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  • The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., category of sleep–wake disorders encompasses insomnia, hypersomnolence, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep–wake disorders, nonrapid eye movement (NREM) sleep arousal disorders, nightmare disorder, rapid eye movement (REM) sleep behavior disorder, restless legs syndrome, and substance/medication-induced sleep disorder.


  • Humans typically have four to six cycles of NREM and REM sleep each night, each cycle lasting 70–120 minutes. Usually, there is progression through the four stages of NREM sleep before the first REM period.

  • Stage 1 of NREM is the stage between wakefulness and sleep. Stages 3 and 4 sleep are called delta sleep (ie, slow-wave sleep).

  • In REM sleep, there is a low-amplitude, mixed-frequency electroencephalogram, increased electrical and metabolic activity, increased cerebral blood flow, muscle atonia, poikilothermia, vivid dreaming, and fluctuations in respiratory and cardiac rate.

  • Older individuals have lighter more fragmented sleep with more arousals and gradual reduction in slow-wave sleep.

  • REM sleep is turned on by cholinergic cells. Dopamine has an alerting effect. Neurochemicals involved in wakefulness include norepinephrine and acetylcholine in the cortex and histamine and neuropeptides (eg, substance P and corticotropin-releasing factor) in the hypothalamus.

  • Polysomnography (PSG) measures multiple electrophysiologic parameters simultaneously during sleep (eg, electroencephalogram, electrooculogram of each eye, electrocardiogram, electromyogram, air thermistors, abdominal and thoracic strain belts, and oxygen saturation) to characterize sleep and diagnose sleep disorders.


  • Insomnia is subjectively characterized as trouble initiating or maintaining sleep associated with daytime consequences.

  • Transient (two or three nights) and short-term (less than 3 months) insomnia is common. Chronic insomnia (more than 3 months duration) occurs in 9%–12% of adults and in up to 20% of older individuals.


  • A complete diagnostic examination should include routine laboratory tests, physical and mental status examinations, as well as ruling out any medication- or substance-related causes.

  • Causes of insomnia include stress; jet lag or shift work; pain or other medical problems; mood or anxiety disorders; substance withdrawal; stimulants, steroids, or other medications.


  • Goals of Treatment: Correct the underlying sleep complaint, improve daytime functioning, and avoid adverse drug effects.

Nonpharmacologic Therapy

  • Behavioral and educational interventions that may help include short-term cognitive behavioral therapy, relaxation therapy, stimulus control therapy, cognitive therapy, sleep restriction, paradoxical intention, and sleep hygiene education (Table 71-1).

  • Management includes identifying the cause of insomnia, educating about sleep hygiene, managing stress, monitoring for mood symptoms, and eliminating unnecessary pharmacotherapy.

  • In patients aged 55 years and older, cognitive behavioral therapy may be more effective than pharmacologic therapy at improving certain measures of insomnia.

  • Transient and short-term insomnia should be treated with good sleep hygiene and careful use of sedative–hypnotics if necessary. Chronic insomnia calls for careful assessment for a medical cause, ...

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