What are the best patient assessment tools for a patient with chronic long-standing insomnia?

Best Patient Assessment Tools for Chronic Long-Standing Insomnia

For chronic insomnia assessment, at minimum use: (1) a two-week sleep diary, (2) the Insomnia Severity Index (ISI), and (3) the Epworth Sleepiness Scale (ESS), supplemented by a general medical/psychiatric questionnaire to identify comorbid conditions. 1

Core Assessment Instruments (Required)

Sleep Diary - The Foundation

• Complete a two-week sleep log prior to any treatment intervention to establish baseline sleep-wake patterns and day-to-day variability 1, 2
• Document the following parameters daily:
  • Bedtime and rise time
  • Sleep onset latency (time to fall asleep)
  • Number and duration of nighttime awakenings
  • Wake after sleep onset (WASO)
  • Total sleep time and time in bed
  • Sleep efficiency percentage (total sleep time/time in bed × 100%)
  • Nap frequency, timing, and duration
  • Sleep quality ratings
  • Daytime impairment
  • Medications, caffeine, and alcohol consumption 1
• Continue sleep diary collection during active treatment and at 6-month intervals for long-term monitoring, as relapse rates for insomnia are high 1

Insomnia Severity Index (ISI)

• The ISI is the most widely used and validated tool to measure self-reported insomnia symptom severity 1, 3
• This 7-item categorical scale provides total scores with established criteria for defining treatment response and remission 1
• The ISI demonstrates strong internal consistency, concurrent validity with sleep diaries and polysomnography, and sensitivity to detect treatment changes 3
• Use the ISI both at baseline and longitudinally to measure treatment response 1

Epworth Sleepiness Scale (ESS)

• Administer the ESS to identify excessive daytime sleepiness and screen for comorbid sleep disorders such as sleep apnea 1, 2
• Significant sleepiness should prompt investigation for other sleep disorders beyond insomnia 1

General Medical/Psychiatric Questionnaire

• Complete a comprehensive questionnaire to identify comorbid medical and psychiatric disorders that may cause or perpetuate insomnia 1, 2
• Screen specifically for:
  • Cardiovascular, pulmonary, neurological, pain, gastrointestinal, and endocrine conditions 1, 2
  • Depression, anxiety disorders, bipolar disorder, and post-traumatic stress disorder 2
  • Medications that disrupt sleep (SSRIs, stimulants, decongestants, beta-blockers, diuretics, theophylline) 1, 2
  • Substance use including caffeine, alcohol, nicotine, and recreational drugs 1, 2

Additional Validated Assessment Tools (Recommended)

Pittsburgh Sleep Quality Index (PSQI)

• The PSQI measures global sleep quality and is one of the two most widely used tools alongside the ISI 1
• This categorical scale provides total scores that can be evaluated across treatment with accepted criteria for treatment response 1
• The PSQI has demonstrated adequate structural validity in chronic insomnia populations 4

Dysfunctional Beliefs and Attitudes About Sleep (DBAS) Scale

• Include the DBAS to identify unhelpful sleep-related beliefs that perpetuate insomnia and to measure changes during cognitive-behavioral therapy 1

Daytime Function and Quality of Life Measures

• Assess daytime impairments including fatigue, mood disturbances, cognitive difficulties, and overall quality of life, as these are what typically drive patients to seek treatment 1
• Various validated self-report questionnaires for daytime fatigue should be included 1

Objective Assessment Tools (Selective Use Only)

When Polysomnography IS Indicated

• Polysomnography is NOT indicated for routine evaluation of chronic insomnia 1
• Order polysomnography only when:
  • Reasonable clinical suspicion exists for sleep-disordered breathing (sleep apnea) or movement disorders 1
  • Initial diagnosis remains uncertain after comprehensive evaluation 1
  • Treatment fails (both behavioral and pharmacologic interventions) 1
  • Precipitous arousals occur with violent or injurious behavior 1

Actigraphy

• Consider wrist actigraphy for at least 7 days to objectively characterize circadian rhythm patterns or when circadian rhythm disorders are suspected 1, 2
• Actigraphy provides complementary information to sleep diaries but is not required for diagnosis 1

Critical Assessment Considerations

Differential Diagnosis Requirements

• Multiple insomnia disorders may coexist—the presence of one does not exclude others 1
• Systematically evaluate for:
  • Sleep-related breathing disorders (obstructive sleep apnea)
  • Movement disorders (restless legs syndrome, periodic limb movements)
  • Circadian rhythm sleep disorders
  • Comorbid medical or psychiatric conditions
  • Primary insomnia subtypes (psychophysiological, idiopathic, paradoxical) 1

Bed Partner Interview

• Include bed partner interviews when available to obtain collateral information about snoring, breathing pauses, movements, and sleep behaviors 1

What NOT to Order Routinely

• Laboratory testing (blood work, radiographic studies) is NOT indicated for routine chronic insomnia evaluation unless specific suspicion exists for comorbid disorders 1
• Daytime multiple sleep latency testing (MSLT) is NOT indicated in routine chronic insomnia evaluation 1

Common Pitfalls to Avoid

• Failing to collect a two-week sleep diary before initiating treatment—this is essential for establishing baseline patterns and guiding behavioral interventions 1, 2
• Ordering polysomnography for uncomplicated chronic insomnia—this wastes resources and is not guideline-recommended 1
• Neglecting to screen for comorbid sleep disorders with the ESS, potentially missing treatable conditions like sleep apnea 1, 2
• Using only subjective questionnaires without daily sleep diaries—diaries are less subject to recall bias and capture day-to-day variability 1
• Failing to reassess with these same tools during treatment—repeated administration guides treatment adjustments and identifies relapse 1