Sleep-Wake Disorders Treatment & Management

Evaluate patients for other primary sleep disorders (eg, sleep apnea); the impact of prescribed medication; and underlying medical, psychiatric, and substance abuse disorders. Teach good sleep hygiene. If necessary, consider medication.

Consultation can help evaluate patients for medical (including psychiatric) causes of insomnia. The evaluation team optimally should include a psychiatrist, neurologist, pulmonologist, sleep medicine specialist, and dietitian. Surgical referral may be indicated to correct some underlying medical conditions that cause insomnia, such as for palate surgery in some cases of sleep apnea.

Educating patients in good sleep hygiene is the keystone of treatment. The following advice should be given to patients:

• Use the bed for sleep and sex only (no television watching or reading in bed)

• Avoid caffeine, especially late in the day; avoid activities that will get you stimulated and upset late in the day; practice relaxation techniques before bedtime

• Exercise each day

• Maintain a regular schedule for bedtime and wakening; avoid naps

• Do not watch the clock while in bed; avoid struggling to fall asleep in bed—instead, get up and spend quiet time out of bed until sleep comes

Sleep apnea can be alleviated by losing weight, the use of continuous positive airway pressure (CPAP), and, sometimes, surgical treatment.

When patients who are sleepwalkers, it may be necessary to prevent them from accidentally hurting themselves at night by walking into things or out of the house.

Light-phase shift therapy is useful for sleep disturbances associated with circadian rhythm abnormalities. Patients may be exposed to bright light, from either a light box or natural sunlight, to help normalize the sleep schedule.

Cognitive behavioral therapy (CBT) are efficacious for short-term treatment of insomnia, as are hypnotic medications (see below), but few patients achieve complete remission with any single treatment.

Morin et al studied 160 adults with persistent insomnia and demonstrated that CBT, either alone or in combination with zolpidem, yielded significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy. ^[8] Combined therapy produced a higher remission rate than CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% vs 43%). Long-term outcome was optimized when medication was discontinued during maintenance CBT.

A variety of software programs are commercially available that use wrist bands or motion-detection technology embedded in smart phones to identify and record a patient’s sleep cycles and behavior. This information is then used to give feedback to the patient about the duration and quality of their sleep and to make suggestions on how they can get more consistent and refreshing sleep. Some of the devices incorporate an alarm that is programmed to avoid waking the patient from deep sleep.

Many agents are useful in treating insomnia. ^[9] Short-term drug therapy is preferred to restore a normal sleep pattern. Generally, hypnotic drugs are approved for 2 weeks or less of continuous use. In chronic insomnia, longer courses may be indicated, which require long-term monitoring to ensure ongoing appropriate use of the medication.

Barbiturates and chloral hydrate are seldom used now, because of safety concerns related to their undesirably low therapeutic indexes.

Drugs that block the histamine type 1 receptor are used primarily in over-the-counter preparations, which are inexpensive and help some patients. However, in view of the anticholinergic properties of these agents, they should be used cautiously in older patients and in patients who have conditions such as prostatic hypertrophy, cognitive disorders, and constipation. In addition, most of these drugs have a long duration of action, and their sedative effects may persist well into the following day.

Zolpidem and zaleplon ^[10] are the newest and, arguably, the safest agents that have been approved by the US Food and Drug Administration (FDA) for short-term hypnotic use. Zolpidem is available an extended-release version that lasts slightly longer than the original preparation. In addition, the FDA has approved eszopiclone as the first agent for long-term use in the management of chronic insomnia.

Tasimelteon (Hetlioz) was approved by the US Food and Drug Administration (FDA) in January 2014 for treatment of non–24-hour sleep-wake disorder in the totally blind. Approval was based on results of 2 trials: the Safety and Efficacy of Tasimelteon (SET) trial, a 26-week study that included 84 patients, and the Randomized Withdrawal study of the Safety and Efficacy of Tasimelteon (RESET), a 19-week trial that included 20 patients, all of whom had been previously screened during the SET trial and entrained during open-label tasimelteon treatment.

Entrainment of the circadian rhythm, as measured by urinary 6-hydroxymelatonin sulfate (aMT6s), a main metabolite of melatonin, was the primary efficacy endpoint for SET. Scores on the 24-hour clinical response scale were another defined endpoint for SET. Outcomes for RESET included maintenance of entrainment (aMT6s) and maintenance of clinical response. Study results demonstrated that tasimelteon entrains the master clock (both melatonin and cortisol) and has clinically meaningful effects on the sleep-wake cycle in terms of the timing and amount of sleep, and improved measure of global functioning. ^{[11, 12]}

Suvorexant (Belsomra) was approved by the FDA in August 2014 and is the first orexin receptor antagonist for insomnia. It is indicated for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The orexin neuropeptide signaling system is a central promoter of wakefulness. Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R by suvorexant is thought to suppress wake drive. Approval was based on three clinical trials involving more than 500 participants. The recommended dose is 10 mg for most patients. After taking 20 mg, impairment of next-day driving was observed. ^[13]

Trazadone is frequently used and has a relative good safety profile. 

No special diet is needed to treat insomnia, but large meals and spicy foods should be avoided in the 3 hours before bedtime. Patients should avoid sleep-disturbing substances such as alcohol, nicotine, and caffeine. Alcohol creates the illusion of good sleep, but it adversely affects sleep architecture. Nicotine and caffeine are stimulating and should be avoided in the second half of the day, from late afternoon on. Consumption of tryptophan-containing foods may help induce sleep; the classic example is warm milk.

Strenuous exercise during the day may promote better sleep, but this same exercise during the 3 hours before bedtime can cause initial insomnia. Stimulating activities should be avoided 3 hours before bedtime. Examples include tense movies, exciting novels, thrilling television shows, arguments, and vigorous physical exercise other than coitus.

Inpatient care is rarely, if ever, required for treatment of insomnia. Only a severe underlying medical, psychiatric, or substance abuse disorder would warrant inpatient care. The numerous possible medical causes of sleep disorders make them difficult to diagnose and necessitate regular appropriate follow-up care until the final diagnosis has been made and successful treatment has been implemented. Several medical specialists may be needed for care and consultations; these may be coordinated by the patient’s internist, personal physician, or medical sleep specialist. Regular follow-up care, even if infrequent, is necessary once appropriate medication is successfully in use. (However, medication may be unnecessary.)