Insomnia, Applying Q2

Insomnia, Applying Q2

by | General, Insomnia, Letters to Winston, Professional, Sleep Disorders, Sleep Disorders, Sleep Evaluations, Sleep Symptoms

Winston

You didn’t ask for this.  You probably do not even want it.  Yes I know, but I promised you a primer on how to apply the qualitative and quantitative analyses of insomnia complaints.  Remember, insomnia as a complaint can represent many different issues.  These include difficulty going to sleep and staying asleep as well as going back to sleep after awakening or combinations of those issues.  Before you can apply that information, you need a simple overview of how to consider the multiple factors that can produce difficulty with sleep.

The approach I find most helpful is based on general factors known to often cause difficulty with sleep.  The categories along with a brief description are:

ENVIRONMENTAL:  Environmental causes are usually recognized by the patient, but not always.  Factors such as pets, spouses, lighting, thermostat settings and others are some reasons people do not sleep well.

MEDICAL:  At some point almost all medical conditions may interfere with sleep.  Frequent conditions are usually muscular skeletal such as injuries and arthritis.  Other common, though short-term, issues include allergies and upper respiratory illnesses.

MEDICATIONS:  You are not surprised to see medications, are you?  Their side effects on sleep is an obsession of mine.  A careful review is in order.  The website has a listing under the medication tab of those and of those that frequently cause excessive sleepiness and sleeplessness.

PSYCHOLOGICAL:  We all experience short term stresses and emotional upheavals that lead to anxiety and depression.  Long term difficulties with insomnia can result from persistent problems with anxiety and depression.  Similarly, anxiety and depression can cause difficulties with sleep.  The degree of anxiety and depression needed to produce these complaints is of a magnitude that should be apparent to the patient and a perceptive doctor, though psychological issues are often difficult to assess.    

HABITS:  Habits can produce insomnia.  Familiar to all, caffeine containing products lead the list.  Less well-known dietary factors are alcohol, tea and chocolate.  Not for their caffeine, but for other components.  The activities a person pursues prior to sleep also can play a significant role.  Food, drink, exercise, TVs and computers and lighting need reviewing.

STRUCTURE:  Sleep structure refers to timing of sleep.  What is the patient’s sleep duration and their time spent in bed trying to sleep?  How long does the patient sleep when he sleeps well?  Is the patient a night owl (likes to stay up late and wake late) or a lark (likes to go to bed early and wake early)?  Are the sleep hours stable or do they change on weekends.  Does the patient do shift work?  How much sleep does this patient actually need?  All these are factors that need to be considered.

SLEEP DISORDERS:  The last category of potential issues are the disorders of sleep.  Recognized disorders of sleep may produce difficulty with what a patient considers insomnia.  For example, obstructive sleep apnea, thought to occur in 25% of all adults, can cause difficulty with sleep maintenance but rarely causes difficulty with initiating sleep.  Restless legs and periodic limb movements need to be considered when insomnia is reported.  Primary insomnia, insomnia without a known cause, is a diagnosis under this group. 

Applying a qualitative and quantitative assessment allows the doctor to focus on specific areas of concern. Often, a provider will consider a patient to have primary insomnia without giving the other factors consideration.  They take the patient’s complaints of insomnia – the patient’s perceptions of their sleep difficulties as insomnia – to be insomnia without a cause and proceed with medications to help induce sleep.  Getting needed information from the patient is often difficult and time can limit the providers’ opportunities to explore other possible issues.  For example, frequently a patient will tell me they have stopped using caffeinated products, but upon questioning, tea or energy drinks are still being used.  Another major issue is medications.  Patients may be on multiple medications which can produce sleeplessness or sleepiness.  It can be impossible at times to separate their specific effects. Clearly identifying the details of the complaint will direct the provider to specific items to be considered for the patients diagnosis and treatment.

It is possible to identify contributing or causative factors in many patients with insomnia complaints.  The qualitative and quantitative assessments often lead to specific addressable issues that can be modified or treated without the use of sleep-inducing medications.  My working patterns can be summarized best in a tabular form that I have reproduced below.

When a patient’s complaints fall into one of these patterns, a more detailed history and investigation to assess that issue will follow.

And yes, Winston, I will try not to bother you with any more advice on insomnia.

RGH 29430

 COMMON PATTERNS OF INSOMNIA COMPLAINTS IN SPECIFIC SLEEP PROBLEMS
SLEEP DISORDER DIAGNOSIS         IS      MS     RTS     WE     EDS
Primary Insomnia  ++++  ++++  ++++  ++++  —–
Obstructive Sleep Apnea  ——  +++  —–  —–  +++
Restless Legs Syndrome  ++++  —–  ——  —–  +
RLS with Periodic Limbs  ++++  ++  +  —–  +
Periodic Limb Movements  ——  ++++  +++  —–  ++
Circadian disorders (type dependent)  +++  ——  ——  +++  +
REM Behavior Disorder  —–  ——  —–  ——  —–
INGESTED PRODUCTS
Caffeine/
Coffee		  +++  ++  +  ——  +
Tea/
Chocate		  +++  +++  +++  —— +
Alcohol  —–  +++  ++  +  +
MEDICATIONS (drug dependent)
May produce any pattern  ++++  ++++  ++++  ++++  ++++
PSYCHOLOGICAL
Anxiety  ++++  ++  +++  +  +
Depression  +  + ++  +++  +++

                  LEGEND

                                    IS        initiating Sleep

                                    MS     Maintaining Sleep

                                    RTS    Returning to Sleep

                                    WE    Waking Early

                                    EDS  Excessive Day time Sleepiness

                                    —–            Unusual complaint

                                    +               Infrequent complaint

                                    ++             Occasional complaint

                                    +++          Frequent complaint

                                    ++++        Very common complaint

Insomnia, Applying Q2

Insomnia – A Qualitative and Quantitative Analysis

by | General, Healthcare, Insomnia, Letters to Winston, Professional, Sleep Blog, Sleep Disorders, Sleep Evaluations, Sleep Symptoms

Winston

Yes, that is what I said;  “A problem with insomnia needs to be analyzed qualitatively.”

During my college years, I majored in the study of chemistry. The study requirements included courses in qualitative and quantitative analysis.  Essentially, the study of what a substance is made of and how much of each component part is included.  My comment on analyzing insomnia qualitatively means that a physician should know the components of the complaint. 

The term, insomnia, has a multitude of meanings in common use as well as in medicine.  The physician needs to know what the person using the term is experiencing.  In essence, what are the specific issues involved?  It is only with this type of clarity that the patient’s situation can be assessed.  The analysis includes the effects on daytime activities and is designed for nocturnal sleepers.  Those whose primary sleeping time is during the day, for example shift workers, require a different approach.  

Difficulty falling asleep or initiating sleep is the most recognized problem described by the term.  Defining the time required for sleep onset is the first step in assessing insomnia.  A problem with sleep initiation may be someone’s sole issue or it may be just one part of the patient’s problem.

Another difficulty often described as insomnia is waking frequently during the sleep period.  It is common and considered normal to wake once or twice a night.  Waking more often disrupts sleep and is frequently an issue for the patient.   Those with this complaint may or may not have a third type of problem, returning to sleep.

Returning to sleep after waking during your night of sleep, can be a singular issue or can be associated with other insomnia issues.  Some will wake frequently while others will wake only once or twice.  A problem returning to sleep can occur in either situation.

Waking earlier than desired is another issue commonly reported as insomnia.  All of these complaints may occur independently or in combination with one or more of the others.   

Knowledge of the effects of the sleep problem on daytime wakefulness and napping is helpful diagnostically.  Is the person sleepy during the day?  Do they nap?  Do they nod off?

To analyze complaints of insomnia, a physician needs to understand:

  • Are there problems with sleep initiation?
  • Are there problems with sleep maintenance? 
  • Are there problems with returning to sleep after awaking?
  • Are there problems with waking too early for the day?
  • Are there problems with daytime sleepiness?

A patient’s historical ‘insomnia qualitative profile’ information is required for accurate assessment.  Unfortunately, getting the information can be difficult, time consuming and even impossible. When obtainable, it will help with establishing a diagnosis, but a pattern of difficulty does not indicate a specific reason or cause for the issues.  In fact, many or most individuals will have more than one potential causative or aggravating issue.  

The frequency the symptoms occur and their intensity are important in narrowing the potential reasons or contributing factors to the sleeplessness problem.  How significant is each of the symptoms reported?  This step is the quantitative analysis of each of these factors 

Diagnostic considerations of insomnia require knowledge of the specific complaints (the qualitative analysis) and the degree to which they are present (the quantitative analysis) for assessing factors that are known to produce insomnia.  

So Winston, I have returned to my youth of qualitative and quantitative analysis.  A famous troubadour once penned a song; “All my life’s a circle, sunrise to sunset.”  So it appears to be.  I suspect this is more than you probably wanted to know.  Maybe I should prepare a short primer for you on the roles of the qualitative and quantitative assessments in identifying the factors, conditions and behaviors known to produce and aggravate insomnia.