Insomnia due to chronic medical conditions

Paula is a 60-year-old lady with a 3 year history of difficulty initiating and maintaining sleep, which is associated with daytime tiredness. Her main medical problems include osteoarthritis and osteoporosis requiring a left knee replacement and stable angina.

She normally goes to bed between 10pm-midnight but it takes her at least 1½ hour to fall asleep. She wakes 2-3 times per night usually with shoulder and lower back pain. Her final wake-up time is about 6am. After that she dozes on and off until 7.30am when she would get up feeling unrefreshed.

Gladys had no history of snoring. She had no history of depression or anxiety. She has some degree of restless legs syndrome at least 2-3 times a week. On occasion she has used some sleeping tablets like temazepam and zolpidem but only with limited success.

In Gladys’s case the difficulty falling asleep and staying asleep seems to be related to at least two issues. One is fragmentation of sleep due to chronic pain because of the osteoporosis and osteoarthritis affecting her shoulder and back. The other is restless legs. Her sleep pattern of falling asleep often after midnight suggests delayed sleep phase.

Gladys was asked to maintain a regular bedtime between 11.30pm-6.30am irrespective of how much sleep she had obtained. She was also asked to avoid napping through the day. She was given Melatonin 3mg to be taken around 9pm and a small amount (5mg) of slow release morphine to take about 10.30 pm (an hour before intended bedtime).

At follow-up 2 weeks later she was happy to report a significant improvement in sleep quality. She continued Melatonin for 4 weeks and her sleep pattern has remained of good quality at the follow-up 6 weeks later.

In this case the problem with Gladys’s sleep quality was related principally to fragmentation of sleep due to chronic pain. We tend to move in bed every 20-30 minutes. Even people who feel they have gone to sleep in one position and wake up in the same position actually do change positions regularly. The presence of a chronic painful condition is a common reason for fragmentation of sleep. Therefore management of the chronic pain is essential to improve the quality of sleep and treat insomnia.

In this case the choice of slow release morphine was geared at reducing the pain due to the osteoarthritis and osteoporosis as well as to the management of restless legs syndrome.

Restless legs syndrome, although in this case mild (only 2-3 times/week), was nevertheless an important issue. Restless leg is characterized by a sensation of creepy crawly feeling in the calves, sometimes in the thigh and even in the arms. The person has a need to move around to relieve the discomfort. In rare cases the trunk and the head can be involved. This can often prevent the person from falling asleep at bedtime. Although there are a variety of medications that can be used for restless leg, including anti-Parkinson medication (Sifrol®,Reprive®), benzodiazepine (Valium™ group kind of medications, like temazepam (Temaze®, Normison®) and Clonazepam (Rivotril®) the use of slow release morphine or similar medications are also very effective. It should be noted that morphine given to a “healthy” adult (in experimental conditions) makes sleep quality worse. Not so when used in people whose sleep is disturbed by chronic pain. In some people pain killers like paracetamol can also be effective.

Because of the degree of delayed sleep phase (falling asleep after midnight) the use of Melatonin at 9pm (about 3 hours before intended bedtime) was also useful for the first 3-4 weeks.

Other medical conditions, which often can cause insomnia include: gastric reflux, poorly controlled asthma, severe emphysema and chronic bronchitis, heart failure, prostate problem and chronic arthritis (e.g. rheumatoid, lupus). It is therefore important that these conditions are well treated and controlled by your family doctors and health professionals.