Insomnia, snoring and daytime sleepiness

Clarify the complaint

Ask whether the main problem is difficulty falling asleep, waking, an irregular schedule, non-restorative sleep or daytime sleepiness. Record duration, opportunities for sleep, shift work, naps, substances and medication timing. A sleep diary can clarify patterns. Assess mood, anxiety, pain, breathing symptoms, restless legs and environmental disruption. Insomnia and obstructive sleep apnoea can coexist; improvement in one does not prove the other is absent. Distinguish fatigue from an irresistible tendency to fall asleep because the safety and differential differ.

Evaluate functional harm, including work, falls, driving and caregiving. A patient who falls asleep at the wheel needs immediate safety advice and prompt assessment, not simply a hypnotic prescription. Ask about snoring, witnessed apnoeas, choking awakenings and morning headache. Screening tools estimate risk but do not establish or exclude OSA in every individual. Body size influences risk but does not make OSA impossible in a thin person. Craniofacial, upper-airway and neurological factors can matter.

Insomnia treatment

Chronic insomnia is commonly treated with cognitive behavioural therapy for insomnia, combining stimulus control, appropriate sleep scheduling, cognitive work and other components. Basic sleep hygiene alone is often insufficient. Explain consistent wake time, the role of time awake in bed and a tailored plan rather than simply advising “try harder to sleep.” Digital or brief structured programs may improve access where suitable. Check whether an underlying mood episode, pain, substance withdrawal or untreated breathing disorder requires parallel treatment.

Sedative medicines can cause falls, cognitive effects, dependency and impaired driving. If used, agree the indication, duration, review and stopping plan, considering age, respiratory disease and other depressants. Avoid routine long-term benzodiazepines or Z-drugs without reassessment. Melatonin suitability depends on the sleep problem, formulation, age and product indication; it is not a guaranteed treatment for every insomnia. A patient already dependent on sedatives needs a supported taper rather than abrupt cessation, which can cause severe withdrawal.

Obstructive sleep apnoea

OSA involves recurrent upper-airway obstruction during sleep, with intermittent hypoxaemia and arousal. Arrange an appropriate sleep study and specialist/primary-care pathway according to risk and comorbidity. CPAP can reduce obstruction and symptoms in suitable patients; adherence, mask fit and patient experience determine benefit. Oral appliances and other interventions are selected according to anatomy, severity and preference. Lifestyle and positional measures may help but should not delay indicated treatment of severe symptomatic disease. Explain that treating snoring alone is not equivalent to confirming that apnoeas are controlled.

Alcohol and sedatives can worsen airway obstruction or respiratory depression. Weight management can help some people, but OSA deserves treatment while longer-term changes are attempted. Review hypertension, cardiovascular risk and perioperative implications. A known OSA diagnosis should be communicated before anaesthesia, with plans for postoperative analgesia and monitoring. CPAP device use needs practical support for nasal symptoms, travel, electricity and dexterity; failure to tolerate the first mask does not mean the patient has rejected all treatment.

Other sleep disorders

Restless legs involves an urge to move with uncomfortable sensations, worse at rest and in the evening and relieved by movement. Review iron status, renal disease, pregnancy and aggravating medicines when appropriate. It differs from cramps or general anxiety. Treatment is individualised; some dopaminergic regimens can cause augmentation, worsening or earlier onset of symptoms. Do not escalate indefinitely without reviewing the pattern. Periodic limb movement findings and symptoms require clinical interpretation rather than assuming every sleep-study movement needs medication.

Narcolepsy may produce excessive daytime sleepiness with cataplexy and other REM-related symptoms, requiring specialist assessment. Parasomnias such as sleepwalking differ from nocturnal seizures; injury, atypical features or adult onset may need investigation. REM sleep behaviour symptoms, including dream enactment with injury, require assessment and bedroom safety measures. Circadian disorders and shift-work problems call for timing-based strategies rather than a standard bedtime for everyone. A reduction in sleep need with elevated mood or increased activity raises mania rather than uncomplicated insomnia.

Cases and follow-up

A person with insomnia and loud snoring should be assessed for both conditions; CBT-I can be coordinated with OSA treatment. A shift worker needs a feasible schedule and occupational-safety plan. A patient with reduced sleep but no fatigue, pressured speech and increased risky activity needs mood assessment. Another patient taking an opioid and benzodiazepine with daytime somnolence needs medication/ventilation risk review. The next action follows the mechanism and immediate danger, not the generic word “poor sleep.”

Review sleep function, treatment adherence, adverse effects and driving safety over time. Address barriers to behavioural treatment and devices, and use shared goals such as staying awake safely at work or reducing distress around bedtime. Document safety advice and arrange timely review for persistent sleepiness, witnessed apnoeas or new neurological features. Bed-partner reports can help, obtained with consent without allowing the partner's preference to replace the patient's choices.

RACGP non-drug interventions, including CBT-I and CPAP.

Review checkpoints

• CBT-I is an important first-line treatment for chronic insomnia.
• Snoring with witnessed apnoeas or daytime sleepiness raises concern for obstructive sleep apnoea.
• Sedative prescribing should consider falls, driving and breathing risks.