Guideline sources The following summarized guidelines for the evaluation and management of chronic insomnia are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2020) and the American Academy of Sleep Medicine (AASM 2018). 2 3 4 4 5 5 Definition Chronic insomnia is defined as persistent symptoms of trouble falling asleep, staying asleep, or waking up too early in the morning accompanied by at least one symptom of impaired daytime function (not getting enough sleep or daytime sleepiness). 4 Epidemiology Chronic insomnia is caused by hyperarousal state primarily due to physiologic or neurophysiologic factors. 5 Disease course Chronic insomnia is characterized by difficulty sleeping, frequent nocturnal awakening, prolonged periods of wakefulness during sleep period, and poor quality sleep. Insomnia impacts physical https://web.pathway.md/diseases/recrzThzlizCnmicz 1/6 6/29/23, 3:53 AM Chronic insomnia Pathway functioning, role limitation due to physical and emotional health problems, body pain, general health perceptions, vitality, social functioning, and mental health. 5 Prognosis and risk of recurrence Persistent insomnia has been associated with an increased risk of all-cause mortality (HR 1.58, 95% CI 1.02-2.45), while intermittent insomnia has not been associated with an increased risk. 4 Guidelines 1. Classification and risk stratification Home sleep apnea test: Consider using a manually scored type III home sleep apnea test with unattended portable monitor, using an event index (such as respiratory disturbance index and apnea-hypopnea index) 15 events per hour to establish the diagnosis of moderate-to-severe obstructive sleep apnea, for patients with a high pretest probability of obstructive sleep apnea. C Perform repeated testing (such as home sleep apnea testing or laboratory-based polysomnography) for obstructive sleep apnea, for patients with a high pretest probability of obstructive sleep apnea and a nondiagnostic home sleep apnea test having a technical inadequacy or apnea-hypopnea index < 5 events per hour. B Athens Insomnia Scale: consider using the Insomnia Severity Index or the Athens Insomnia Scale to evaluate patients with suspected insomnia disorder, as part of a comprehensive sleep assessment. C 2. Diagnostic investigations Screening for OSA/SDB: Consider using the snoring, tiredness, observed apnea, BP (STOP) questionnaire for patients who report sleep symptoms, to stratify risk for obstructive sleep apnea. C Consider assessment for sleep-disordered breathing in patients with a history of cardiovascular or cerebrovascular events, congestive HF, and long-term prescription opioid use. C Actigraphy: consider using actigraphy to estimate sleep parameters in adult patients with insomnia disorder and in the assessment of pediatric patients with insomnia disorder. C 3. Respiratory support Positive airway pressure: advise patients with obstructive sleep apnea receiving positive airway pressure therapy to use this treatment for the entirety of their sleep periods. B Show 4 more https://web.pathway.md/diseases/recrzThzlizCnmicz 2/6 6/29/23, 3:53 AM Chronic insomnia Pathway 4. Medical management Suvorexant: insufficient evidence to recommend for or against the use of suvorexant for treatment of chronic insomnia disorder. I Ramelteon: insufficient evidence to recommend for or against the use of ramelteon for treatment of chronic insomnia disorder due to insufficient evidence. I Trazodone: consider avoiding use of trazodone for treatment of chronic insomnia disorder. D Diphenhydramine: consider avoiding use of diphenhydramine for treatment of chronic insomnia disorder. D Melatonin: consider avoiding use of melatonin for treatment of chronic insomnia disorder. D General principles: offer alternative/salvage therapies to patients with obstructive sleep apnea who cannot tolerate or have declined all other recommended treatments. B Show 2 more Topical nasal steroids: consider avoiding routine use of topical nasal steroids for patients without nasal congestion for the sole purpose of improving positive airway pressure adherence. D Doxepin: consider using low-dose doxepin in patients who are offered short-course pharmacotherapy for treatment of chronic insomnia disorder. C Nonbenzodiazepine benzodiazepine receptor agonist: consider prescribing a nonbenzodiazepine benzodiazepine receptor agonist in patients who are offered short-course pharmacotherapy for treatment of chronic insomnia disorder. C Benzodiazepines: consider avoiding use of benzodiazepines for treatment of chronic insomnia disorder. D Antipsychotic drugs: consider avoiding use of antipsychotic drugs for treatment of chronic insomnia disorder. D 5. Nonpharmacologic interventions Cognitive behavioral therapy: offer CBT-I for treatment of chronic insomnia disorder. B Show 3 more Acupuncture: Offer auricular acupuncture with seed and pellet for treatment of chronic insomnia disorder. B Insufficient evidence to recommend for or against acupuncture other than auricular acupuncture with seed and pellet for treatment of chronic insomnia disorder. I Exercise therapy: insufficient evidence to recommend for or against aerobic exercise, resistive exercise, tai chi, yoga, and qigong for treatment of chronic insomnia disorder. I Cranial electrical stimulation: consider avoiding cranial electrical stimulation for treatment of chronic insomnia disorder. D https://web.pathway.md/diseases/recrzThzlizCnmicz 3/6 6/29/23, 3:53 AM Chronic insomnia Pathway Mindfulness meditation: insufficient evidence to recommend for or against mindfulness meditation for treatment of chronic insomnia disorder. I Alternative medicine: Consider avoiding use of valerian and chamomile for treatment of chronic insomnia disorder. D Avoid using kava for treatment of chronic insomnia disorder. D 6. Surgical interventions Nasal surgery: consider performing evaluation for nasal surgery in patients with anatomical nasal obstruction as a barrier to positive airway pressure use. C Hypoglossal nerve stimulation: consider performing evaluation for surgical treatment with hypoglossal nerve stimulation therapy, for patients with obstructive sleep apnea with an apnea- hypopnea index of 15-65 events per hour and a BMI < 32 kg/m who cannot adhere to positive airway pressure therapy. C Maxillomandibular advancement surgery: consider performing evaluation for alternative treatment with maxillomandibular advancement surgery, in patients with severe obstructive sleep apnea who cannot tolerate or are not appropriate candidates for other recommended therapies. C 7. Patient education Sleep hygiene education: consider avoiding sleep hygiene education as a standalone treatment for chronic insomnia disorder. D Clinical findings Symptoms Past medical history Anxiety Asthma Asthenia Diabetes mellitus Being unable to concentrate on tasks Gastroesophageal reflux Hyperthyroidism Depression Increased errors or accidents Difficulty falling asleep at night Medications Difficulty sleeping Not feeling well-rested after a night's sleep Eating too much late in the evening Ongoing worries about sleep Irritability Waking up during the night Pain Sleeping disorder Waking up too early https://web.pathway.md/diseases/recrzThzlizCnmicz 4/6 6/29/23, 3:53 AM Chronic insomnia Pathway Social history Alcohol consumption Current cigarette smoking References 1. Sateia MJ, Buysse DJ, Krystal AD et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15;13 2 307 349. Open 2. Vincent Mysliwiec, Jennifer L Martin, Christi S Ulmer et al. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med. 2020 Mar 3;172 5 325 336. Open 3. Michael T Smith, Christina S McCrae, Joseph Cheung et al. Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2018 Jul 15;14 7 1231 1237. Open 4. Sairam Parthasarathy, Monica M. Vasquez, Marilyn Halonen et al. PERSISTENT INSOMNIA IS ASSOCIATED WITH MORTALITY RISK. Am J Med. 2015 Mar; 128 3 268 275.e2. Open 5. Thomas Roth. Insomnia: Definition, Prevalence, Etiology, and Consequences. J Clin Sleep Med. 2007 Aug 15; 3 5 Suppl): S7 S10. Open 6. Qaseem A, Kansagara D, Forciea MA et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. 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