From the Guidelines
The patient's insomnia is likely caused by a combination of factors, including his screen time before bedtime, untreated hypertension, and hyperlipidemia, which can be addressed through sleep hygiene education and management of his chronic conditions. The patient's difficulty falling asleep can be attributed to the blue light emitted from electronic devices, which suppresses melatonin production, as well as the physiological stress caused by his untreated hypertension and hyperlipidemia 1.
Key Factors Contributing to Insomnia
- Screen time before bedtime: The patient's use of electronic screens within 30 minutes of bedtime is a significant contributor to his insomnia, as it suppresses melatonin production 1.
- Untreated hypertension and hyperlipidemia: The patient's untreated chronic conditions may be causing physiological stress that impacts sleep quality.
- Lack of sleep hygiene education: The patient may benefit from education on sleep hygiene practices, such as avoiding screens at least one hour before bedtime, establishing a consistent sleep schedule, and creating a relaxing sleep environment.
Recommended Treatment Approach
- Sleep hygiene education: The patient should be educated on sleep hygiene practices, including avoiding screens at least one hour before bedtime, establishing a consistent sleep schedule, and creating a relaxing sleep environment 1.
- Management of chronic conditions: The patient should resume management of his hypertension and hyperlipidemia to reduce physiological stress and improve sleep quality.
- Consideration of short-term sleep aids: After addressing the patient's behavioral factors and underlying health conditions, consideration of short-term sleep aids may be appropriate.
- Cognitive-behavioral therapy for insomnia (CBT-I): The patient may also benefit from CBT-I, which combines cognitive therapy strategies with education about sleep regulation, stimulus control instructions, and sleep restriction therapy 1.
From the Research
Potential Causes of Insomnia
- The patient's past medical history (PMH) of hypertension (HTN) and hyperlipidemia (HLD) may be contributing factors to insomnia, as there is evidence of a strong association between insomnia and various medical comorbidities 2, 3
- The patient's report of difficulty falling asleep and screen time within 30 minutes of bedtime may be maladaptive behaviors resulting in poor sleep, which can be addressed through cognitive behavioral therapy for insomnia (CBT-I) 2, 4
- The patient's history of HTN and HLD may increase the risk of cardiovascular disease (CVD), which has been linked to insomnia in observational and Mendelian randomization studies 3
Contributing Factors
- Easy arousability, poor self-reported health, and chronic pain are factors associated with the onset of insomnia, although it is unclear if these factors are present in this patient 4
- Psychiatric and medical problems, medication use, and substance abuse should be ruled out as contributing factors to insomnia, although the patient has been off medication for years 4
- The patient's age and gender may also be contributing factors, as insomnia is more common in older adults and has a higher prevalence in certain populations 4
Diagnosis and Treatment
- A comprehensive sleep history can confirm the diagnosis of insomnia, and treatment planning should address contributing and precipitating factors as well as maladaptive behaviors resulting in poor sleep 2, 4
- Nonpharmacologic therapies, such as sleep hygiene, cognitive behavior therapy, and relaxation therapy, may be effective in treating insomnia, and referral to a sleep specialist may be considered for refractory cases 4
- Pharmacologic therapies, such as zolpidem extended-release, may be used to treat insomnia characterized by difficulty falling asleep and maintaining sleep 5