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KEY CONCEPTS

KEY CONCEPTS

  • imageCommon causes of insomnia include concomitant mental illness, significant psychosocial stressors, 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 pharmacotherapy, should be part of patient education and treatments for insomnia.

  • imageLong-acting benzodiazepines should be avoided in older individuals.

  • imageBenzodiazepine receptor agonist tolerance and physical 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 pharmacotherapy 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 rapid eye movement (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.

  • imageThe alpha-2-delta ligands, gabapentin, gabapentin enacarbil, and pregabalin, are standard therapy for chronic restless legs syndrome and have not caused symptom augmentation during chronic therapy.

PATIENT CARE PROCESS

Patient Care Process for Sleep–Wake Disorders

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Collect

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

  • Information about nighttime sleep complaints and daytime consequences from patient and bed partner

  • Detailed medication history of prescription, over the counter(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 (eg, caffeine, alcohol, and tobacco use)

  • Results from sleep testing (if available)

Assess

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

  • Assess medications to determine if any 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 (eg, serum ferritin, TSH, and so on).

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

Plan*

  • Optimize sleep hygiene and related behaviors (Tables 92-1 and 92-2) that may influence sleep and daytime symptoms.

  • For insomnia, if sedative-hypnotic therapy is prescribed, match the agent’s duration of action to sleep complaint (eg, short-duration agents for difficulty initiating sleep and moderate duration agents for difficulty maintaining sleep) (Table 92-3).

  • Ensure that lowest doses of medication 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. Add as needed short-acting stimulants for late afternoon or evening periods requiring wakefulness (Table 92-4).

Implement*

  • Provide patient education regarding all elements of treatment ...

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