Elsevier

Sleep Medicine Reviews

Volume 15, Issue 6, December 2011, Pages 369-378
Sleep Medicine Reviews

Clinical Review
Insomnia in central neurologic diseases – Occurrence and management

https://doi.org/10.1016/j.smrv.2011.01.005Get rights and content

Summary

The objective of this review is to highlight the impact of insomnia in central neurological disorders by providing information on its prevalence and give recommendations for diagnosis and treatment.

Insomnia in neurological disorders is a frequent, but underestimated symptom. Its occurrence may be a direct consequence of the disease itself or may be secondary to pain, depression, other sleep disorders or the effects of medications. Insomnia can have a significant impact on the patient’s cognitive and physical function and may be associated with psychological distress and depression. Diagnosis of insomnia is primarily based on medical history and validated questionnaires. Actigraphy is a helpful diagnostic tool for assessing the circadian sleep–wake rhythm. For differential diagnosis and to measure the duration of sleep full polysomnography may be recommended.

Prior to initiating treatment the cause of insomnia must be clearly identified. First line treatment aims at the underlying neurologic disease. The few high quality treatment studies show that short term treatment with hypnotics may be recommended in most disorders after having ruled out high risk for adverse effects. Sedating antidepressants may be an effective treatment for insomnia in stroke and Parkinson’s disease (PD) patients. Melatonin and light treatment can stabilize the sleep–wake circadian rhythm and shorten sleep latency in dementias and PD. Cognitive behavioral therapy (CBT) can be effective in treating insomnia symptoms associated with most of the central neurological diseases.

The prevalence and treatment of insomnia in neurological diseases still need to be studied in larger patient groups with randomized clinical trials to a) better understand their impact and causal relationship and b) to develop and improve specific evidence-based treatment strategies.

Introduction

There is increasing awareness that sleep disorders are frequently associated with neurological diseases. Most studies in the field cover the whole array of sleep disorders or focus on excessive daytime sleepiness, periodic limb movement disorder (PLMD), and rapid eye movement (REM) sleep behavior disorder (RBD). Despite its high prevalence ranging from 30 to 100%1 in neurodegenerative disease, the topic of studying insomnia in neurological diseases has been largely neglected. It is assumed that the impact of insomnia on the course and long-term outcome of neurological diseases is underestimated. This may be due to the lack of a specific pathophysiological model of insomnia associated with neurological diseases, which would allow identifying insomnia as a co-morbid sleep disorder or secondary to depression, pain or other features associated with the underlying neurological disease. The World Health Organization developed an interview to assess the general impact of co-morbid diseases in health burden.2 Among the most important factors were neurological disease, insomnia and major depression. To underline the importance of insomnia this article will describe the present state of the art of diagnostic instruments, prevalence and management of insomnia in central neurological diseases.

Section snippets

Definition of insomnia

Insomnia can be classified according to the diagnostic and statistical manual of mental disorders (DSM) IV,3 international classification of sleep disorders (ICSD) 24 or international classification of diseases (ICD) 10. The criteria for primary (DSM-IV)3 and non-organic insomnia (ICD-10) strongly overlap: difficulty initiating or/and maintaining sleep, non-restorative sleep for at least one month coupled with impaired daytime functioning. DSM-IV3 differentiates primary insomnia from secondary

Pathophysiology of insomnia

The pathophysiology of insomnia per se is not yet fully understood. State of the art models of primary insomnia are mainly based on the hyperarousal concept9 which assumes psychological and physiological hyperarousal at the core of chronic insomnia. Psychobiological studies demonstrated that patients with chronic primary insomnia display increased levels of subjective and autonomous, neuroendocrine, neurophysiologic and brain metabolic activity compared to good sleepers. A widely accepted model

Search strategy

Several electronic literature databases were searched including MEDLINE, PUBMED, EMBASE, WEB OF SCIENCE, and Cochrane. The search was performed for the years 1986–2010 restricted to literature on adult subjects. The search terms were “insomnia in neurologic disease” and “insomnia in central neurologic diseases”. Language was restricted to English.

Selection criteria: The literature had to contain at least a definition of insomnia that is compatible with the standard classification systems. All

Diagnostic instruments for insomnia in neurological disorders

The evaluation of insomnia in patients with neurological disorders requires a detailed medical and sleep history plus a physical and psychiatric examination. Specific sleep diaries to assess sleep habits (bedtimes, etc), sleep parameters (sleep onset latency, wake time after sleep onset, etc), drug and alcohol intake, etc., for periods of 7–14 days should be filled out by patients regularly on a daily basis.24 The Pittsburgh Sleep Quality Index,25 Sleep Disorders Questionnaire,26 and Insomnia

Frequency of insomnia in neurological disorders

Studies reporting the frequency of insomnia in central neurological diseases are summarized in Table 1.

Management of insomnia in neurological diseases

The first step in managing insomnia in neurological diseases is to establish a correct diagnosis. If the sleep disorder is co-morbid with a medical or psychiatric condition such as pain, depression, anxiety, or RLS, the underlying disease has to be treated. However, if the treatment of the co-morbid disorder alone does not relieve insomnia a management of insomnia symptoms per se has to be performed to prevent the consequences.

Sleep disorders may be the result of adverse effects of medications

Conclusion

The frequency of insomnia in central neurological diseases is high. Only a few studies on the topic are of sufficient quality. Insomnia definitions used in hitherto published studies are often not in line with the international classifications. There are many confounders like co-morbid depression, pain and/or other sleep disorders that make it difficult to evaluate the impact of one symptom on the burden of disease. In addition the assessment of insomnia by clinical interview and or by

Conflicts of interest

  • Yves Dauvilliers has consulted and/or gave talks for UCB Pharma, Cephalon, Sanofi-Aventis, Bioprojet, and Boehringer Ingelheim.

  • Geert Mayer is participating in advisory boards of UCB and Sanofi-Aventis. He received speaker’s honoraria from Cephalon, Sanofi-Aventis and UCB and was the recipient of research support from Cephalon and UCB.

  • Poul Jennum is participating in an advisory board of UCB

  • Dieter Riemann has received speaker’s honoraria from Sanofi-Aventis, Lundbeck, Servier, GSK, Cephalon and

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