Before treating insomnia with drugs:
Take a thorough sleep history
(Is the insomnia initial or middle insomnia? Is there early morning
wakening? Consider whole lifetime: most primary insomniacs have
always been poor sleepers.)
Determine the
pattern of sleep. (Is the sleep pattern normal? Has the
diurnal rhythm been disturbed? Other factors, eg. jet lag, shift working)
Duration of disturbance
(Is the sleep disturbance chronic and stable or acute?)
Look for possible causes [Psychiatric illness, drug induced (eg. theophylline, caffeine, nocturnal anticholinergics), drug withdrawal in dependence, medical disorder (eg. thyroid disease, menopausal symptoms, pain), coming into hospital or change of environment].
Sleep hygiene:
Go to bed only when sleepy
Use bedroom
only for sleeping in. Avoid watching television, reading, eating, drinking
etc, in bedroom
Make sure the
bed and bedroom are comfortable - not too cold and not too noisy
Take time to
relax properly before going to bed. Aromatherapy may be helpful
If not asleep
within 40 minutes of getting into bed, leave the bedroom and do
something such as read
Return to bed
when sleepy
If awake in the
night and unable to resume sleep after 20 minutes, leave the room
again (as above)
Get up at
normal time, ensure no lie-ins or daytime napping
Reduce caffeine
intake and avoid after 6pm, advise a warm milky drink or consider
herbal teas, eg. camomile
Anxiety
management and relaxation techniques may help
Exercise in the
day BUT not late at night
Treat
underlying causes
Reassurance of
elderly that 5-6 hours sleep may be enough
Continue with above programme until a normal sleeping pattern is achieved.
Benzodiazepines
General rules for prescribing benzodiazepines are that they should be:
*kept to a minimum
*reviewed regularly, and
*discontinued as soon as possible
For each admission, enquiry should be made by both medical and nursing staff to determine whether the patient is an occasional or regular user of benzodiazepines. The outcome should be documented in the nursing kardex, on the prescription chart and in the medical record.
Regular users should not have their treatment stopped suddenly.
Patients who have not previously been prescribed a benzodiazepine should not be routinely written up for them either on an as required or regular basis. If a benzodiazepine is indicated, every prescription must be reviewed after five days.
Nursing staff should counsel patient about the use of hypnotics, explain that they should only be used for a short time and outline the risks of tolerance, dependence and withdrawal.
Unless patients have been chronic benzodiazepine users, patients should not, normally receive a discharge prescription for them. The need for continuation of therapy should be carefully assessed for each individual patient.
All discharge prescriptions for benzodiazepines should clearly indicate to the GP whether the drug is to be continued and, where appropriate, the mechanism for review of the prescription.
Lorazepam carries a greater risk of withdrawal symptoms, and this drug should not be prescribed unless the patient is a chronic user.
Hypnotics should be avoided in respiratory failure and used with caution in addiction-prone individuals.
High doses should be avoided.
Abrupt withdrawal should be avoided if use has been continuous for more than 2 weeks.
Particular difficulties, such as falls may be created by the use of benzodiazepines in the elderly, and their use in this group of patients should be avoided. If deemed necessary however, the dose should be reduced and long-acting benzodiazepines, which have a hangover effect should be avoided.
Prescribing of other hypnotics as alternatives to benzodiazepines, particularly buspirone and zopiclone, is inappropriate. Routine substitution of antidepressant and antipsychotic drugs should also be discouraged.
Guidelines for prescribing 'z' drugs (NICE April 2004)
Hypnotics should only be prescribed for severe insomnia interfering with normal life, for short periods only strictly in line with their 2-4 week licence.
Due to the lack of compelling evidence to distinguish between zaleplon, zopiclone, zolpidem or the shorter-acting benzodiazepine hypnotics, the drug with the lowest purchase cost should be prescribed.
Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the anothers.
Switching between hypnotic drugs should only occur if adverse effects directly attributable to the drug are experienced.
In line with the above guidelines, 'z' drugs should not be prescribed on discharge unless the patient is a chronic user.