Insomnia is a major health issue in the United States; about 50 million Americans report a sleep disturbance within the past year and 33-40% report insomnia nearly every night [1,2]. It is common among the elderly who use a large percentage of sleep medications and people with mental health or medical disorders, asthma, heart failure, chronic fatigue, pain, and anxiety and those who work nights. Transient insomnia lasts less than a week; short-term insomnia continues from 1-3 weeks, and chronic insomnia (more than 3 weeks) occurs in about 10-15% of cases. Insomnia may be defined as difficulty falling asleep, difficulty maintaining sleep, early morning awakening, or non-restorative sleep. Insomnia creates excess sleepiness which can be hazardous when you drive a car or operate machinery. People self-medicate with over the counter remedies, drugs or alcohol and would benefit from non-pharmacological options and may avoid medications which can be addictive. However, insomnia is rarely reported [3] and so most insomnia remains untreated.

Although most people know what insomnia is, many assume it is normal. Few seek advice from their health care provider and do not know the available non-pharmacological treatments. Whether in a clinical or hospital setting, nurses are in a pivotal position to identify sleep problems, educate patients about interventions, and refer them for follow up. Sleep deprivation impairs the immune system, white blood count, brain function and heart variability [1]. It impacts mood, cognition, and fatigue and delays recovery and healing. Disturbed sleep can also suggest medical or neurological problems that require evaluation (e.g., heart failure, osteoarthritis, Parkinson’s disease) [3,4]. (see Figure 1 case example).

Figure 1:Case example: Vignette of Mrs. J.

The purpose of this article is to review the basic concepts regarding sleep, assessment, management and non-pharmacological treatments. The nurse will have effective approaches to evaluate, educate, and refer people with insomnia and to recommend non-pharmacological treatments (e.g., relaxation, mindfulness, acupressure).

While the specific functions of sleep are debated, it plays an essential role in the health -it is restorative, enhances energy conservation and yet sleep needs vary with age and activity. Sleep is a dynamic process involving brain activity. The functions of sleep impact the brain, immune system, and nerves. Sleep progresses from four stages of Non-Rapid Eye Movement (NREM) that progress to Rapid Eye Movement (REM). In stage 1 or the transitional stage, wakefulness moves to the early stage of sleep (e.g., physiology is altered, peristalsis slows, core body temperature drops and sensory awareness lessens) (Reinoso-Suarez, 2011). Stage 2 is the longest stage and Stages 3-4 are deep restorative sleep. During REM sleep blood pressure and respiratory rates fluctuate and respirations become shallow and dreams can be remembered. REM appears important in memory and potentially sustaining life [5].

A sleep cycle lasts between 1½ to 2 hours as stage 2 and REM increase. The sleep/wake cycle is circadian. As daylight turns to night, melatonin, a natural sedative, is secreted. Aging changes the sleep cycle as time in Stage 3 and REM decrease and stages 1 and 2 increase. The hours of sleep required decrease from 7-8 hours to 6-6 ½ for older adults. Natural remedies that improve sleep include foods with tryptophan, cherry juice, seaweed, kiwi fruit, melatonin and valerian. The DSM V includes diagnoses of insomnia disorder, narcolepsy, breathing related sleep disorders (e.g., apnea and hypoventilation), circadian sleep-wake disorders, REM behavior disorder and restless legs syndrome [2,4].

A Nursing assessment of sleep rests on sleep quality and patterns, medical, substance and psychiatric history. Assessment includes a risk factors and sleep history (e.g., usual sleep patterns, sleep onset and duration, time to fall asleep, frequency of awakenings, and difficulty returning to sleep) (See Case Example in Figure 1). Sometimes if pain, worry, or anxiety are triggering the insomnia, the nurse can recommend some relaxation or improved pain management. Risk factors for insomnia include: traveling, shift work, elderly, pregnancy, menopause, substance abuse, stimulants (e.g., caffeine, nicotine), medications, medical disorders, and pain.

Descriptions of sleep disruptions and self-management strategies are important (e.g., early morning awakening, nightmares, or restlessness). The nurse considers medical or psychological disorders, medications, or behaviors (e.g., snoring, alcohol, sleep apnea) that impair sleep. A sleep history (e.g., sleep schedule, habits, timing, quality, symptoms and sleep duration) assists evaluation. A description of the symptoms during the day and the consequences of insomnia are helpful in identifying precipitants (e.g., daytime sleepiness, fatigue, and irritability). With the assessment, the nurse may be able to resolve the sleep problems with interventions or may work with the health care team to conduct a more thorough assessment for other disorders such as sleep apnea.

Assessment can be improved by using standardized self-report instruments such as an Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Scale that provides objective data of sleep and sleep diaries or logs to track sleep wake patterns and daily variations [6]. The Epworth Sleepiness Scale is a self-report tool that rates daytime sleepiness and the chance of dozing or sleeping on a scale (0-never to 3 high chance) for various experiences: sitting and reading, watching TV, sitting inactive in a public place and 4 other activities). A score of 10 or more is sleepy and should suggest an evaluation or improved sleep hygiene, 18 is very sleepy [7]. The Pittsburgh Sleep Quality Index (PSQI) differentiates older adults’ poor and good sleep by measuring sleep quality, latency, duration, disturbances, medication and daytime dysfunction. It uses a 0 to 3 scale (e=negative extreme) [8]. A sum of 5 or more indicates a poor sleeper. It includes items for a bed partner to complete. The Fatigue Severity Scale is a copyright self-rated measure of how fatigue affects motivation, exercise, physical functioning in various medical and neurologic conditions. It is a 9 item tool measured on a 7 point Likert scale (e.g., I am easily fatigued). A high score indicates agreement with the item. The score is the average of all items. People with depression alone score 4.5 but those with fatigue from a chronic disease average about 6.5.

Educating patients about healthy sleep and nonpharmacological interventions is important. Nurses should promote good sleep habits and offer non-pharmacological or behavioral interventions (e.g., relaxation, CAM, sleep restriction, stimulus control, relaxation) and pharmacology to promote sleep in conjunction with behavioral interventions.

Education on healthy sleep habits is an essential and includes a regular sleep/wake schedule, avoidance of stimulants, alcohol and caffeine 4-6 hours before bedtime, and sleep hygiene. Sleep hygiene includes lowering the core body temperature with a warm bath or socks is useful, reducing exposure to bright light before bedtime, and eliminating daytime naps. Recommendations include minimizing light and noise, maintaining a comfortable room temperature and using the bedroom only for sleep (e.g., removing TVs or computers). Sleep recommendations also include: sleep until you feel rested, exercise regularly 20 minutes/day; avoid stimulants, smoking, hunger before bed, reduce worries, and create a cool environment for sleeping [2]. Cognitive restructuring helps to counter any negative thoughts regarding sleep or sleep restriction. Cognitive behavioral therapy has been effective in 60% – 80% of cases.

Many patients prefer non-pharmacological interventions that may be natural, herbal, or behavioral and often without side effects. They may fear becoming addicted to sleep medications or not tolerate them well.

Resolve barriers to sleep (e.g., symptoms, medications, worry). If symptoms hinder sleep, treat the symptoms (e.g., headache or cough). Next, consider if medications that disrupt sleep can be withdrawn or replaced. If pain interrupts sleep, improve pain management. If noise is a problem (e.g. in hospitals), consider ear plugs or sound machines. Educate the patient about healthy sleep habits, regular exercise, and elimination of alcohol, caffeine and smoking before bedtime. Stress management or relaxation therapy is useful for reducing anxiety (12). Hypnosis tapes or self-hypnosis can improve sleep. Some people find herbal remedies (e.g., chamomile tea, valerian root, and melatonin) and essential oils (lavender) helpful. Others like warm milk and foods containing tryptophan such as peanuts that help them fall asleep. Literature and resources on healthy sleep habits are useful for many patients.

Short term treatment often involves benzodiazepines Zolpidem (Ambien) 10 orally at bedtime and elderly patients typically start at a half dose or Zaleplon (Sonata) 5-10 mg orally at bedtime. Melatonin is produced in the dark hours and may be helpful. Benzodiazepines (e.g. temazepam (Restoril), flurazepam (Dalmane) VERY long acting, triazolam (Halcion), estazolam (ProSom, Eurodin), lorazepam (Ativan), and clonazepam (Klonopin) are commonly prescribed. Short acting benzodiazepines such as Halcion and used with caution as they are addictive. For long term treatment, antihistamines, sedating antidepressants (e.g., trazodone, mirtazapine (Remeron), paroxetine (Paxil) can be useful if the patient is also depressed. These medications are discontinued gradually to avoid rebound insomnia. Clinicians need to be mindful of the potential for tolerance, dependence, and withdrawal with benzodiazepines. If the patient has a history of substance abuse or mental illness, clinicians will be wise to consult with a psychiatrist. The nurse will want to educate patients about when to take the drugs, side effects, and the potential impact on gait and balance particularly for elderly patients. If the symptoms are secondary to a psychiatric disorder (e.g., mood disorder or anxiety) nurses can refer to a psychiatrist or advanced practice psychiatric nurse. Patients with sleep apnea (e.g. heavy snoring) require referral to a sleep specialist. Antihistamines are not usually helpful for long term treatment as people develop tolerance or have side effects drug.

Follow up appointments should be weekly for short term problems to monitor treatment effectiveness, compliance and tolerance potential. Side effects of these drugs require monitoring to see if the patient experiences any dizziness, impaired balance, fall risk, confusion, or other symptoms. Elderly patients should take these drugs starting at a half dose and before bedtime to avoid excessive daytime sleepiness. Fall risk is important so discuss this thoroughly and have the patient discontinue the drug if gait or balance is impaired.

If the insomnia occurs for longer than a month, consider consultation or referral. Nurses are well positioned to educate patients about healthy sleep habits and to recommend non-pharmacological strategies. In many clinical settings patients report difficulty sleeping and the nurse can help them improve sleep hygiene and understand the various treatments available. Untreated insomnia can lead to chronic fatigue or decreased activity and unmanaged sleep apnea can be fatal. Nurses can use the information about sleep hygiene and insomnia treatments to help their patients and themselves improve the quality of sleep.

Insomnia is a common problem for many Americans and can range from a brief to chronic disorder. It is a common problem for shift workers, travelers, and those with pain and anxiety. While many people self-medicate their insomnia with OTC pills, they need evaluation for medical or mental health causes of the problem and education about sleep hygiene and other non-pharmacological treatments available. Nurses who detect insomnia can evaluate the symptoms, educate the person about sleep hygiene and non-pharmacological treatments and refer the patient for further evaluation and management. Without treatment, insomnia can impair the quality of life and pose dangers if the person drives or operates machinery. Encouraging patients to try mindfulness or other complimentary therapies as well as CBT and sleep hygiene is helpful.