Managing Insomnia in the 21st Century

Alon Avidan, MD, MPH, Director, UCLA Sleep Disorders Center Professor, UCLA Department of Neurology David Geffen School of Medicine at UCLA, highlighted recent research on the management of insomnia disorder with case examples during a virtual presentation at Neurology Week.

“Insomnia is very common and it’s also under diagnosed, and patients can benefit from both behavioral as well as pharmacologic therapy,” explained Dr Avidan.

Approximately 25 million adults in the US have chronic insomnia, with an assumed 10% prevalence of chronic or occasional insomnia that has increased during the COVID-19 pandemic.

Available research shows the recommended hours of sleep per night for adults aged 18 and older is 7 to 8 hours daily, excluding naps.

Dr Avidan defined insomnia as difficulties falling asleep, maintaining sleep, and early morning awakenings despite adequate opportunity for sleep. He also explained the impact on functioning. The disorder causes next-day consequences effecting quality of life such as pain, depression, memory loss, cognitive problems, problems with maintaining work and social relationships, and more.

Data shows there has been an overall increase in the rate of morbidity and mortality for patients with chronic insomnia, which is associated with higher C-reactive protein, signaling inflammation.

While untreated persistent chronic insomnia over 1 to 2 decades can potentially impact survival rates, there is not a lot of available data about the overall health effect on patients with insomnia over one year, specifically those who began showing insomnia symptoms during lockdowns for the pandemic.

Dr Avidan went on to share scenarios from six of his patients. One of these patients was recently unemployed, with a history of anxiety and insomnia, and worries about financial matters were keeping him up at night. This individual wondered what could have caused his recent insomnia and how to prevent it.

Dr Avidan broke down the Spielman 3 P Model for insomnia, which identifies the causes of insomnia by 3 categories: predisposing factors, including genetic and personality traits; precipitating factors, including triggers such as stress; and perpetuating factors, including poor sleep hygiene.

The presentation suggested precipitating factors, including unemployment, divorce, grief, COVID-19 related hospitalizations, and other pandemic related stressors, could be a cause for the recent increase in cases of insomnia.

Steps to addressing insomnia include discussing patients sleep habits; establishing diagnosis; providing education; prescription, hypnotic, cognitive and behavioral therapy; and referral to a sleep specialist if there is treatment failure.

“I hope that my anecdotes were helpful in your appreciation of what's available and how we approach chronic insomnia,” Dr Avidan concluded.

—Erin McGuinness

Avidan, A. Challenging Cases: New Paradigms in the Management of Insomnia in the 21st Century. Presented at Neurology Week 2021; July 14-18. Virtual.