Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 8: Neuropsychiatric Disorders

Insomnia

Background

Insomnia is a common accompaniment to HIV infection, especially as the disease progresses and complications worsen. Once present, insomnia tends to be chronic, unlike the transient disturbances of sleep that are a normal part of life. Most insomnia related to HIV can be characterized by the amount, quality, or timing of sleep. Insomnia may cause progressive fatigue and diminished functioning.

S: Subjective

The patient may complain of the following:

• Difficulty initiating sleep
• Early-morning waking
• Mind-racing thoughts (eg, "I can't turn off my thoughts.")
• Difficulty maintaining sleep
• Nonrestorative sleep (ie, although the amount of sleep is adequate, the patient does not feel rested upon awakening)
• Nighttime restlessness

Take a history to include:

• Determine the patient's bedtime sleep habits; if possible, request additional history from a sleep partner.
• Try to quantify how long the patient actually sleeps each night.
• Ask about alcohol and recreational drug use, caffeine intake, and concurrent medications that may cause insomnia as an adverse effect (eg, efavirenz, corticosteroids, pseudoephedrine, and decongestants).
• Screen for depression and anxiety.
• Ask about nightmares, life stressors, and any over-the-counter medications or supplements used to promote sleep.
• Ask about shift work, exercise, nighttime reflux or heartburn, snoring, and periods of apnea (not breathing).
• Ask about collar size (size >16 or 16 1/2 is more often associated with sleep apnea).

O: Objective

Perform a general symptom-directed physical examination, including evaluation of body habitus, neurologic status, and mental status.

Polysomnography may be indicated when a physiologic cause is suspected or insomnia is severe.

A: Assessment

A partial differential diagnosis includes the following:

• Alcohol intake (interferes with sleep 2-4 hours after ingestion)
• Anxiety disorder
• Caffeine intake
• Cognitive impairment
• Disturbance of the sleep/wake cycle because of excessive time in bed
• Major depression (insomnia is a primary symptom)
• Medication adverse effects (eg, from steroids, efavirenz)
• Other identifiable sleep disorders (eg, obstructive sleep apnea, periodic leg movements)
• Pain
• Recreational drug use
• Transient insomnia related to acute stress

P: Plan

Treatment

The following options are available for treatment:

Behavioral strategies

• To correct deleterious sleep habits, patients should do the following:
  • Establish a bedtime routine.
  • Avoid stimuli before bedtime.
  • Avoid vigorous exercise within 3-4 hours of bedtime.
  • Reduce or eliminate daytime napping.
  • Avoid eating, reading, watching TV, or working in bed.
  • Wake up at the same time each day regardless of total hours of sleep.
  • Have a dark, quiet, comfortable environment conducive to sleep.
• If unable to fall sleep after 15-20 minutes, the patient should get up, go into another room for nonstimulating activity in dim light (such as reading), and not go back to bed until sleepy.
• The patient should discontinue use of caffeine, central nervous system stimulants, alcohol, and tobacco, with tapering if necessary to avoid withdrawal symptoms.
• Teach or refer the patient for relaxation techniques.

Pharmacotherapy

The following options are available:

• Antihistamines, such as diphenhydramine or hydroxyzine 25-50 mg at bedtime (be aware of anticholinergic adverse effects).
• Sedating antidepressants such as trazodone 25-50 mg at bedtime, or amitriptyline 10-50 mg at bedtime. Check for drug interactions with antiretroviral agents and other medications. Mirtazapine (Remeron) is a newer antidepressant with fewer drug interactions that may be used at low dosages (7.5-15 mg) for insomnia.
• Sedative hypnotics, such as triazolam (Halcion) 0.125-0.25 mg at bedtime as needed; temazepam (Restoril), 15 mg at bedtime; and newer agents such as zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata). Because of addictive potential and problems such as amnesia and confusion, these should be used only for short-term management (5-7 days).
• Note that protease inhibitors and nonnucleoside reverse transcriptase inhibitors may raise blood concentrations of many benzodiazepines. If benzodiazepines are used, they should be started at low dosages, and other central nervous system depressants should be avoided. Consult with a clinical pharmacist before prescribing.
• Midazolam (Versed) and triazolam (Halcion) are contraindicated with all protease inhibitors and delavirdine and efavirenz.
• Consult with a skilled mental health clinician if problems persist or depression is suspected.

Patient Education

• Behavioral interventions can help to reduce insomnia.
• Patients should report new or worsening symptoms to their health care provider.

References

• Darko DF, McCutchan JA, Kripke DF, et al. Fatigue, sleep disturbance, disability, and indices of progression of HIV infection. Am J Psychiatry. 1992 Apr;149(4):514-20.
• Lee KA. An overview of sleep and common sleep problems. ANNA J. 1997 Dec;24(6):614-23, 677; quiz 624-5.
• Norman SE, Chediak AD, Kiel M, et al. Sleep disturbances in HIV-infected homosexual men. AIDS. 1990 Aug;4(8):775-81.
• Uphold CR, Graham MV. Clinical Guidelines in Adult Health. 2nd ed. Gainesville, FL: Barmarrae Books; 1999:95-99.
• Weiss RE. Neuropsychiatric Complications of HIV Infection. In: Buckley RM, Gluckman SJ, eds. HIV Infection in Primary Care. Philadelphia: Saunders; 2002:192.