What can be added to manage sleep disturbances?

Management of Sleep Disturbances

For sleep disturbances, cognitive behavioral therapy (CBT) combined with sleep hygiene education, relaxation therapy, and sleep restriction therapy is the most effective first-line approach, with pharmacological options like trazodone (25-100mg) reserved for when non-pharmacological interventions are insufficient. 1

Non-Pharmacological Interventions (First-Line)

Sleep Hygiene Education

• Wake up at the same time every day
• Maintain a consistent bedtime
• Exercise regularly but not within 2-4 hours of bedtime
• Perform relaxing activities before bed
• Keep the bedroom quiet, dark, and temperature-regulated
• Avoid watching the clock at night
• Avoid caffeine and nicotine for at least 6 hours before bedtime
• Drink alcohol only in moderation and avoid use for at least 4 hours before bedtime
• Avoid napping and excess fluid intake before bedtime 1

Cognitive Behavioral Therapy (CBT)

• Most effective non-pharmacological intervention with strong evidence
• Multimodal approach including:
  • Sleep hygiene education
  • Sleep restriction (limiting time in bed)
  • Stimulus control (associating bed with sleep only)
  • Cognitive restructuring (addressing negative thoughts about sleep)
  • Relaxation techniques 1
• Multiple randomized trials have shown CBT improves sleep in cancer patients and survivors 1
• Can be delivered in individual or group formats, and even online 1

Physical Activity

• Regular morning or afternoon exercise
• Yoga has shown significant improvements in sleep quality, daytime functioning, and sleep efficiency 1
• Meta-analyses show exercise improves sleep at 12-week follow-up 1

Mind-Body Interventions

• Mindfulness meditation significantly decreases sleep disturbance compared to sleep hygiene education alone 1
• Progressive muscle relaxation helps reduce somatic arousal that interferes with sleep 2
• Web-based self-hypnosis therapy has shown some reduction in insomnia severity 1

Pharmacological Interventions (Second-Line)

When non-pharmacological approaches are insufficient after 4-6 weeks of consistent implementation, consider pharmacological options:

Preferred Options

• Trazodone (25-100mg at bedtime):

  • Preferred over benzodiazepines
  • Initial dose of 25-50mg, can be gradually increased
  • Take shortly after a meal or light snack 2, 3

• Mirtazapine (7.5-30mg at bedtime):

  • Particularly useful when depression and insomnia coexist
  • Has shown to increase total nighttime sleep 1, 2

Other Options

• Melatonin (3mg):

  • Helps establish normal sleep patterns
  • Non-habit forming 4
  • May increase sleep length during daytime sleep (by approximately 24 minutes) 5

• Non-benzodiazepine hypnotics (zolpidem, zaleplon):

  • Use with caution and in reduced doses
  • Short-term use only 1
  • Not recommended for long-term use due to risk of dependence 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity and type of sleep disturbance
   • Rule out sleep apnea and restless legs syndrome
   • Check for underlying causes (pain, fatigue, depression)
   • Consider keeping a sleep diary for 2 weeks 1

2. First-Line Treatment (4-6 weeks minimum):

   • Implement comprehensive sleep hygiene measures
   • Initiate CBT if available
   • Incorporate regular exercise, preferably morning/afternoon
   • Add mind-body techniques (meditation, relaxation)

3. If Insufficient Response:

   • Add pharmacotherapy with trazodone 25-50mg at bedtime
   • For comorbid depression, consider mirtazapine 7.5-15mg
   • For circadian rhythm issues, consider melatonin 3mg

4. Follow-up and Adjustment:

   • Reassess every 2-4 weeks
   • Adjust medication doses according to response
   • Attempt gradual withdrawal of medications when stability is achieved

Common Pitfalls to Avoid

• Relying solely on sleep hygiene without additional interventions
• Using sedating medications long-term without addressing underlying causes
• Ignoring comorbid conditions that may affect sleep (pain, depression)
• Using long-acting benzodiazepines, especially in elderly patients (risk of falls, cognitive impairment)
• Failing to maintain consistent sleep-wake schedules, even on weekends 2

Special Considerations

• For restless legs syndrome, consider gabapentin or dopamine agonists 1
• For shift workers, strategically timed melatonin and light therapy may help reset circadian rhythms 5
• Atypical antipsychotics are not recommended as first-line treatment for insomnia due to metabolic side effects 1
• When pharmacotherapy is used, choose the specific agent based on symptom pattern, treatment goals, patient preference, and comorbid conditions 1