Insomnia Insomnia
Insomnia Insomnia
Insomnia Insomnia
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42 Attarian<br />
15 to 40 seconds. PLMs are not considered abnormal unless they lead to severe<br />
sleep disturbance or excessive daytime sleepiness, or both, in which case they form<br />
a separate intrinsic sleep disorder, PLMD (10). RLS can be easily differentiated<br />
from primary insomnias by history due to the characteristic symptoms with which<br />
it presents. <strong>Insomnia</strong> as a result of PLMD may require the aid of a polysomnogram<br />
(PSG; see later) to make the correct diagnosis.<br />
Other Sleep Disorders<br />
Occasionally, insomnia is the presenting complaint in obstructive sleep apnea<br />
(OSA) syndrome. In a group of older adults with insomnia, a respiratory disturbance<br />
index (RDI) of at least 15 per hour was found in 29% of patients (17). In<br />
another study of a large group of patients with insomnia, RDI of at least 30 per hour<br />
was found in 2.3% of patients vs 1.3% of controls (18). The presence of excessive daytime<br />
sleepiness, snoring, and observed apneas raises the possibility of OSA syndrome.<br />
In circadian rhythm abnormalities, patients sleep well but not at socially acceptable<br />
times (5). Those with the advanced sleep-phase syndrome have excessive<br />
sleepiness in the evening and undesired early morning awakening. Those with the<br />
delayed sleep-phase syndrome have sleep-onset insomnia, excessive daytime<br />
sleepiness (particularly in the morning), or both. Other circadian rhythm abnormalities<br />
presenting with a variety of insomnia symptoms include irregular sleep–<br />
wake cycle, non-24-hour sleep–wake syndrome and sleep disturbances in blind<br />
individuals, and those resulting from social circumstances: jet lag and shift-work<br />
sleep disorder (19). Having patients fill out sleep diaries or sleep logs during a 1- or<br />
2-week period when they are free of social restrictions of their bedtime and wake<br />
time (going to bed whenever they are sleepy and getting up on their own without an<br />
alarm) helps make the diagnosis of circadian rhythm abnormalities.<br />
Occasionally, narcolepsy presents as insomnia because 50% of patients with<br />
narcolepsy have disrupted sleep at night (20,21). Again, excessive daytime sleepiness<br />
and ancillary symptomatology (sleep paralysis, hypnic hallucinations, and<br />
cataplexy) differentiate insomnia resulting from narcolepsy from the primary<br />
insomnias.<br />
Neurologic and Medical Conditions<br />
Conditions that can cause insomnia, among other symptoms, include neurodegenerative<br />
diseases (22), pain, allergies (23), gastroesophageal reflux (24), and<br />
asthma (25). All of these can be easily differentiated from primary insomnias by<br />
history and physical exam.<br />
Menopause-Related <strong>Insomnia</strong><br />
There is a high level of sleep disturbance occurring in about 42% of middle-aged<br />
women (26). Although cross-sectional analyses indicate that sleep disturbance may<br />
be independent of menopausal status, transition into postmenopausal status is associated<br />
with deleterious changes in sleep among women not receiving hormone<br />
replacement therapy (26,27).