The pathway for problem focused therapy of sleep problems and insomnia
Opening: listen, take the problem seriously, obtain a history and if necessary perform a physical examination.
Elicit the patients' experience, understanding of their problem and health beliefs.
Frame the problem and its context in a way that both you and the patient are able to agree.
Check whether there are any comorbid disorders and treatable or reversible causes of disturbed sleep. Enquire about recent stress or medical problems, e.g. pain, depression, cardiac or respiratory illness, heartburn, nocturia, thyrotoxicosis; check medications and other agents that may affect sleep, e.g. alcohol, caffeine, nicotine CNS stimulants, diuretics, decongestants, withdrawal of CNS drugs, antidepressants, beta blockers, steroids.
Check for specific sleep disorders:
Periodic limb movement in sleep (PLMS): a condition of repetitive stereotypic leg or arm movements occurring in non-rapid eye movement (non-REM) sleep; PLMS increases with age; limb movements typically occur every 20-40 seconds and can last hours or even much of the night; each movement may be associated with arousal from sleep; refer to sleep clinic.
Restless leg syndrome (RLS): an uncontrollable urge to move the legs at night, usually with difficulty in initiating sleep and often associated with a family history; diagnosis is usually made on the patient's description of their symptoms.
Sleep apnoea: snoring, gasping or breathing stopping during sleep; patients are usually obese, often complain of morning headache and may have a change in personality; their bed partner may describe loud snoring, cessation in breathing, choking sounds during sleep; risk factors include alcohol, dementia, large body mass, age over 65 years and male gender; check for obesity: BM ≥30 or collar size ≥17 inches; patients should be referred to a sleep or respiratory clinic if suspected of having sleep apnoea.
Assess severity using the ISI.
Introduce and explain the sleep diary.
Provide initial advice on sleep hygiene and a patient information leaflet (see under behavioural treatments) depending on the time available and arrange to review the patient in 1-2 weeks with their sleep diary.