What is the recommended workup for a patient with insomnia?

Comprehensive Workup for Insomnia

The recommended workup for insomnia should include a two-step process starting with an initial screening followed by a comprehensive assessment for those who screen positive, focusing on identifying underlying causes, comorbidities, and appropriate treatment pathways. 1

Initial Screening

• Screen for sleep problems using two key questions: (1) "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" and (2) "Does the problem with your sleep negatively affect your daytime functioning?" 1
• If the patient answers yes to both questions, proceed with a more focused assessment 1
• Consider using validated screening tools such as the Insomnia Severity Index to identify cases of insomnia and assess treatment effects 1
• The Epworth Sleepiness Scale can help rule out comorbid sleep disorders 1

Comprehensive Assessment

Sleep History and Patterns

• Obtain a detailed sleep history including specific insomnia complaints, sleep-wake patterns, and daytime consequences 2
• Request completion of a 2-week sleep diary/log documenting:
  • Bedtime and wake times
  • Sleep onset latency
  • Number and duration of awakenings
  • Total sleep time
  • Nap frequency and duration 1, 2
• Consider actigraphy for at least 7 days to objectively measure sleep-wake patterns, particularly when circadian rhythm disorders are suspected 2

Medical and Psychiatric Evaluation

• Assess for medical conditions that commonly cause insomnia:
  • Cardiovascular diseases (heart disease, hypertension)
  • Pulmonary conditions (COPD, sleep apnea)
  • Neurological disorders (Parkinson's disease, stroke)
  • Pain conditions (arthritis, cancer, neuropathy)
  • Gastrointestinal disorders
  • Endocrine disorders (diabetes, thyroid dysfunction) 1
• Screen for psychiatric conditions commonly associated with insomnia:
  • Depression
  • Anxiety disorders
  • Bipolar disorder
  • Post-traumatic stress disorder 3

Medication and Substance Use Review

• Conduct a thorough review of all medications that may contribute to insomnia:
  • Beta-blockers
  • Bronchodilators
  • Corticosteroids
  • Decongestants
  • Diuretics
  • SSRIs and SNRIs
  • Stimulants 1
• Assess use of substances that can disrupt sleep:
  • Caffeine
  • Alcohol
  • Nicotine
  • Over-the-counter sleep aids
  • Recreational drugs 1

Physical Examination

• Perform a focused physical examination based on findings from the clinical history 1
• Consider laboratory testing only when clinically indicated by history and physical examination findings 1

Differential Diagnosis Considerations

• Distinguish between primary insomnia and comorbid (secondary) insomnia 1
• Consider other sleep disorders in the differential diagnosis:
  • Obstructive sleep apnea
  • Restless legs syndrome
  • Circadian rhythm sleep disorders (e.g., delayed sleep phase syndrome) 2
• Be aware that multiple sleep disorders may coexist, requiring comprehensive evaluation 2

Common Pitfalls to Avoid

• Failing to distinguish between fatigue and sleepiness 2
• Relying solely on subjective reports without objective measures when indicated 2
• Overlooking medications or substances that can cause or exacerbate insomnia 1
• Neglecting to assess for comorbid medical and psychiatric conditions 1
• Assuming sleep hygiene education alone is sufficient treatment for chronic insomnia 1

Treatment Considerations Based on Assessment Findings

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for chronic insomnia 1, 4
• Pharmacological options should be considered when non-pharmacological approaches are insufficient:
  • Short-intermediate acting benzodiazepine receptor agonists or ramelteon as first-line pharmacotherapy 1
  • Sedating antidepressants when comorbid depression/anxiety exists 1
  • Avoid over-the-counter antihistamines and herbal supplements due to limited efficacy and safety data 1
• Combined therapy (CBT-I plus medication) may be appropriate based on symptom pattern, treatment goals, and patient factors 1

By following this structured approach to the workup of insomnia, clinicians can identify underlying causes, rule out other sleep disorders, and develop appropriate treatment plans that address both the insomnia symptoms and any contributing factors.