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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 71, Sleep–Wake Disorders.



  • imageCommon causes of insomnia include concomitant psychiatric disorders, significant psychosocial stressors, excessive alcohol use, caffeine intake, and nicotine use.

  • imageGood 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.

  • imageLong-acting benzodiazepines should be avoided in the elderly.

  • imageBenzodiazepine receptor agonist tolerance and dependence are avoided by using low-dose therapy for the shortest possible duration.

  • imageObstructive 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.

  • imageNasal continuous positive airway pressure is the first-line therapy for obstructive sleep apnea, and weight loss should be encouraged in all obese patients.

  • imagePharmacologic management of narcolepsy is focused on two primary areas: treatment of excessive daytime sleepiness and REM sleep abnormalities.

  • imageShort-acting benzodiazepine receptor agonists, ramelteon, or melatonin taken at appropriate target bedtimes for east or west travel reduce jet lag and shorten sleep latency.

  • imageDopamine agonists are standard therapy for restless legs syndrome but have adverse effects that require careful monitoring by patient and providers.


Patient Care Process for Sleep–Wake Disorders



  • Patient characteristics (eg, age, sex, concomitant medical conditions, environmental or social stressors)

  • Information about nighttime sleep complaints and daytime consequences from patient and bedpartner

  • Detailed medication history of prescription, OTC, and complementary/alternative medication use

  • Subjective and objective data about daytime sleepiness, sleep quality, limb movements, snoring, witnessed apneas, and parasomnias

  • Information about sleep routine, sleep hygiene, and social history (caffeine, alcohol, and tobacco use)

  • Results from sleep testing (if available)


  • Evaluate if individual environmental or social issues are contributing to sleep difficulties.

  • Assess patient medications to determine if any medication may be contributing to sleep and/or daytime complaints.

  • Assess any laboratory or sleep study test results that aid in assessment/treatment of sleep complaints (serum ferritin, TSH, etc.).

  • Concomitant psychiatric or other medication conditions that should be addressed as part of sleep evaluation (eg, presence of anxiety, depression, chronic pain).


  • Optimize sleep hygiene and related behaviors (Tables 89-1 and 89-2) that may influence sleep and daytime symptoms.

  • For insomnia, if sedative-hypnotic therapy is prescribed, match the duration of action for agent to sleep complaint (eg, short-duration agents for difficulty initiating sleep and moderate duration agents for difficulty maintaining sleep) (Table 89-3).

  • Ensure that lowest doses of medication possible are used, but if response is inadequate, consider increasing dose or adding complementary medication.

  • For narcolepsy or sleepiness disorders, consider use of long-acting stimulants to increase wakefulness throughout the day with as needed ...

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