Insomnia Workup

  • Author: Ron A Shatzmiller, MD, MSc; Chief Editor: Selim R Benbadis, MD   more...
 
Updated: Jan 17, 2012
 

Approach Considerations

Insomnia is a clinical diagnosis. Diagnostic studies are indicated principally for the clarification of comorbid disorders.

Before therapy is instituted, most patients are asked to keep a sleep log for 2-4 weeks. This log, in which the patient records bed and wake times, sleep duration, and daytime naps and activities, gives a clearer picture of the degree of sleep disturbance and allows development of a tailored treatment.

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Arterial Blood Gas Study

Patients with a history suggestive of chronic obstructive pulmonary disease (COPD) and insomnia should have an arterial blood gases (ABG) study performed to determine if they are hypoxemic. Insomnia in COPD frequently begins with the development of nocturnal hypoxemia, although nocturnal hypoxemia is not required for insomnia to occur. Treatment with oxygen may improve, but rarely eliminates, the insomnia.

Nocturnal hypoxemia is present if the patient has daytime hypoxemia or, frequently, exercise-related hypoxemia. If the ABG result is negative for hypoxemia, an exercise desaturation study or overnight oximetry may be helpful to determine if the patient needs oxygen.

Other laboratory testing is indicated only when comorbid disorders are suspected.[3]

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Polysomnography

Polysomnography and daytime multiple sleep latency testing (MSLT) are not routinely indicated for the workup of insomnia.[50, 3] However, patients with a history suggestive of sleep apnea or restless legs syndrome (RLS)/periodic limb movement disorder (PLMD) should be referred to a sleep center for polysomnography, as should patients with violent or injurious behavior due to precipitous arousals. Treatment failure may also be an indication for polysomnography.[3]

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Actigraphy

Actigraphy uses a portable device worn around the wrist like a watch to record gross motor activity and light/darkness over extended periods. This study provides an indirect objective measure of sleep and wake time. Actigraphy has shown excellent concordance with polysomnography in the assessment of total sleep time.[51]

Actigraphy can help document sleep patterns and circadian rhythms. Distinguishing primary insomnia from circadian rhythm disorders and identifying paradoxical insomnia is useful, particularly in those patients who are refractory to treatment.

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Sleep Diary

A sleep diary is appropriate when a patient reports an irregular sleep schedule. Maintaining a sleep diary can be done in conjunction with wrist actigraphy.

The patient should maintain a sleep diary for 1-2 weeks. In the diary, patients should record estimates of the time at which they do the following:

  1. Go to bed
  2. Fall asleep
  3. Awaken during the night
  4. Lay in bed awake
  5. Get out of bed in the morning

The patient should also record when and how long they exercise, when they take medications, and when they consume caffeinated or alcoholic beverages.

The 2008 AASM guideline recommends collection of sleep diary data both before and during active treatment and afterward if a relapse occurs or if the patient’s status needs to be reevaluated.[3]

While the sleep diary provides detailed information about sleep patterns, it can be confounded by the patient's subjective assessment of when they fall asleep and awaken during the night. (Click on the following image to download a sample sleep diary.)

Sleep diary. Sleep diary.
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Contributor Information and Disclosures
Author

Ron A Shatzmiller, MD, MSc  Assistant Clinical Professor, Department of Neurology, Keck School of Medicine of the University of Southern California; Specialty Lead Physician, Healthcare Partners Medical Group, Arcadia, California

Ron A Shatzmiller, MD, MSc is a member of the following medical societies: American Academy of Neurology and American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Erasmo A Passaro, MD, FAAN  Director, Comprehensive Epilepsy Program/Clinical Neurophysiology Lab, Bayfront Medical Center, Florida Center for Neurology

Erasmo A Passaro, MD, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association, and American Society of Neuroimaging

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Chief Editor

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Additional Contributors

Carmel Armon, MD, MSc, MHS Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center

Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi

Disclosure: Avanir Pharmaceuticals Consulting fee Consulting

Kendra Becker, MD, MPH Sleep Medicine Department, Kaiser Permanente Fontana Medical Center

Kendra Becker, MD, MPH is a member of the following medical societies: American Academy of Sleep Medicine, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Jose E Cavazos, MD, PhD, FAAN Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the eMedicine articles that I wrote or edited.

Zab Mosenifar, MD Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

James A Rowley, MD Professor, Fellowship Program Director, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine

James A Rowley, MD is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Silverio M Santiago, MD Clinical Professor of Medicine, University of California at Los Angeles School of Medicine; Chief, Department of Pulmonary and Critical Care Medicine, Medical Director, Sleep Disorders Center, Veterans Affairs Medical Center of West Los Angeles

Silverio M Santiago, MD is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Peter Smethurst, MD Attending Physician, Pulmonary, Critical Care and Sleep Medicine, St Joseph's Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory Tino, MD Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital

Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

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Theoretical model of the factors causing chronic insomnia. Chronic insomnia is believed to primarily occur in patients with predisposing or constitutional factors. These factors may cause the occasional night of poor sleep but not chronic insomnia. A precipitating factor, such as a major life event, causes the patient to have acute insomnia. If poor sleep habits or other perpetuating factors occur in the following weeks to months, chronic insomnia develops despite the removal of the precipitating factor. Adapted from Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec;10(4):541-53.
Mallampati airway scoring.
Diagnostic algorithm for major depression.
Diagnostic criteria for generalized anxiety disorder.
Sleep diary.
GABAA receptor subunit function(s).
GABAA receptor complex subunits and schematic representation of agonist binding sites.
Sleep-wake cycle.
The ascending arousal system. Adapted from Saper et al. Hypothalamic Regulation of Sleep and Circadian Rhythms. Nature 2005;437:1257-1263.
Ventrolateral pre-optic nucleus inhibitory projections to main components of the arousal system to promote sleep.
Schematic flip-flop switch model. Adapted from Saper C et al. Hypothalamic regulation of sleep and circadian rhythms. Nature 2005;437:1257-1263.
Epworth Sleepiness Scale.
Frequency of insomnia causes.
 
 
 
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