show that although about 32% of elderly people suffer sleep disturbances, the figures are around 12% when applied to the classification of insomnia. The most frequent complaints are related to “waking up early” and “waking up tired”7,9.

Although not all sleep disorders are pathological for these age groups, severe sleep disturbances can contribute to depression and cognitive impairment18. Some studies report that chronically disturbed sleep affects daytime functioning (eg mood, energy, performance) and quality of life, and there is evidence that these sleep disturbances contribute significantly to increased health-care costs27.

The prevalence rates of insomnia are even higher when taking into account the coexistence of other clinical or psychiatric conditions. Lifestyle changes associated with retirement, the higher incidence of health problems and an increased use of medication put older people at greater risk of sleep disturbances27.

The consequences of chronic insomnia in the elderly result in slower reaction times and greater difficulty in maintaining balance, which brings an increased risk of falls. These falls are directly related to an increased risk of mortality. People also have attention and memory deficits as a result of poor or little sleep, which are symptoms that could be misinterpreted as those of mild cognitive impairment or dementia25,28.

 

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Section 04 bibliography


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  2. 4. Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002; 159:5-11.
  3. 5. National Sleep Foundation. 2008 Sleep in America Poll. Summary of Findings. [sede Web]*. National Sleep Foundation, 2008 [acceso 20-11-2008]; Disponible en: www. sleepfoundation.org
  4. 6. Backhaus J, Junghanns K, Mueller-Popkes K et al. Short-term training increases diagnostic and treatment rate for insomnia in general practice. European Archives of Psychiatry and Clinical Neuroscience. 2002; 252:99-104.
  5. 7. Vela-Bueno A, De IM, Fernandez C. [Prevalence of sleep disorders in Madrid, Spain]. Gac Sanit. 1999; 13:441-448.
  6. 8. Fernández-Mendoza J, Vela-Bueno A, Vgontzas AN et al. Nighttime sleep and daytime functioning correlates of the insomnia complaint in young adults. Journal of Adolescence. 2009; 32:1059-1074.
  7. 9. Blanco J, Mateos R. Prevalencia de trastornos del sueño en el anciano. INTERPSIQUIS. 2005.
  8. 10. Escuela Andaluza de Salud Pública. Aproximación al Treatment of insomnia en atención primaria. [Monografía en Internet]. Escuela Andaluza de Salud Pública, 2000 [acceso 20-12-2008]; (Granada. Cadime: BTA (Boletín Terapéutico Andaluz)): Disponible en: http://www.easp.es/web/documentos/MBTA/00001188documento.2.2000.pdf Open new window
  9. 11. Cañellas F, Llobera J, Ochogavia J et al. Trastornos del Sueño y Consumo de Hipnóticos en la Isla de Mallorca. Revista Clínica Española. 1998; 198:719-725.
  10. 12. Zhang B, Wing YK. Sex differences in insomnia: a meta-analysis. Sleep. 2006; 29:85- 93.
  11. 13. Bixler EO, Vgontzas AN, Lin HM et al. Insomnia in central Pennsylvania. J Psychosom Res. 2002; 53:589-592.
  12. 14. Kales A, Kales JD. Evaluation and treatment of insomnia. 1984.
  13. 15. Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behav Sleep Med. 2003; 1:227-247.
  14. 16. Morin CM, Espie CA. Insomnia: a clinical guide to assessment and treatment. 2004.
  15. 17. Taylor DJ, Lichstein KL, Durrence HH et al. Epidemiology of insomnia,depression, and anxiety. Sleep. 2005; 28:1457-1464.
  16. 18. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA. 1989; 262:1479-1484.
  17. 19. Taylor DJ, Mallory LJ, Lichstein KL et al. Comorbidity of chronic insomnia with medical problems. Sleep. 2007; 30:213-218.
  18. 20. NIH State-of-the-Science Conference. Statement on manifestations and management of chronic insomnia in adults. NIH Consensus & State-of-the-Science Statements. 2005; 22:1-30.
  19. 21. Leger D, Poursain B. An international survey of insomnia: under-recognition and undertreatment of a polysymptomatic condition. Curr Med Res Opin. 2005; 21:1785-1792.
  20. 22. Ozminkowski RJ, Wang S, Walsh JK. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep. 2007; 30:263-273.
  21. 23. Hossain JL, Shapiro CM. The prevalence, cost implications, and management of sleep disorders: an overview. Sleep Breath. 2002; 6:85-102.
  22. 24. Taylor DJ. Insomnia and depression. Sleep. 2008; 31:447-448.
  23. 25. Lianqi L, Ancoli-Israel S. Insomnia in the Older Adult. Sleep Med Clin. 2006; 1: 409-421.
  24. 26. Pereira J CJÁEGR. La medida de los problemas de salud en el ámbito internacional: los estudios de carga de enfermedad. Rev Admin Sanitaria 2001;V(19): 441-66. 2001.
  25. 27. Montgomery P, Dennis J. Bright light therapy for sleep problems in adults aged 60+. [Review] [67 refs]. Cochrane Database of Systematic Reviews (2):CD003403. 2002.
  26. 28. Walsh JK, Benca RM, Bonnet M et al. Insomnia: assessment and management in primary care. National Heart, Lung, and Blood Institute Working Group on Insomnia. Am Fam Physician. 1999; 59:3029-3038.

Latest update: May 2010

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