CCFP priority topic 55 of 105
Insomnia on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Insomnia. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
Name the sleep problem
Use the history to tell insomnia from mental illness or another sleep disorder.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Choosing Wisely Canada, Health Canada
On the exam
A 9-year-old boy lies awake for an hour at bedtime. Expect a short menu (pick several from a list) of history questions.
Pick the questions that sort the problem.
Common mistakes
Asking about bedwetting, teeth grinding or dreams: those happen once he is asleep. Or skipping snoring and mood, the questions that find another cause.
Approach
- Pin down the pattern first: trouble falling asleep, waking in the night, or waking too early. Then ask how the days are affected.
- Ask about loud snoring, pauses in breathing and gasping. Without them, big tonsils alone do not point to sleep apnea.
- Ask about an urge to move the legs at rest in the evening, eased by moving. That is restless legs.
- Ask about leg jerks during sleep (periodic limb movements). Sleepwalking and sleep talking also start after sleep begins, so they do not explain lying awake.
- Screen for depression and anxiety, and ask about pain. Each can cause poor sleep, and a sleeping pill can hide depression.
- Ask when it began and what changed then. A cause has to come before the problem, not after it.
| Problem | Clue in the history | Best witness |
|---|---|---|
| Obstructive sleep apnea | Loud snoring, pauses in breathing, gasping, daytime sleepiness | Bed partner or parent |
| Restless legs | Urge to move the legs at rest in the evening, eased by moving | The patient |
| Periodic limb movements | Repeated leg jerks during sleep | Bed partner |
| Sleepwalking or sleep talking | Events after falling asleep, not trouble getting there | Bed partner or parent |
| Depression or anxiety | Low mood, worry, waking too early | The patient |
Key feature 2 of 5
Witnesses and substances
Get the bed partner's or parent's account, and check every drug, caffeine and alcohol.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Choosing Wisely Canada
On the exam
A grandmother brings a boy on a morning stimulant for attention problems, with new melatonin gummies. Expect a short menu (pick several from a list).
Pick the history that finds the cause.
Common mistakes
Blaming the morning stimulant he slept well on for months, or the gummies begun after the problem. Missing afternoon cola and a tablet in bed.
Approach
- Ask the bed partner or parent what they see at night. Snoring, pauses in breathing, leg jerks and night walking happen while the patient sleeps.
- List every drug: prescribed, bought at the pharmacy, and recreational. Line up when each began against when the poor sleep began.
- A drug taken unchanged through months of normal sleep is unlikely to explain new insomnia. Look for what changed.
- Ask about caffeine in coffee, tea, cola and energy drinks, and when it is taken. Advise none after 3 p.m., or earlier if needed.
- Ask about alcohol. It brings sleep on at first, then wakes people later in the night.
- Ask about bright screens before bed, and about pharmacy sleep aids that contain diphenhydramine, a sedating antihistamine.
Key feature 3 of 5
Habits and CBT first
Teach sleep habits to every patient with insomnia, and offer cognitive behavioural therapy.
CFPC skill Clinical reasoning, patient-centred approachPhase TreatmentSources Choosing Wisely Canada
On the exam
Melatonin 1 mg has not helped the boy, and the family asks for more. Expect one best answer.
Choose the first treatment.
Common mistakes
Raising the melatonin dose while afternoon cola and the tablet in bed carry on. Later, allowing daytime naps or long lie-ins once sleep improves.
Approach
- Same bedtime and same wake time every day, weekends too.
- No caffeine after 3 p.m., or earlier if needed. Limit alcohol.
- No bright screens before bed. Keep the bedroom calm. Read or watch TV in a chair, not in bed.
- Not asleep soon? Get up, do something calm such as reading, and go back to bed when drowsy.
- Exercise during the day, but not in the last few hours before bed. Finish eating at least 3 hours before bed.
- Offer cognitive behavioural therapy for insomnia (CBT-I). It improves sleep, and it helps people come off sleeping pills. Online programs exist.
- A sleep diary shows the pattern. Stimulus control (bed only for sleep) and sleep restriction (less time in bed) raise the share of bed time spent asleep.
Key feature 4 of 5
Starting a sleeping pill
Prescribe sleeping pills rarely, warn of their harms, and agree on a stop plan.
CFPC skill Clinical reasoning, communication, selectivity, patient-centred approachPhase TreatmentSources Health Canada, Choosing Wisely Canada
On the exam
A woman of 45 cannot sleep after losing her job and asks for zopiclone. Expect a short menu (pick several from a list).
Pick what you say and prescribe.
Common mistakes
Refusing outright when lost sleep is wrecking her days. Or a month of nightly zopiclone with refills and no stop date.
Approach
- Keep a sleeping pill for insomnia that clearly harms daytime function. Look for a cause and try non-drug treatment first.
- Zopiclone, a Z-drug (a sleeping pill that works like a benzodiazepine): usually no more than 7 to 10 nights. Reassess fully past 2 to 3 weeks. Never more than a month's supply.
- Use the lowest dose. At 65 or older, zopiclone no more than 5 mg. Not for anyone under 18.
- Warn about next-day impairment. Wait at least 12 hours before driving, even if alert. No alcohol with it.
- Warn about dependence, falls, memory problems and sleep-driving: doing things while not fully awake, with no memory of it.
- At the start, agree how long it will last and how the dose will come down.
- Not a first choice in older adults: a benzodiazepine or Z-drug. Not routinely, at any age, for insomnia on its own: an antipsychotic such as quetiapine.
| Drug | Where it fits | Watch for |
|---|---|---|
| Zopiclone | Short term, adults only; usually 7 to 10 nights | Next-day impairment, sleep-driving, dependence (more often past 4 weeks) |
| Benzodiazepines (temazepam, lorazepam) | Not a first choice for insomnia in older adults | Falls, hip fracture, car crashes, withdrawal |
| Antipsychotic (quetiapine) | Not routinely for insomnia on its own, at any age | Weight gain and metabolic harm, even at low doses |
| Tricyclic antidepressant (amitriptyline) | Sometimes used for sleep | Often no safer than the sedative it replaces |
| Diphenhydramine (pharmacy sleep aids) | Avoid in older adults | Next-day drowsiness, confusion, constipation, dry mouth, trouble passing urine |
Key feature 5 of 5
Renewal requests
At a refill request from a long-term user, review, teach, and offer a taper.
CFPC skill Patient-centred approach, professionalismPhase Hypothesis generation, treatmentSources Choosing Wisely Canada, Health Canada
On the exam
A 78-year-old woman on lorazepam at bedtime for 10 years asks for a refill. Expect a short menu (pick several from a list).
Pick what to do at this visit.
Common mistakes
Refilling for a year because she feels fine. Stopping it at once is wrong too: sudden withdrawal can bring rebound insomnia (sleep worse than before), tremor and even seizures.
Approach
- Ask why it was started and whether that reason still holds.
- Renew a small amount only, and book a visit to talk about whether it is still safe.
- Explain the harms: falls, hip fracture, memory problems and car crashes. Explain the small gain: about 23 more minutes of sleep a night.
- Using it only on bad nights is no safer. That pattern carries the highest risk of hip fracture.
- If she is ready, taper slowly with her; never stop suddenly. Warn about withdrawal symptoms and plan how to cope.
- Replace the pill with CBT-I, a sleep diary and better sleep habits. Swapping to an antipsychotic or a tricyclic is often no safer.
- If she is not ready, keep the door open. Stopping usually takes several conversations.
Flashcards
Answer it first, then check.
KF 1A child lies awake an hour at bedtime. Big tonsils, no snoring. Is apnea likely?
No. Without snoring or pauses in breathing, big tonsils alone do not suggest it. This is trouble falling asleep.
KF 2Who tells you about snoring, pauses in breathing or leg jerks at night?
The bed partner or a parent. The patient is asleep when these happen.
KF 2What drink habit do you ask about when someone cannot fall asleep?
Caffeine, including cola, and its timing. Advise none after 3 p.m., or earlier if needed. Source: Choosing Wisely Canada
KF 3The patient is not asleep soon after going to bed. What should they do?
Get up and do something calm, like reading. Go back to bed when drowsy. Source: Choosing Wisely Canada
KF 4How long should a course of zopiclone usually last?
No more than 7 to 10 nights. Past 2 to 3 weeks, reassess the patient fully. Source: Health Canada
KF 4A patient took zopiclone last night and feels alert. When can they drive?
At least 12 hours after the dose. Impairment can be there even when they feel fully awake. Source: Health Canada
KF 5In older adults, how many take a sedative-hypnotic for one to sleep better? To harm one?
Thirteen for one to sleep better. Only 6 for one to be harmed. Source: Choosing Wisely Canada
KF 5An older patient takes the pill only on bad nights. Is that safer?
No. Using it now and then carries the highest risk of hip fracture, even above daily use. Source: Choosing Wisely Canada
FAQ
Which Canadian guideline does the exam follow for insomnia?
No single Canadian guideline is named for this topic. Know the Choosing Wisely Canada advice: non-drug treatment first, no sedative as a first choice in older adults, and a stop plan.
Are sleep habits enough on their own?
Often not. Give sleep habit advice and offer cognitive behavioural therapy for insomnia (CBT-I) at the same visit. CBT-I adds stimulus control and sleep restriction, and it helps people come off sleeping pills.
Do I stop a long-term sleeping pill at the first visit?
No. Raise it, renew a small supply and book a visit. Stopping suddenly risks withdrawal, so taper slowly once the patient is ready, and warn them what to expect.
Is quetiapine a safer sleeping pill than a benzodiazepine?
No. Choosing Wisely Canada advises against routine use of antipsychotics such as quetiapine for insomnia on its own, at any age. They cause weight gain and metabolic harm, even at low doses.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada