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  • 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 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 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)


  • 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).


  • 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).


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

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