Insomnia

Probability diagnosis

Stress and anxiety

Depression

Inappropriate sleep hygiene or lifestyle

Environmental e.g. noisy household

Drug withdrawal inc. alcohol, hypnotics

Biorhythm disruption e.g. shift work, travel

Serious disorders not to be missed

Vascular:

• Peripheral vascular disease

• Congestive cardiac failure

Tumours:

• Pharyngeal

Other:

• Pain syndromes e.g. back, arthritis, CTS, cancer

• Respiratory e.g. asthma, COPD, nasal obstruction

• Post traumatic stress disorder

• Psychosis

• Restless legs/nocturnal myoclonus

Pitfalls (often missed)

Sleep apnoea

GORD

Dementia

Menopausal symptoms

Rarities:

• Macroglossia/tonsillar hypertrophy

• Malnutrition

• Parasomnias e.g. night terrors

• Malnutrition

Masquerades checklist

Depression

Diabetes

Drugs: stimulants, alcohol, beta blockers, SSRIs, steroids

Thyroid/other endocrine: hyperthyroid

Spinal dysfunction

Urinary tract infection: nocturia

Is the patient trying to tell me something?

A consideration if nil findings.

Some cases are normal variant or idiopathic.

Key history

A careful history is required because some patients have unrealistic expectations about the required amount of sleep they need or have misperceptions of how long they have slept. Explore lifestyle factors esp. psychosocial reasons, painful conditions, drug use and abuse, appetite, energy, sexual issues and physical factors. Examine past medical history including diabetes, hypertension and cerebrovascular disease, as well as drug history, esp. alcohol. Check thyroid status, esp. hyperthyroidism.

Key examination

• General features: appearance of patient, vital signs including BMI, inspection of the nasal passages, throat and neck (goitre)

• General respiratory and cardiovascular examination

Key investigations

Nil for most cases. Others according to history and findings.

Consider:

• FBE

• ESR/CRP

• LFTs (γGT)

• TFT

• sleep studies

Diagnostic tips

Pay close attention to drugs use, esp. alcohol, caffeine, narcotics, illicit agents, SSRIs, benzodiazepines, and esp. if desperate request for drugs.

Be aware of the effects of ageing including carpal tunnel syndrome, arthritis, prostate problems and incontinence.