- Common causes of insomnia include concomitant psychiatric disorders, significant psychosocial stressors, excessive alcohol use, caffeine intake, and nicotine use.
- Good sleep hygiene, including relaxing before bedtime, exercising regularly, establishing a regular bedtime and wake-up time, and discontinuing alcohol, caffeine, and nicotine, alone and in combination with drug therapy, should be part of patient education and treatments for insomnia.
- Long-acting benzodiazepines should be avoided in the elderly.
- Benzodiazepine tolerance and dependence are avoided by using low-dose therapy for the shortest possible duration.
- Obstructive sleep apnea may be an independent risk factor for the development of hypertension. When hypertension is present, it is often refractory to drug therapy until sleep-disordered breathing is alleviated.
- Nasal continuous positive airway pressure is the first-line therapy for obstructive sleep apnea, and weight loss should be encouraged in all obese patients.
- Pharmacologic management of narcolepsy is focused on two primary areas: treatment of excessive daytime sleepiness and rapid eye movement (REM) sleep abnormalities.
- Short-acting benzodiazepine receptor agonists, ramelteon, or melatonin taken at appropriate target bedtimes for east or west travel reduce jet lag and shorten sleep latency.
- Dopamine agonists are effective for restless legs syndrome and have replaced levodopa as first-line therapy.
After completing this chapter, the student should be able to:
Explain physiologic and systemic changes that occur during sleep.
Classify and discuss the etiologies for sleep disorders.
Discuss the association between specific sleep disorders and quality of life and risk for systemic diseases.
Appropriately identify and evaluate specific sleep disorders, including insomnia, sleep apnea, narcolepsy, restless legs syndrome, periodic limb movements of sleep, and circadian rhythm disorders.
Develop patient-specific nondrug and drug treatment plans for specific or coexisting sleep disorders, including insomnia, sleep apnea, narcolepsy, restless legs syndrome, periodic limb movements of sleep, and circadian rhythm disorders.
Apply principles of pharmacokinetics and pharmacodynamics to appropriately select a benzodiazepine receptor agonist for the treatment of insomnia.
Identify relevant adverse effects of benzodiazepine and GABAA agonist therapy and how to manage them during the treatment of insomnia.
Distinguish between the various wake-promoting therapies and their appropriate use for the treatment of narcolepsy.
Identify adverse effects and precautions of therapies for restless legs syndrome.
Differentiate between non-REM and REM parasomnias and recommend appropriate management and therapy.
Describe the differences in significance and management between PLMS and RLS.
Utilize standardized questionnaires and sleep laboratory findings to assess severity of sleep disorders.
Assess the effectiveness of and optimize nonpharmacologic and pharmacologic therapies for sleep disorders.
Educate and counsel patients on the importance of sleep and good sleep hygiene.
Discuss how unrecognized and poorly treated sleep disorders may affect the treatment and severity of concomitant systemic diseases.
Approximately 70 million Americans suffer with a sleep-related problem, and as many as 60% of those experience a chronic disorder.1 In a study by the National Institute on Aging, of 9,000 patients aged 65 years and older, more than 80% report a sleep-related disturbance.1