Insomnia
Chronic insomnia is persistent difficulty falling or staying asleep with daytime impairment; a root-cause evaluation looks at the sleep-disrupting habits, health conditions, and circadian factors behind it, managed per the American Academy of Sleep Medicine (AASM) clinical practice guideline.
Symptoms
Difficulty falling asleep, staying asleep, or waking too early, occurring 3 or more nights per week for 3 months or longer, along with daytime fatigue, mood changes, or difficulty concentrating.
Causes and risk
Irregular sleep schedules, evening caffeine or alcohol, screen exposure close to bedtime, chronic stress, and underlying conditions (anxiety, depression, thyroid dysfunction, sleep apnea) can all disrupt sleep; identifying which of these is driving a given case shapes the right approach.
How it is evaluated
Diagnosis is clinical, based on frequency and duration of symptoms, often supported by a sleep diary, per current NEJM clinical guidance. Single-timepoint salivary cortisol testing is not a validated way to diagnose or guide treatment of insomnia -- cortisol's normal daily rhythm makes a single measurement unreliable.
Treatment
CBT for insomnia (CBT-I) is the strongly recommended first-line treatment, per the AASM guideline, alongside consistent sleep-wake timing, reduced evening caffeine and alcohol, and treating any underlying condition (like thyroid dysfunction or sleep apnea) that's contributing. Medication is a secondary option; benzodiazepines, Z-drugs, and antihistamines are specifically cautioned against in older adults per the American Geriatrics Society Beers Criteria.
When to seek care
Insomnia paired with thoughts of self-harm, or with symptoms of a serious sleep disorder like loud gasping or choking during sleep (possible sleep apnea), warrants prompt evaluation.