Screening Procedures for Insomnia In Primary Care Practice

The most common sleep complaint seen in primary care practice is insomnia.1 Although 70% of patients do not report sleep problems to their doctor, of those who do, insomnia ranks higher than any other sleep concern.  Defined as any of the following: difficulty initiating sleep (sleep onset), staying asleep (sleep maintenance), waking up much before normal rising time (early morning awakening) or non-restorative sleep, accompanied by reduced daytime functioning in the form of lowered alertness, energy level, or cognitive function,2 insomnia is a major health concern3-4 and  a vital pathway for the primary care physician. 5-6

Since patients rarely present for treatment of a sleep condition as their primary concern, asking the patient about their sleep takes on greater importance.  How to distinguish one sleep complaint from another in a limited-time exam, where the patient is presenting with another complaint is a challenging task.  An ideal diagnostic tool, if time were less limited, would be a complete sleep history, with screening for the psychiatric conditions, most often anxiety and depression, which are common co-morbid conditions with insomnia and for substance abuse.  Screening tools play an increasingly important role in directing the physician where to look for areas of further exploration.

Attached to this summary are some quick screening measures that can be used in primary care practice that are both part of an initial assessment and referral and the foundation of an ongoing, skilled sleep medicine exam.  These three questionnaires are known to differentiate insomnia patients from a normal sleeping population, and from those with other sleep disorders.
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The Epworth Sleepiness Scale7, easily administered and completed, evaluates the degree of patient sleepiness in varying situations where wakefulness would be expected and when the patient would be at rest. Sleepiness is more a hallmark of sleep apnea, while fatigue is more characteristic of insomnia.  Screening tests useful to evaluate the fatigue that characterizes insomnia are the Insomnia Severity Index10 and the Sleep Disorders Questionnaire8. The Pittsburg Sleep Quality Index9 is more often used for research.

References

1.  National Sleep Foundation. Summary of Findings: 2005. Sleep in America Poll. March, 2005.  http://www.sleepfoundation.org.
2.  American Sleep Disorders Association.  International Classification of Sleep Disorders, Revised:  Diagnostic and coding manuals.  Rochester, MN: American Sleep Disorders Association, 1997.
3.  Gallup Organization.  Sleep in America.  Princeton, N.J.: Gallup Organization, 1995.
4.  Partinen, M.  Epidemiology of Sleep Disorders.  In: Kryger, M.H., Roth, T. and Dement, W.C., eds.  Principles and Practice of Sleep Medicine.  Philadelphia:  W.B. Saunders Company, 1994.
5.  Culpepper, L., Doghramji, P., Kornstein, S., and Roth, T.  The Art of Sleep: Recognizing and treating insomnia in primary care practice.  Supplement to the J. Fam. Practice, 2008, April, S1-S11.
6.  Shochat, T., Umphress, J.,  Israel, A.G.,  and Ancoli-Israel, S. Insomnia in primary care patients.  Sleep, 1999; 22(Supplement 2): S366-S372.
7.  Johns, M.  A New Method for Measuring Daytime Sleepiness:  The Epworth Sleepiness Scale  17(2): 160-167.e. Sleep. 1991: 14(6): 331-338.
8.  Douglass. A/. Bornstein, R., Nino-Murcia, G. et al.  The Sleep Disorders Questionnaire I:  Creation and Multivariate Structure of SDQ.  Sleep, 1994;
9.  Buysse, D.J., Reynolds, C.F., Monk, R.H. Berman, S.R. and Kupfer, D.J. (1989) The Pittsburg Sleep Quality Index (PQSI): A new instrument for psychiatric research and practice.  Psychiatry Research, 28(2), 193-213.
10. Bastien, Celyne H., Vallieres, Annie and Morin, Charles M. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine. 2001:2:4,429-307.

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