Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 25-15: Sleep-Wake Disorders + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Transient episodes are usually of little significance Common factors Stress Caffeine Physical discomfort Daytime napping, early bedtime Psychiatric disorders are often associated with persistent insomnia +++ General Considerations ++ Sleep consists of two distinct states REM (rapid eye movement) sleep, also called dream sleep NREM (non-REM) sleep, is divided into stages 1, 2, 3, and 4 Dreaming occurs mostly in REM and to a lesser extent in NREM sleep Sleep is a cyclic phenomenon, with four or five REM periods during the night accounting for about one-fourth of the total night's sleep (1½–2 hours) The first REM period occurs about 80–120 minutes after onset of sleep and lasts about 10 minutes Later REM periods are longer (15–40 minutes) and occur mostly in the last hours of sleep. Most stage 4 (deepest) sleep occurs in the first several hours Age-related changes in normal sleep include An unchanging percentage of REM sleep A marked decrease in stage 3 and stage 4 sleep An increase in wakeful periods during the night These normal changes, early bedtimes, and daytime naps contribute to the insomnia in older people Variations in sleep patterns may be due to circumstances (eg, "jet lag") or to idiosyncratic patterns ("night owls") in persons with different "biological rhythms" who habitually go to bed late and sleep late in the morning Creativity and rapidity of response to unfamiliar situations are impaired by loss of sleep Desynchronization sleep disorder: rare; chronic difficulty in adapting to a 24-hour sleep-wake cycle; can be resynchronized by altering exposure to light Depression is usually associated with Fragmented sleep Decreased total sleep time Earlier onset of REM sleep A shift of REM activity to the first half of the night Loss of slow-wave sleep Manic disorders Sleeplessness is a cardinal feature and an important early sign of impending mania in bipolar cases Total sleep time is decreased Shortened REM latency and increased REM activity Sleep-related panic attacks occur in the transition from stage 2 to stage 3 sleep in some patients with a longer REM latency in the sleep pattern preceding the attacks Abuse of alcohol May cause or be secondary to the sleep disturbance There is a tendency to use alcohol as a means of getting to sleep without realizing that it disrupts the normal sleep cycle Acute alcohol intake Produces a decreased sleep latency with reduced REM sleep during the first half of the night REM sleep is increased in the second half of the night, with an increase in total amount of slow-wave sleep (stages 3 and 4) Vivid dreams and frequent awakenings are common Chronic alcohol abuse Increases stage 1 and decreases REM sleep (most drugs delay or block REM sleep) Symptoms persist for many months after the person has stopped drinking Acute alcohol or other sedative withdrawal Delayed onset of sleep and REM rebound Intermittent awakening during the night Heavy smoking (> 1 pack a day) causes difficulty falling asleep Excess intake of stimulants near bedtime of caffeine, cocaine, and other stimulants (eg, over-the-counter cold remedies) causes decreased total sleep time—mostly NREM sleep—with some increased sleep latency Benzodiazepine sedative-hypnotics tend to Increase total sleep time Decrease sleep latency Decrease nocturnal awakening Have variable effects on NREM sleep Withdrawal causes just the opposite effects and results in continued use of the drug for the purpose of preventing withdrawal symptoms Non-benzodiazepine hypnotics (such as zolpidem) have similar effects on sleep as do the benzodiazepines Antidepressants decrease REM sleep (with marked rebound on withdrawal in the form of nightmares) and have varying effects on NREM sleep REM sleep deprivation produces improvement in some depressions Persistent insomnias are also related to a wide variety of medical conditions, particularly Delirium Pain Respiratory distress syndromes Uremia Asthma Thyroid disorders Nocturia due to benign prostatic hyperplasia Adequate analgesia and proper treatment of medical disorders reduce symptoms and decrease the need for sedatives + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Difficulty getting to sleep or staying asleep Intermittent wakefulness during the night Early morning awakening Combinations of any of the latter +++ Differential Diagnosis ++ Nocturia Diuretics Benign prostatic hyperplasia Incontinence Chronic heart failure Restless legs syndrome Medications Corticosteroids Selective serotonin reuptake inhibitors Theophylline Benzodiazepine withdrawal Circadian rhythm disorder + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Consider thyroid-stimulating hormone + Treatment Download Section PDF Listen +++ +++ Medications ++ There are two broad classes of treatment, and the two may be combined Psychological (cognitive-behavioral) Pharmacologic Pharmacologic In situations of acute distress, such as a grief reaction, pharmacologic measures may be most appropriate These drugs are often effective for the elderly population and can be given in larger doses—twice what is prescribed for the elderly—in younger patients Lorazepam 0.5 mg orally at bedtime Eszopiclone 2–3 mg orally at bedtime Temazepam 7.5–15.0 mg orally at bedtime Zolpidem 5–10 mg orally at bedtime Zaleplon 5–10 mg orally at bedtime Zaleplon is often used to treat insomnia characterized by middle-of-the-night awakening with difficulty falling back to sleep Eszopiclone (2–3 mg orally) is similar in action to zolpidem and zaleplon and has a longer duration of action Longer-acting agents such as flurazepam (half-life of > 48 h) may accumulate in the elderly and lead to cognitive slowing, ataxia, falls, and somnolence In general, it is appropriate to use medications for short courses of 1–2 weeks Antihistamines such as diphenhydramine 25 mg orally at bedtime or hydroxyzine 25 mg orally at bedtime may be useful Their anticholinergic effects may produce confusion or urinary symptoms in the elderly Trazodone 25–150 mg orally at bedtime is a non–habit-forming effective sleep medication in lower than antidepressant doses Priapism is a rare side effect requiring emergent treatment Doxepin, a tricyclic antidepressant, is also efficacious in low doses of 3–6 mg per night for insomnia Ramelteon 8 mg orally at bedtime helps with sleep onset and does not appear to have abuse potential Triazolam is popular because of its very short duration of action It has been associated with dependency, transient psychotic reactions, anterograde amnesia, and rebound anxiety, therefore, it has been removed from the market in several European countries If used, it should be prescribed only for short periods of time Dual orexin receptor antagonist (DORAs) Approved to help initiate and maintain sleep DORAs such as suvorexant (10–20 mg orally given about 30 minutes before bedtime) may be more effective than other hypnotics for some patients However, cost may be a factor and suvorexant is associated with significant increase in depressive symptoms in a subset of patients +++ Therapeutic Procedures ++ With primary insomnia initial efforts should be psychologically based, particularly in the elderly Psychological Educate the patient regarding good sleep hygiene Go to bed only when sleepy Use the bed and bedroom only for sleeping and sex If still awake after 20 minutes, leave the bedroom, pursue a restful activity (such as a bath or meditation), and return only when sleepy Get up at the same time every morning, regardless of the amount of sleep during the night Discontinue caffeine and nicotine, at least in the evening if not completely Establish a daily exercise regimen Avoid alcohol because it may disrupt continuity of sleep Limit fluids in the evening Learn and practice relaxation techniques Establish a bedtime ritual and a routine time for going to sleep Cognitive behavioral therapy for insomnia may be efficacious + Outcome Download Section PDF Listen +++ +++ Prevention ++ Discontinue use of caffeine and nicotine Avoid alcohol Engage in regular exercise program + References Download Section PDF Listen +++ + +Espie CA et al. Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA Psychiatry. 2019 Jan 1;76(1):21–30. [PubMed: 30264137] + +Khoury J et al. Primary sleep disorders. Psychiatr Clin North Am. 2015 Dec;38(4):683–704. [PubMed: 26600103] + +Krystal AD et al. The assessment and management of insomnia: an update. World Psychiatry. 2019 Oct;18(3):337–52. [PubMed: 31496087] + +Sateia MJ et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017 Feb 15;13(2):307–49. [PubMed: 27998379] + +Trauer JM et al. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015 Aug 4;163(3):191–204. [PubMed: 26054060]