Practice Parameters for the Evaluation of Chronic Insomnia

PRACTICE PARAMETERS FOR THE EVALUATION OF CHRONIC INSOMNIA
Practice Parameters for the Evaluation of Chronic Insomnia
An American Academy of Sleep Medicine Report
Standards of Practice Committee of the American Academy of Sleep Medicine
Andrew Chesson, Jr.,1 Kristyna Hartse,2 W. McDowell Anderson,3 David Davila,4 Stephen Johnson,5 Michael Littner,6 Merrill Wise,7 Jose
Rafecas8
1Neurology Department, Louisiana State University Medical Center, Shreveport, LA, 2Sleep Consultants, Fort Worth, TX,
3College of Medicine, University of South Florida, Tampa, FL, 4Baptist Medical Center, Little Rock, AR, 5St. Patrick
Hospital Sleep Center, Missoula, MT, 6Department of Medicine, VA Medical Center, Sepulveda, CA, 7Departments of
Pediatrics and Neurology, Baylor College of Medicine, Houston, TX, 8Sleep Disorders Center of Ohio, Green, Ohio
Summary: Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia
patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement
concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common
basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No sys-
tematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommen-
dations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of
these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing
this care can benefit from their use.
Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia.
Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily func-
tioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history
focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep
Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint
of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep
apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evi-
dence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds
are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom
checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments
have not been shown to differentiate subtypes of insomnia complaints.
Key words: Practice parameters; Sleep disorders; Insomnia; Sleep disturbance
BACKGROUND
as well as social impact,6-9 it continues to be underdiag-
nosed and poorly understood by both patients and physi-
INSOMNIA IS A COMPLAINT OF POOR QUALITY
cians alike.10-13
SLEEP that is often associated with daytime sequelae
It is widely recognized that there are a number of condi-
including fatigue, irritability, decreased memory and con-
tions which are associated with insomnia including specif-
centration, and pervasive malaise which affects many
ic sleep disorders, medical and psychiatric illness, and psy-
aspects of daytime functioning. The frequency of insomnia
chological stressors such as anxiety.14-16
The first step
complaints is high, and there is an abundance of epidemio-
toward effective treatment of insomnia is an initial assess-
logical data that suggest it is the most common sleep com-
ment with establishment of a differential diagnostic list.
plaint in the industrialized world.1-5 However, despite the
Determining the etiology of insomnia is complicated not
high frequency of this problem and the negative economic
only by the absence of clear assessment guidelines, but also
by the multidimensional characteristics of this problem
which necessitates a broad awareness of multiple potential
Accepted for publication December 1999
etiologies. Moreover, there are virtually no data available
Correspondence: Standards of Practice Committee, American Academy of
which have systematically evaluated the impact of medical
Sleep Medicine, 6301 Bandel Road, Suite 101, Rochester MN 55901, Phone:
507.287.6006, Fax: 507.287.6008, Email: aasm@aasmnet.org
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and psychological assessment in terms of diagnostic valid-
AASM practice parameters. When scientific data are
ity and treatment outcomes. Although strategies may have
insufficient or inconclusive, this is identified and consensus
been developed which a clinician believes are effective
opinion may be used to support the available evidence.
tools for assessment, these strategies are often anecdotally
Recommendation grades and evidence levels are identified
based, without an evidence-based rationale.17 Thus, it is
for each practice parameter.
not surprising that chronic insomnia is often ineffectively
The Board of Directors of the American Academy of
treated.
Sleep Medicine approved these recommendations. All
The purpose of this practice parameter paper is to pre-
members of the American Academy of Sleep Medicine
sent recommendations, based upon the accompanying
Standards of Practice Committee and Board of Directors
review paper,18 for the clinical assessment of patients com-
completed detailed conflict-of-interest statements and were
plaining of insomnia. The intent here is not to present treat-
found to have no conflicts of interest with regard to this
ment options directly, but rather to present the evidence for
subject.
the clinical assessment of insomnia which, however, may
These practice parameters define principles of practice
affect diagnosis and treatment decisions. Polysomno-
that should meet the needs of most patients in most situa-
graphic evaluation of insomnia has been addressed in a pre-
tions. These guidelines should not, however, be considered
vious practice parameter paper which is available for guid-
inclusive of all proper methods of care or exclusive of other
ance.19
Nonpharmacological treatment of insomnia has
methods of care reasonably directed to obtaining the same
also been addressed in a recent practice parameters paper.20
results. The ultimate judgement regarding propriety of any
specific care must be made by the physician in light of the
METHODS
individual circumstances presented by the patient and the
available diagnostic and treatment options and resources.
Based on the referenced review18 and accompanying
The American Academy of Sleep Medicine expects
text, the Standards of Practice Committee of the American
these guidelines to have an impact on professional behav-
Academy of Sleep Medicine, in conjunction with special-
ior, patient outcomes, and, possibly, health care costs.
ists and other interested parties, developed recommenda-
These practice parameters reflect the state of knowledge at
tions included in this paper. In most cases the conclusions
publication and will be reviewed, updated, and revised as
are based on evidence from controlled studies that were
new information becomes available. This position paper is
published in peer reviewed journals. Because of an over-
referenced by square-bracketed numbers to the relevant
lap with other topics, references are also made to prior
TABLE 1—AASM Classification of Evidence
Recommendation
Evidence
Study
Grades
Levels
Design
A
I
Randomized well-designed trials with low-alpha & low-beta errors*
B
II
Randomized trials with high-beta errors*
C
III
Nonrandomized controlled or concurrent cohort studies
C
IV
Nonrandomized historical cohort studies
C
V
Case series
ADAPTED FROM SACKETT21
*Alpha error refers to the probability (generally set at 95% or greater) that a significant result (e.g., p<0.05) is the correct conclusion of
the study or studies. Beta error refers to the probability (generally set at 80% or 90% or greater) that a nonsignificant result (e.g., p>0.05)
is the correct conclusion of the study or studies. The estimation of beta error is generally the result of a power analysis. The power
analysis includes a sample size analysis which projects the size of the study population necessary to ensure that significant differences
will be observed if actually present.
TABLE 2—AASM Levels of Recommendations
Term
Definition
Standard
This is a generally accepted patient-care strategy which reflects a high degree of clinical certainty. The term
standard generally implies the use of Level I Evidence, which directly addresses the clinical issue, or over-
whelming Level II Evidence.
Guideline
This is a patient-care strategy which reflects a moderate degree of clinical certainty. The term guideline
implies the use of Level II Evidence or a consensus of Level III Evidence
Option
This is a patient-care strategy which reflects uncertain clinical use. The term option implies either inconclu-
sive or conflicting evidence or conflicting expert opinion.
ADAPTED FROM EDDY22
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sections and tables in the accompanying background
enings often associated with depression may be the result
paper.18 Other citations are noted in parentheses and refer
of sleep apnea occurring during REM sleep in the early
to the reference list at the end of this paper. The Standards
morning hours. The glossary of the accompanying review
of Practice Committee's assessments of the levels of evi-
paper references several disorders producing insomnia sec-
dence for each of the evidentiary articles, which are used to
ondary to medical and neurological diseases for which a
support the strength of the recommendations in this paper,
physical examination and medical evaluation have diag-
are recorded in the evidence tables in the background paper
nostic importance.18 Knowledge about sleep symptoms will
[Tables 1, 4, 5, 6, 7, 8, 10, and 11].
impact decisions for further assessment and treatment. The
following elements should be included in the sleep history
RECOMMENDATIONS
or considered with reference to examination findings in
order to help differentiate between a primary and a sec-
The classification for evidence was adapted from the
ondary diagnosis of insomnia.
suggestions of Sackett (Table 1). Recommendations are
Symptoms of heightened arousal.
Hyperarousal and
given as standards, guidelines and options, as defined in
hyperreactivity to stressors are common characteristics of
Table 2. Unless otherwise specified, the recommendations
insomniac patients. Recent studies have, in fact, demon-
in this paper are supported by Level II to Level V evidence.
strated an increased metabolic rate in insomniacs, suggest-
ing a strong physiological component to the complaint of
1. The healthcare practitioner should screen patients
difficulty with sleep.29
for symptoms of insomnia during health examinations.
Symptoms or a history of depression, anxiety, obsessive
[1.0, 3.2, 3.4, 7.2, Table 2] (Standard)
compulsive disorder, or other major psychological symp-
Assessment of sleep quality is often overlooked during
tomatology.
These psychological disorders are usually
routine health evaluations, and patients themselves may be
readily diagnosed by their distinctive symptom profiles.
reluctant to raise the issue of poor sleep quality.
There is a high prevalence of psychiatric disorders in
Furthermore, both the practitioner and the patient may min-
patients presenting with insomnia.14
imize the impact of poor sleep upon work performance, the
Symptoms of restless legs syndrome (RLS) and periodic
risk of serious accidents, and psychological well being. By
limb movement disorder (PLMD). Both of these conditions
including an assessment of sleep problems as part of gen-
are prevalent in patients with insomnia complaints and may
eral health screening, the treatment and prevention of med-
be the presenting complaint for further underlying medical
ical and psychiatric causes for poor sleep can be integrated
or neurologic problems (such as iron deficiency,
into an overall plan of patient care.23
Parkinsonism, peripheral neuropathy).30,31
There are certain populations, including the elderly and
Sleep/wake schedule disorders.
These disorders are
women, which may be at heightened risk for the develop-
identified by patient history and by several weeks of sleep
ment of insomnia complaints.2,24,25 The healthcare profes-
logs kept by the patient at home.32
sional must systematically implement evaluation proce-
Snoring and other symptoms of sleep apnea. Although
dures aimed at diagnosing specific medical, neurologic and
patients who have symptoms of sleep apnea may report
psychologic disorders in these populations. Pregnancy,
excessive daytime sleepiness, interrupted nighttime sleep is
depression, medication use, and an increase in the inci-
frequently perceived as the etiology of the excessive sleepi-
dence of sleep apnea and periodic limb movements with
ness during the day and may be a primary complaint.33
aging are all additional risk factors in the development of
Symptoms or a history of drug or alcohol abuse. Drug
insomnia complaints.14,26-28
and alcohol use can have long lasting effects upon sleep
quality, and a detailed history of current and past usage is
2. An in-depth sleep history is essential in identifying
essential.34
the cause of insomnia. Additionally, a physical exami-
Current medication use. A complete history of prescrip-
nation is an important element in the evaluation of
tion and over-the-counter medication use should be
insomnia patients with medical symptoms. [4.1, 4.2, 4.5,
obtained to determine if medications may be contributing
4.8, 5.0, 5.1, Table 3, Table 11, Glossary] (Standard)
to the patient's current insomnia complaints.35
As the medical history is vital for most patient com-
plaints of illness, the sleep history is fundamental to initial
3. Polysomnography is not indicated for the routine
assessment of the insomnia complaint and in specific cases
evaluation of chronic insomnia. However, symptoms of
may be the primary diagnostic tool. The practitioner must
insomnia do not exclude polysomnographic evaluation
have a working knowledge of the signs and symptoms of
in assessing the complaint. There should be a valid indi-
the spectrum of sleep disorders since these may contribute
cation and a clear rationale, based upon specific ele-
to the insomnia complaint. For example, awakenings with
ments of the history, to support use of polysomno-
breathlessness in sleep apnea syndrome may present as
graphic evaluation. [4.2, 6.1] (Standard)
nocturnal panic attacks, or conversely early morning awak-
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The practitioner may be unable to determine a specific
This recommendation is based upon the limited amounts
cause for insomnia if signs and symptoms of another sleep
of satisfactory evidence addressing these techniques with
disorder are present. Patients complaining of difficulty
specific regard to insomnia. There is a high prevalence of
with sleep and who have other symptoms of specific sleep
insomnia complaints in the general population, and it is
disorders such as sleep apnea, periodic limb movements,
almost certainly the case that a very large number of
narcolepsy or violent behaviors during sleep are likely to
patients require evaluation beyond an initial clinical
require polysomnographic assessment.33
assessment. Therefore, the development of alternative
means of assessment is desirable. However, the effective-
4. Instruments which are helpful in the evaluation and
ness of these currently identified alternative assessment
differential diagnosis of insomnia include self-adminis-
devices has not been systematically evaluated and further
tered questionnaires, at-home sleep logs, symptom
assessment of these and other evaluation techniques are
checklists, psychological screening tests, and bedpart-
needed.39
ner interviews. [4.3, 4.4.1, 4.6, Tables 7, 8. 9]
(Guideline)
This recommendation is based upon level II-V evidence,
SUGGESTIONS FOR FURTHER RESEARCH
although applicability to individual patients may be vari-
Virtually no systematic data are available which corre-
able among these different tools. These instruments can
late evaluation procedures for insomnia with outcomes of
provide clinically useful information in the initial assess-
therapy. Well designed studies which focus on the best
ment of the complaint, particularly as it relates to the
methods of eliciting a comprehensive sleep history, the
patient's perception of the problem. Clinical practice indi-
contribution of psychological screening to the diagnosis,
cates that these measures can be used to guide and enhance
and the development of testing procedures as alternatives
the sleep and medical histories taken by the clinician. A
to formal polysomnography are needed. Insomnia is a per-
limited number of these instruments, including the Epworth
vasive problem with potentially far reaching social and
Sleepiness Scale36 and the Sleep Disorders Questionnaire37
economic consequences, and the absence of these data may
differentiate insomnia patients from normal populations
not allow the clinician to implement the most judicious and
and other patients with sleep disorders. However, there is
cost effective choices in the assessment of the insomnia
little data to indicate that questionnaires are able to dis-
complaint. Although effective management of insomnia is
criminate between different causes for insomnia, although
ultimately the desired goal, treatment is dependent upon
these instruments may be able to differentiate insomniacs
effective evaluation. Indeed, there is evidence to suggest
from normal patients. An additional potential function of
that the early detection of insomnia may present an oppor-
these tools is to assess the effectiveness of treatment inter-
tunity for intervention to circumvent later development of
vention.
depression.40
Similar potential for early intervention to
prevent or limit the development of other medical and psy-
5. The multiple sleep latency test (MSLT) is not rou-
chiatric disease processes may also exist. The emphasis on
tinely indicated for the evaluation of insomnia. [4.4.1,
outcomes of insomnia evaluation procedures will add sig-
4.4.2] (Guideline)
nificantly to better treatment of the insomnia patient and
These recommendations are based upon level II-IV evi-
thus may reduce health care costs in several areas.
dence, as well as prior guidelines. Although nighttime
symptoms are of significance, often the major complaints
REFERENCES
of insomnia patients are daytime tiredness, lethargy and
fatigue. These and other symptoms may raise the question
1.
Ancoli-Israel, S. and Roth, T. Characteristics of insomnia in the
of the diagnosis of narcolepsy. Most often, a history of the
United States: Results of the 1991 National Sleep Foundation Survey.
combined day- and nighttime symptoms is sufficient to
Sleep, 1999; 22(Supplement 2):S347-S353.
2.
Gallup Organization. Sleep in America. Princeton NJ: Gallup
judge whether insomnia is the primary problem, and a
Organization, 1995.
treatment response may help clarify the differential diagno-
3.
Lugaresi, E., Cirignotta, F., and et al. An epidemiological survey of
sis. An MSLT may be indicated, however, if there is a need
the San Marino population. In: Guilleminault, C. and Lugaresi, E., eds.
to objectively assess the presence and degree of daytime
Sleep/wake disorders: Natural history, epidemiology, and long-term evo-
lution. New York: Raven Press, 1983:1-12.
sleepiness in accordance with previous practice parameter
4.
Partinen, M. Epidemiology of sleep disorders. In: Kryger, M.H.,
papers.33,38
Roth, T., and Dement, W.C., eds. Principles and Practice of Sleep
Medicine. Philadelphia: W. B. Saunders Company, 1994.
6. There is insufficient evidence to make recommenda-
5.
Weissman, N.M., Greenwald, S., Nino-Murcia, G., and Dement,
tions about the diagnostic role, effectiveness or reliabil-
W.C. The morbidity of insomnia uncomplicated by psychiatric disor-
ders. Gen Hosp Psychiatry, 1997; 19:245-250.
ity of portable sleep studies, actigraphy, & static charge
6.
Zammit, G.K., Weiner, J., Damato, N., Sillup, G.P., and McMillan,
sensitive beds in the assessment of insomnia. [6.2]
C.A. Quality of life in people with insomnia. Sleep, 1999;
SLEEP, Vol. 23, No. 2, 2000
4
Practice Parameters for the Evaluation of Chronic Insomnia—Chesson et al

---

22(Supplement 2):S379-S385.
31. Standards of Practice Committee of the American Academy of
7.
Walsh, J.K. and Engelhardt, C.L. The direct economic costs of
Sleep Medicine. Practice parameters for the treatment of restless legs
insomnia in the United States for 1995. Sleep, 1999; 22(Supplement
syndrome and periodic limb movement disorder. Sleep, 1999;
2):S386-S393.
22(7):961-968.
8.
Leger, D., Levy, E., and Paillard, M. The direct costs of insomnia
32. Standards of Practice Committee of the American Academy of
in France. Sleep, 1999; 22(Supplement 2):S394-S401.
Sleep Medicine. Practice parameters for the use of light therapy in the
9.
Stoller, M.K. Economic effects of insomnia. Clin Ther, 1994;
treatment of sleep disorders. Sleep, 1999; 22:641-660.
16:873-997.
33. Chesson, A.L., Ferber, R.A., Fry, J.M., et al. The indications for
10. Everitt, D.E. and Avorn, J. Clinical decision-making in the evalua-
polysomnography and related procedures. Sleep, 1997; 20:423-485.
tion and treatment of insomnia. Amer J Med, 1990; 89:357-362.
34. Gillin, J.C. Sleep and psychoactive drugs of abuse and depen-
11. Hohagan, F., Rink, K., Kappler, C., et al. Prevalence and treatment
dence. In: Kryger, M.H., Roth, T., and Dement, W.C., eds. Principles
of insomnia in general practice. A longitudinal study. Eur Arch
and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company,
Psychiatry Clin Neurosci, 1993; 242:329-336.
1994:934-942.
12. Haponik, E.F. Sleep disturbances of older persons: Physicians' atti-
35. Hauri, P.J. Consulting about insomnia: A method and some pre-
tudes. Sleep, 1992; 15:168-172.
liminary data. Sleep, 1993; 16:344-350.
13. Jacobs, E.A., Reynolds, C.F., Kupfer, D.J., Lovin, P.A., and
36. Johns, M. A New Method for Measuring Daytime Sleepiness: The
Ehrenpreis, A.B. The role of polysomnography in the differential diag-
Epworth Sleepiness Scale. Sleep, 1991; 14(6):331-338.
nosis of chronic insomnia. Am J Psychiatry, 1988; 145:346-349.
37. Douglass, A., Bornstein, R., Nino-Murcia, G., et al. The Sleep
14. Benca, R.M., Obermeyer, W.H., Thisted, R.A., and Gillin, J.C.
Disorders Questionnaire I: Creation and Multivariate Structure of SDQ.
Sleep and psychiatric disorders: A meta-analysis. Arch Gen Psychiatry,
Sleep, 1994; 17(2):160-167.
1992; 49:651-668.
38. American Sleep Disorders Association. The clinical use of the mul-
15. Moran, M.G. and Stoudemire, A. Sleep disorders in the medically
tiple sleep latency test. Sleep, 1992; 15:268-276.
ill patient. J Clin Psychiatry, 1992; 53:29-36.
39. American Sleep Disorders Association. Practice parameters for the
16. Nino-Murcia, G. Diagnosis and treatment of insomnia and risks
use of actigraphy in the clinical assessment of sleep disorders. Sleep,
associated with lack of treatment. J Clin Psychiatry, 1992; 53:43-49.
1995; 18:285-287.
17. National Center on Sleep Disorders Research, National Heart Lung
40. Ford, D.E. and Kamerow, M.D. Epidemiologic study of sleep dis-
and Blood Institute, and National Institutes of Health. Insomnia:
turbances and psychiatric disorders. An opportunity for prevention?
Assessment and management in primary care. Sleep, 1999;
JAMA, 1989; 262:1479-1484.
22(Supplement 2):S402-S408.
18. Sateia, M., Doghramji, K., Hauri, P., and Morin, C. Evaluation of
chronic insomnia. Sleep, 2000; 23:In Press.
19. Standards of Practice Committee of the American Sleep Disorders
Association. Practice parameters for the use of polysomnography in the
evaluation of insomnia. Sleep, 1995; 18:55-57.
20. Standards of Practice Committee of the American Academy of
Sleep Medicine. Practice parameters for the nonpharmacologic treat-
ment of chronic insomnia. Sleep, 1999; 22(8):1128-1133.
21. Sackett, D. Rules of evidence and clinical recommendation. Can J
Cardiol, 1993; 9:487-489.
22. Eddy, D.M. A Manual for Assessing Health Practices and
Designing Practice Policies: The Explicit Approach. Philadelphia:
American College of Physicians, 1992.
23. Shochat, T., Umphress, J., Israel, A.G., and Ancoli-Israel, S.
Insomnia in primary care patients. Sleep, 1999; 22(Supplement 2):S366-
S372.
24. Foley, D.J., Monjan, A.A., Simonsick, E.M., Wallace, R.B., and
Blazer, D.G. Incidence and remission of insomnia among elderly adults:
An epidemiologic study of 6,800 persons over three years. Sleep, 1999;
22(Supplement 2):S366-S372.
25. Foley, D.J., Monjan, A.A., Izmirlian, G., Hays, J.C., and Blazer,
D.G. Incidence and remission of insomnia among elderly adults in a
biracial cohort. Sleep, 1999; 22(Supplement 2):S373-S378.
26. Quera-Salva, M.A., Orluc, A., Goldenberg, F., and Guilleminault,
C. Insomnia and use of hypnotics: Study of a French population. Sleep,
1991; 14:386-391.
27. Ancoli-Israel, S., Kripke, D.F., Klauber, M.R., Mason, W.J., Fell,
R., and Kaplan, O. Sleep-disordered breathing in community-dwelling
elderly. Sleep, 1991; 14:486-495.
28. Ancoli-Israel, S., Kripke, D.F., Klauber, M.R., Mason, W.J., Fell,
R., and Kaplan, O. Periodic limb movements in sleep in community-
dwelling elderly. Sleep, 1991; 14:496-500.
29. Bonnet, M.H. and Arand, D.L. 24-Hour metabolic rate in insomni-
acs and matched normal sleepers. Sleep, 1995; 18(7):581-8.
30. Hening, W., Allen, R., Earley, C., Kushida, C., Picchietti, D., and
Silber, M. The treatment of restless legs syndrome and periodic limb
movement disorder. Sleep, 1999; 22(7):970-999.
SLEEP, Vol. 23, No. 2, 2000
5
Practice Parameters for the Evaluation of Chronic Insomnia—Chesson et al

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