sleep disorders
brain, spinal cord, and nerve disorders
Insomnia and Excessive Daytime Sleepiness (EDS)
Treatment of insomnia depends on its cause and severity but typically involves a combination of the following: Treatment of disorders contributing to insomnia Good sleep hygiene Cognitive-behavioral therapy Sleep aids If insomnia results from another disorder, that disorder is treated. Such treatment may improve sleep. For example, if people have insomnia and depression, treating the depression often relieves the insomnia. Some antidepressant drugs also have sedative effects that help with sleep when the drugs are given before bed. However, these drugs may also cause daytime sleepiness, particularly in older people. Good Sleep hygiene is important whatever the cause and is often the only treatment patients with mild problems need. But if daytime sleepiness and fatigue develop, especially if they interfere with daytime functioning, additional treatment is warranted, mainly counseling ( Cognitive-behavioral therapy ) and sometimes Alcohol is not an appropriate sleep aid and may actually interfere with sleep. It produces an unrefreshing sleep with many awakenings during the night. Sleep hygiene focuses on changes in behavior to help improve sleep. These changes include limiting the amount of time spent in bed, establishing a regular sleep/wake schedule, and doing things to relax before going to bed (such as reading or taking a warm bath). Limiting the amount of time spent in bed is intended to help eliminate long periods of being awake in the middle of the night. Cognitive-behavioral therapy, done by a trained sleep therapist, may help people when insomnia interferes with daily activities and when changes in behavior to help improve sleep (good sleep hygiene) alone are ineffective. Cognitive-behavioral therapy is typically done in four to eight individual or group sessions but can be done remotely through the Internet or by telephone. The effects of this therapy last a long time after therapy ends. The therapist helps people change their behavior to improve sleep. The therapist asks people to keep a sleep diary. In the diary, people record how well and how long they sleep as well as any behavior that might interfere with sleep (such as eating or exercising late at night, consuming alcohol orcaffeine, feeling anxious, or being unable to stop thinking when trying to sleep). Therapists may recommend limiting the amount of time spent in bed so that people spend less time lying in bed and trying unsuccessfully to sleep. Cognitive-behavioral therapy can help people understand their problem, unlearn bad sleeping habits, and eliminate unhelpful thoughts, such as worrying about losing sleep or the next day’s activities. This therapy also includes relaxation training, which may involve techniques such as visual imagery, progressive muscle relaxation, and breathing exercises. When a sleep disorder interferes with normal activities and a sense of well-being, occasionally taking prescription sleep aids (also called hypnotics or sleeping pills) for up to a few weeks may help. Among the most commonly used sleep aids are Misuse of Antianxiety Medications and Sedatives . Most sleep aids require a doctor’s prescription because they may cause problems. Loss of effectiveness:Once people become accustomed to a sleep aid, it may become ineffective. This effect is called tolerance. Withdrawal symptoms:If a sleep aid is taken for more than a few days, stopping it suddenly can make the original sleep problem worse (causing rebound insomnia) and can increase anxiety. Thus, doctors recommend reducing the dose slowly over a period of several weeks until the drug is stopped. Habit-forming or addiction potential:If people use certain sleep aids for more than a few days, they may feel that they cannot sleep without them. Stopping the drug makes them anxious, nervous, and irritable or causes disturbing dreams. Potential for overdose:If taken in higher than recommended doses, some of the older sleep aids can cause confusion, delirium, dangerously slow breathing, a weak pulse, blue fingernails and lips, and even death. Serious side effects:Most sleep aids, even when taken at recommended doses, are particularly risky for older people and for people with breathing problems because sleep aids tend to suppress areas of the brain that control breathing. Some can reduce daytime alertness, making driving or operating machinery hazardous. Sleep aids are especially dangerous when taken with other drugs that can cause daytime drowsiness and suppress breathing, such as alcohol, opioids (narcotics), antihistamines, or antidepressants. The combined effects are more dangerous. Rarely, especially if taken at higher than recommended doses or with alcohol, sleep aids have been known to cause people to walk or even drive during sleep and to cause severe allergic reactions. Sleep aids also increase the risk of falls at night. Benzodiazepinesare the most commonly used sleep aids. Some benzodiazepines (such asflurazepam) are longer acting than others (such astemazepamandtriazolam). Doctors try to avoid prescribing long-acting benzodiazepines for older people. Older people cannot metabolize and excrete drugs as well as younger people. Thus for them, taking these drugs may be more likely to cause daytime drowsiness, slurred speech, falls, and occasionally confusion. Other useful sleep aidsare not benzodiazepines but affect the same areas of the brain as benzodiazepines. These drugs (eszopiclone,zaleplon, andzolpidem) are shorter acting than most benzodiazepines and are less likely to lead to daytime drowsiness.Zolpidemalso comes in a longer-acting (extended-release, or ER) form and a very short acting (low-dose) form. Ramelteon, a newer sleep aid, has the same advantages as these shorter-acting drugs. In addition, it can be used longer than benzodiazepines without losing its effectiveness or causing withdrawal symptoms. It is not habit-forming and does not appear to have overdose potential. However, it is not effective in many people.Ramelteonaffects the same area of the brain asmelatonin(a hormone that helps promote sleep) and is thus called amelatoninreceptor agonist. Three relatively new drugs (daridorexant,lemborexant, andsuvorexant) can be used to treat insomnia. They help people fall asleep and help them stay asleep. These drugs block orexin receptors in the brain that are involved in controlling sleep. Thus, they are called orexin receptor blockers (antagonists). They are taken by mouth once a day shortly before going to bed. However, these drugs are not overly effective for treating insomnia. The most common side effect is drowsiness. Some sleep aids that are available without a prescription (over-the-counter, or OTC) contain Antihistamines However, the drugs that contain antihistamines should not be taken to treat insomnia. Antihistamines may have significant side effects, such as daytime drowsiness or sometimes nervousness, agitation, difficulty urinating, falls, and confusion, especially in older people. Melatonin None Marijuana (cannabis) contains many chemicals, such as CBD (cannabidiol), which causes drowsiness but no euphoria THC (tetrahydrocannabinol), which causes euphoria, reduces pain and nausea, and affects sleep stages CBN (cannabinol), which causes drowsiness, reduces pain, and increases appetite Marijuana, Synthetic is a synthetic version that is used to treat nausea and vomiting associated with cancer chemotherapy and to enhance appetite in AIDS patients. Many other medicinal herbs and dietary supplements, such as skullcap andvalerian, are available in health food stores, but their effects on sleep and their side effects are not well-understood. Some Medications for Treatment of Depression (such as Doxepin, used as an antidepressant when given in high doses, may be an effective sleep aid when given in very low doses. 