What are the guidelines for managing interrupted sleep?

Guidelines for Managing Interrupted Sleep

A multicomponent protocolized approach to improving sleep that favors nonpharmacologic measures offers the best chance for better sleep quality and reduced sleep disruption. 1

Understanding Sleep Disruption

Sleep disruption is characterized by:

• Sleep fragmentation
• Abnormal circadian rhythms
• Increased light sleep (stages N1 + N2)
• Decreased slow-wave (stage N3) and rapid eye movement (REM) sleep 1

Poor sleep is not only a source of emotional distress but may contribute to:

• Delirium
• Prolonged mechanical ventilation
• Deranged immune function
• Neurocognitive dysfunction 1

Assessment of Sleep Disruption

When evaluating interrupted sleep, assess for:

1. Sleep pattern disturbances:

   • Difficulty with sleep initiation
   • Problems with sleep duration
   • Issues with sleep consolidation
   • Poor sleep quality 1

2. Sleep-related breathing disorders:

   • Screen for snoring and symptoms of sleep apnea
   • Consider referral for polysomnogram if sleep apnea is suspected 1

3. Contributing factors:

   • Environmental factors (noise, light, temperature)
   • Psychological factors (stress, anxiety)
   • Medical conditions
   • Medication effects 1

Management Recommendations

First-Line Approach: Nonpharmacologic Interventions

1. Cognitive Behavioral Therapy for Insomnia (CBT-I):

   • Recommended as first-line treatment for chronic insomnia 1, 2
   • Components include stimulus control, sleep restriction therapy, relaxation training, cognitive therapy, and sleep hygiene education 2

2. Sleep Hygiene Practices:

   • Important note: Sleep hygiene alone is not recommended as a stand-alone treatment for chronic insomnia disorder 1, 3
   • However, as part of a comprehensive approach, consider:
     • Maintaining consistent sleep/wake schedule
     • Creating a comfortable sleep environment
     • Limiting exposure to light in the evening
     • Morning exposure to bright light to regulate circadian rhythm 2, 4
     • Regular physical activity (30 minutes daily, preferably morning or afternoon) 2
     • Avoiding caffeine, alcohol, and heavy meals before bedtime 4

3. Environmental Modifications:

   • Minimize noise and light disruptions
   • Maintain comfortable room temperature
   • Use room cool-mist humidifiers to keep airways moist 1
   • Consider earplugs, eye masks, and soothing music 1

4. Clustering of Care:

   • Minimize nighttime interruptions by coordinating care activities 1
   • Early mobilization when appropriate 1

Second-Line Approach: Pharmacologic Interventions

If nonpharmacologic approaches are insufficient, consider short-term medication use:

1. For sleep onset insomnia:

   • Zolpidem: 10mg (adults), 5mg (elderly)
   • Zaleplon: 10mg
   • Ramelteon: 8mg 2

2. For sleep maintenance insomnia:

   • Low-dose doxepin (3-6mg) - has evidence for minimal adverse events
   • Eszopiclone: 2-3mg (1mg for elderly)
   • Temazepam: 15mg
   • Suvorexant: 10-20mg (5mg for elderly) 1, 2

3. Special considerations:

   • Elderly patients: Use lower doses due to increased risk of falls and cognitive impairment 2
   • Patients with substance use history: Prefer non-scheduled options like low-dose doxepin 2
   • Respiratory conditions: Avoid benzodiazepines due to risk of respiratory depression 2

Important Cautions

• Limit pharmacological treatment to 4-5 weeks when possible 2
• Start with the lowest effective dose 2
• Antihistamines (including hydroxyzine) are not recommended for chronic insomnia due to lack of efficacy and safety data 2
• Long-term use of any sleep medication should be avoided due to potential for dependence and tolerance 2
• Opioids are not recommended for insomnia treatment 2

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks after initiating any treatment 2
• Assess sleep parameters and monitor for side effects, particularly:
  • Daytime sedation
  • Falls
  • Cognitive changes 2
• Consider referral to a sleep specialist if insomnia persists or sleep-disordered breathing is suspected 2

Special Populations

For patients with comorbid conditions:

• PTSD with nightmares: Consider prazosin as first-line medication 2
• Depression with insomnia: Consider nortriptyline (10-40mg) or mirtazapine (7.5-15mg) 2
• Denture wearers: Ensure proper fit of dentures and counsel to remove them at night 1

By following these guidelines and tailoring interventions to individual needs, interrupted sleep can be effectively managed to improve quality of life and reduce associated health risks.