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Unformatted text preview: 216 JAMC 25 JANV. 2000; 162 (2) 2000 Canadian Medical Association or its licensors Review Synthse From the Centre for Evaluation of Medicines, St. Josephs Hospital and McMaster University, Hamilton, Ont. This article has been peer reviewed. CMAJ 2000;162(2):21620 See related article page 225 Abstract INSOMNIA , OR THE DISSATISFACTION WITH THE QUANTITY , quality or timing of sleep, is a common complaint. Because the definition of normal sleep is not well estab- lished, the estimates of the prevalence and severity of insomnia vary widely. In- somnia is often secondary to underlying psychiatric and medical conditions, and these should be evaluated and treated as a first measure. Nonpharmacological in- terventions for insomnia including sleep hygiene manoeuvres and exercise are rec- ommended, although the success of these interventions has not been well docu- mented. Benzodiazepines have been the pharmacologic agents of choice for the treatment of insomnia, but there is reason to exercise caution with their use; their overall benefit compared with placebo appears to be minor, and they are often as- sociated with adverse cognitive effects. Unfortunately, no other class of drugs has proven to be superior to the benzodiazepines in terms of benefit:risk ratio. Given the importance of sleep for health and normal daily functioning the diagnosis, prognosis and treatment of insomnia should be a research priority. I nsomnia, as classified in the DSM-IV 1 in the sleep disorders, is associated with complaints about the quantity, quality or timing of sleep at least 3 times a week for at least 1 month. The word complaint should be emphasized here because there are often significant differences between what people perceive and report about their sleep and what is measured objectively (e.g., by EEG monitoring) 2 and individuals vary widely in the amount of sleep they require for optimal functioning. 3 The sleep disturbance must be of sufficient severity to produce noticeable impair- ment in daytime function or mood. The frequency, duration and intensity compo- nents of the definition attempt to exclude the sleep disturbances that occur in everyday life. 4 Insomnia has been classified in at least 3 different ways by comorbidity, dura- tion and severity (Table 1). Subtypes of extrinsic and intrinsic classifications for in- somnia, proposed by the American Association of Sleep Disorders, await valida- tion but some of the subtypes they have proposed, including inadequate sleep hygiene, insufficient sleep, altitude insomnia and environmental insomnia, should also be considered when classifying insomnia. 6 Epidemiology and current practices Patterns of sleep vary with age; 3 it is thought that the amount of time spent in deep sleep decreases and the number of awakenings through the night and total time awake increases with age. Studies have reported more complaints regarding insomnia from older respondents, 3,7 and sleep apnea may also be more prevalent in...
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