Most people with insomnia do not need to get immediate medical care. The following are situations that require immediate medical evaluations. Those with insomnia and

• A recent stroke
• Sleep walking that may put the person at risk for danger – such as walking into the street.
• Falling asleep suddenly – for example, while driving
• Periods of not breathing associated with gasping
• Unstable lung or heart disease
• Violent behavior during sleep

In addition, those individuals who cannot manage their insomnia on their own should consider seeking medical attention. Seeking medical attention does not necessarily mean that the person is seeking sleeping pills. The doctor appointment can be used for teaching, assessment of other disease states to assure they are not causing the problem or setting up referral to a sleep expert.

When all else fails a doctor’s appointment can be set up for pharmacological management of insomnia. Although sleep medications are not recommended as an initial step, they are at times needed. Each patient should engage in sleep hygiene before resorting to medication.

The first step in the evaluation of a medical problem is to understand the problem. The person with insomnia needs to take an inventory of his symptoms. This can be best accomplished with a sleep diary. Important things to document include:

• Normal sleep schedule. When do you go to bed? When do you wake up?
• Timing – Does the patient have difficulty falling asleep, staying asleep? Is there any early morning awakening?
• What is the sleep environment like? Is the bed comfortable? Do you sleep in a bed or chair? Is the room dark? Is there a lot of nose?
• Evaluate the sleep habits. What do you do before bed (read, exercise, eat, watch TV (what shows)?
• Are there any other symptoms?
• Is there any snoring? Has the bed partner witnessed you stop breathing during sleep (apnea)? Do the legs move a lot at night (periodic limb movement disorder)?
• How do you feel during the day? Are you tired, fatigued, have low energy, poor concentration or feel irritable?

Are there any known medical problems? Many medial problems that are not controlled well can lead to sleep problems. Each medical problem should be evaluated to assure they are managed properly.

A review of medications must ensue to help assure they are not leading to sleep problems. Many medications can lead to sleep problems. Review the list above and consider any of those medications as possible contributing factors to the sleep disturbance.

Many social problems can lead to short term insomnia. Changes or things that lead to stress are most to blame. Questions to consider include:

• Has there been any change in personal relationships?
• Has there been any change in jobs or a major change at work?
• Is there increased stress at work?
• Has there been any recent loss?

A physical exam can pick up on some causes of sleep problems.

• What is the body weight? When the body mass index is greater than 30 there is increased risk of sleep apnea.
• Neck circumference greater than 18 inches is also a risk factor of sleep apnea.
• If there are enlarged tonsils or a large tongue there may be sleep apnea present.

Most people with insomnia do not need medical testing. If there is a suspected disease such as sleep apnea or restless leg syndrome than a referral to a sleep lab may help confirm this diagnosis.

Individuals who have a disease state that is not well controlled may be referred for diagnostic testing or lab work to assure that these conditions are well controlled. For example, those with a history of night cough and asthma may be having problems with control of asthma. A referral for spirometry or even stepping up asthma therapy may be indicated. Another example includes; those individuals with a history of chronic obstructive pulmonary disease may need arterial blood gases to see if they have enough oxygen in the blood.