neurologic disorders
Approach to the Patient With a Sleep or Wakefulness Disorder
Treatment of Sleep or Wakefulness Disorders
Specific conditions are treated. The primary treatment for insomnia is cognitive-behavioral therapy, which ideally should be done before hypnotics are prescribed. Good Sleep Hygiene is a component of cognitive-behavioral therapy that is important whatever the cause and is often the only treatment patients with mild problems need. Cognitive-behavioral therapy for insomnia focuses on managing the common thoughts, worries, and behaviors that interfere with sleep. It is typically done in 4 to 8 individual or group sessions but can be done remotely online or by telephone; however, evidence for the effectiveness of remote therapy is weaker. Cognitive-behavioral therapy for insomnia consists of the following: Helping patients improve Sleep Hygiene , particularly restricting time spent in bed, establishing a regular sleep schedule, and controlling stimuli Teaching patients about the effects of sleeplessness and helping them identify inappropriate expectations about how much sleep they should get Teaching patients relaxation techniques Using other cognitive therapy techniques as needed Restricting the amount of time spent in bed aims to limit the time patients spend lying in bed trying unsuccessfully to sleep. Initially, time in bed is limited to the average nightly total sleep time, but not to < 5.5 hours. Patients are asked to get out of bed in the morning at a fixed time and then calculate a bed time based on total sleep time. After a week, this approach typically improves quality of sleep. Then, the time spent in bed can be increased by gradually making bed time earlier, as long as awakenings in the middle of the night remain minimal. General guidelines for use of hypnotics (see table Guidelines for the Use of Hypnotics ) aim at minimizing abuse, misuse, and addiction. For commonly used hypnotics, see table Oral Hypnotics in Common Use . All hypnotics (except Hypnotics differ primarily in elimination half-life and onset of action. Drugs with a short half-life are used for sleep-onset insomnia. Drugs with a longer half-life are useful for both sleep-onset and sleep maintenance insomnia, or, in the case of low-dosedoxepin, only for sleep maintenance insomnia. Some hypnotics (eg, older benzodiazepines) have greater potential for daytime carryover effects, especially after prolonged use and/or in older people. New drugs with a very short duration of action (eg, low-dose sublingualzolpidem) can be taken in the middle of the night, during a nocturnal awakening, as long as patients stay in bed for at least 4 hours after use. Patients who experience daytime sedation, incoordination, or other daytime effects should avoid activities requiring alertness (eg, driving), and the dose should be reduced, the drug stopped, or, if needed, another drug used. Other adverse effects include amnesia, hallucinations, incoordination, and falls. Falling is a significant risk with all hypnotics. When benzodiazepines are to be stopped, they should be tapered and not stopped abruptly. Three dual orexin receptor antagonists (daridorexant,lemborexant,suvorexant) can be used to treat sleep-onset and maintenance insomnia. They block orexin receptors in the brain, thereby blocking orexin-induced wakefulness signals and enabling sleep initiation. Dual orexin receptor antagonists block orexin receptors-1 and -2. The orexin receptor-1 is involved in suppressing the onset of rapid eye movement (REM) sleep; the orexin receptor-2 is involved in suppressing non-REM sleep onset and, to some extent, in controlling REM sleep. However, the mechanism of action for dual orexin receptor antagonists is not fully understood. They are used to treat sleep-onset and/or sleep maintenance insomnia, but these drugs are not overly effective for insomnia, and clinicians should consider the half-lives of these drugs. Forsuvorexant,the recommended dose is 10 mg, taken no more than once a night and taken within 30 minutes of going to bed, with at least 7 hours before the planned time of awakening. The dose can be increased but should not to exceed 20 mg once a day. The most common adverse effect is somnolence. Lemborexant5 mg is taken once a day within 30 minutes of going to bed; the dose can be increased to 10 mg (maximum dose) based on patient response and tolerability. Daridorexant25 to 50 mg is taken once a day within 30 minutes of going to bed.Daridorexanthas the shortest half-life (8 hours) of the dual oxexin receptor antagonists. Hypnotics should be used cautiously in patients with pulmonary insufficiency. In older patients, any hypnotic, even in small doses, can cause restlessness, excitement, falls, or exacerbation of delirium and dementia. Rarely, hypnotics can cause complex sleep-related behaviors, such as sleepwalking and even sleep driving; use of higher-than-recommended doses and concurrent consumption of alcoholic beverages may increase risk of such behaviors. Rarely, severe allergic reactions occur. Prolonged use of Sedatives is typically discouraged because tolerance can develop and because abrupt discontinuation can cause rebound insomnia or even anxiety, tremor, and seizures. These effects are more common with benzodiazepines (particularly Many drugs not specifically indicated for insomnia are used to induce and maintain sleep. Alcoholis used by many patients to help with sleep, but alcohol is a poor choice because it produces unrefreshing, disturbed sleep with frequent nocturnal awakenings, often increasing daytime sleepiness. Alcohol can further impair respiration during sleep in patients with obstructive sleep apnea and other pulmonary disorders such as chronic obstructive pulmonary disease (COPD). Over-the-counter (OTC) antihistamines(eg,doxylamine,diphenhydramine) can induce sleep. However, efficacy is unpredictable, and these drugs have long a half-life and have adverse effects such as daytime sedation, confusion, urinary retention, and other systemic anticholinergic effects, which are particularly worrisome in older people. Over-the-counter antihistamines should not be used to treat insomnia. Antidepressantstaken in low doses at bedtime (eg,doxepin25 to 50 mg,paroxetine5 to 20 mg,trazodone50 mg,trimipramine75 to 200 mg) may improve sleep. However, antidepressants should be used in these low doses mainly when standard hypnotics are not tolerated (rare) or in higher (antidepressant) doses when depression is present. Ultra low dosedoxepin(3 or 6 mg) is indicated for sleep maintenance insomnia. Melatoninis a hormone that is secreted by the pineal gland (and that occurs naturally in some foods). Darkness stimulates secretion, and light inhibits it. By binding withmelatoninreceptors in the suprachiasmatic nucleus,melatoninmediates circadian rhythms, especially during physiologic sleep onset. Oralmelatonin(typically 0.5 to 5 mg at bedtime) may be effective for sleep problems due to delayed sleep phase syndrome. When used to treat this disorder, it must be taken at the appropriate time (a few hours before the evening increase in endogenousmelatoninsecretion—in early evening for most people, typically 3 to 5 hours before the intended bedtime) and at a low dose of 0.5 to 1 mg; taken at the wrong time, it can aggravate sleep problems. For other forms of insomnia,melatonin's efficacy is largely unproved. Melatonincan cause headache, dizziness, nausea, and drowsiness. However, after widespread use, no other worrisome adverse effects have been reported. Available preparations ofmelatoninare unregulated, so content and purity cannot be ensured, and the effects of long-term use are unknown. Marijuana (Cannabis) None CBD oil (cannabidiol), which causes sedation and reduced sleep latency but no euphoria CBN (cannabinol), which causes sedation, reduces pain, and increases appetite THC (tetrahydrocannabinol), which causes euphoria, reduces pain and nausea, and has variable effects on sleep stages Cannabinoids, Synthetic , which is a synthetic analog Whether cannabis is effective for insomnia is unclear, but it is useful for chronic pain. Tolerance can develop; stopping cannabis after long-term use results in insomnia. 