Insomnia and non-restorative sleep

Mrs. Kim is a 55 years old with a history of difficulty initiating and maintaining sleep starting in her mid twenties. She works full time in a local health service. She is happily married with a 34 years old son. She has no significant problems at home. The work environment is somewhat stressful but nothing is of a major concern. She is the eldest of four siblings and she describes her upbringing in very positive terms. The husband has often been away working and when she has been by herself the difficulty initiating and maintaining sleep has been more difficult than at other times.

She normally goes to bed around 10pm but it can take up to 1 hour to fall asleep. She can wake up through the night, but not every night. There is no history of snoring or restless leg syndrome. She normally gets up at 5am to go walking with friends, otherwise she gets up between 6.30-7am and she feels constantly unrefreshed.

Robyn was not anxious or depressed. She had a normal examination and a low probability of psychological distress on the K10 scale (Kessler Psychological Distress Scale, see Appendix).

The possibility of psycho-physiological insomnia (a learned pattern of poor sleep over a long period) was considered. She was on a beta-blocker (a medication used for the treatment of hypertension which tends to suppress Melatonin). We discussed the strategy of restriction of time in bed and the use of Melatonin. This was implemented over a period of 6 weeks but Mrs. Robyn had no significant benefit from this strategy.

At that stage an overnight sleep study at home was carried out. The sleep study showed the Mrs. Robyn fell asleep within 9 minutes of turning the lights out. She slept for 6 hours 40 minutes out of 7 hours in bed. There was no snoring and no sleep apnoea. When she woke in the morning, however, she felt unrefreshed and felt tired during the day, as she has been complaining for a long time.

After discussion with Mrs. Robyn treatment with zolpidem (Stilnox®) slow release 6.25mg about half an hour before going to bed was implemented with much improved sleep quality and sense of good sleep in the morning. Treatment was continued for about 3 weeks and then the medication was reduced to once every second day maintaining significant benefits in terms of her perception of sleep.

This is not an uncommon situation where, although sleep study would suggest a fair amount sleep, the person’ perception is one of poor sleep quality overall or non-restorative sleep. In this situation the use of sleeping tablets may be beneficial in some patients like in Mrs. Robyn’s case and the intermittent use of a sleeping tablet (see table 2 page 00) seems to be appropriate in improving the person’s quality of sleep.

Non-restorative sleep is considered a particular form of insomnia where a person’s main complaint is not so much difficulty initiating sleep and /or staying asleep but rather a sensation of not feeling refreshed on waking up even when the amount of sleep seems adequate. In non-restorative sleep overnight sleep study is often unremarkable. Assessment of other medical problems such as iron, vitamin deficiency or celiac disease (intolerance to gluten) should be undertaken. Eventually once medical and other sleep disorders are excluded, treatment with sleep promoting medications can be tried.