Insomnia Insomnia

Primary Sleep Disorders 149
and walk to relieve these symptoms. She was initially treated with
amytriptiline with only worsening of her symptoms and no relief.
She was tired during the day, but did not fall asleep inappropriately. Her
husband denied she had any kind of leg movements in her sleep. He denied
that she snored or gasped for air or that she had any pauses in her breathing
while asleep.
In the past, before this last 5 years, she had experienced these symptoms periodically
about five times in her life, mainly in the last trimester of each of her
pregnancies.
Her past medical history included hypertension, hysterectomy, carpal tunnel
surgery, window placement in her sinuses, and appendectomy. She was
presently taking Maxzide and reported an allergy to codeine.
She did not smoke or drink alcohol. She did not abuse drugs. Her family
history was significant for RLS in her mother. This was never formally diagnosed,
however. Her physical exam was normal.
The patient was diagnosed with RLS and started on 0.125 mg of
pramipexol at bedtime and an additional 0.125 mg dose as needed during the
day. Her symptoms completely resolved on this regimen.
PROGNOSIS AND COMPLICATIONS
The prognosis is good if the underlying sleep disorder can be effectively treated
and secondary causes of insomnia such as poor sleep hygiene and conditioned
insomnia can be addressed. If the underlying sleep disorder is not effectively treated
or the perpetuating factors are not recognized and treated, then insomnia can persist
or worsen. Complications include hypnotic dependence, ethanol abuse, and persistent
insomnia is a risk factor for depression (40,41).
MANAGEMENT
Effective management requires that the underlying sleep disorder be appropriately
diagnosed and treated. For OSA, general recommendations such as weight
loss if obesity is present and avoidance of CNS depressants at bedtime are made to
all patients. In some patients, apnea may be significant only in the supine position;
in these patients an irritating object such as a tennis ball in a stocking affixed to the
back of a nightgown to promote sleep in the lateral position may be sufficient
therapy. Nasal CPAP remains the gold standard treatment and breathing may be
normalized in most patients, although compliance can be problematic. Patients with
a significant insomnia complaint may find CPAP uncomfortable and it may be difficult
to obtain compliance with therapy. In these patients, time-intensive desensitization
techniques may be helpful. In carefully selected patients, hypnotic
administration to promote CPAP compliance may be appropriate. Surgery on the
upper airway and therapy with an oral prosthesis are other alternative treatments.