How to manage sleep disturbances in a patient without nightmares?

Management of Sleep Disturbances in Patients Without Nightmares

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for managing sleep disturbances in patients without nightmares, as it demonstrates sustained improvements in sleep quality and quantity with better outcomes than prescription medications. 1, 2

Assessment of Sleep Disturbances

• Sleep disturbances can be categorized into three groups: difficulty falling asleep, behavior/movement disturbances during sleep, and excessive daytime sleepiness 3
• Insomnia, the most common sleep disorder, is defined by difficulty initiating sleep, maintaining sleep, or both, resulting in daytime consequences 3
• Sleep disturbances can significantly impair quality of life, resulting in daytime sleepiness, fatigue, and may exacerbate underlying psychiatric distress 4, 5
• Polysomnography is not routinely needed but may be appropriate to exclude other sleep disorders such as sleep-disordered breathing or parasomnias 4

Non-Pharmacological Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I includes several components that have shown efficacy for improving sleep initiation, maintenance, and quality:

• Stimulus Control: Instructions to strengthen the association between the bed/bedroom and sleep 4

  • Only go to bed when sleepy
  • Use the bed only for sleep and sexual activity
  • Leave the bedroom if unable to fall asleep within 15-20 minutes
  • Return to bed only when sleepy again
  • Maintain a regular wake-up time regardless of sleep duration

• Sleep Restriction: Limiting time in bed to match actual sleep time 4, 2

  • Initially restrict time in bed to the total sleep time (not less than 5 hours)
  • Maintain a sleep log to track sleep efficiency
  • Adjust time in bed weekly based on sleep efficiency (increase by 15-20 minutes if efficiency >85-90%, decrease if <80%)

• Sleep Hygiene Education: 4

  • Maintain a regular sleep schedule
  • Avoid caffeine, nicotine, alcohol, and excessive fluids before bedtime
  • Create a quiet, comfortable sleep environment
  • Avoid stimulating activities before bedtime
  • Regular daytime exercise (but not close to bedtime)

• Cognitive Therapy: Addressing dysfunctional beliefs about sleep 4, 2

  • Challenge unrealistic expectations about sleep
  • Address anxiety about sleep loss
  • Correct misconceptions about causes of insomnia

Progressive Deep Muscle Relaxation (PDMR)

• PDMR involves systematically tensing and releasing different muscle groups to induce physical relaxation 4
• Studies show PDMR can significantly decrease sleep disturbances, with one study showing 80% reduction in sleep problems 4

Sleep Dynamic Therapy

• An integrated sleep treatment program combining multiple evidence-based non-pharmacological therapies 4
• Typically delivered in 6 weekly, 2-hour sessions 4
• Has shown significant improvements in sleep quality that are maintained at follow-up 4

Pharmacological Interventions

While non-pharmacological approaches are preferred first-line treatments, medications may be considered in certain situations:

Benzodiazepine Receptor Agonists (BzRAs)

• May be considered for short-term use when non-pharmacological approaches are insufficient 4
• Selection should be based on the patient's specific sleep complaint (difficulty falling asleep vs. staying asleep) 4
• Shorter-acting agents are preferred for sleep initiation problems, while longer-acting agents may help with sleep maintenance 4

Low-Dose Sedating Antidepressants

• May be considered when other treatments have failed or when comorbid depression is present 4, 6
• Options include trazodone, mirtazapine, doxepin, and tricyclic antidepressants 4, 6
• Selection should consider side effect profiles (e.g., trazodone has less anticholinergic activity than doxepin) 4
• Low-dose antidepressants alone are not adequate treatment for major depression 4

Treatment Algorithm

1. First Line: Implement CBT-I components (stimulus control, sleep restriction, sleep hygiene, cognitive therapy) 4, 1, 2

2. Second Line: If CBT-I is partially effective, add relaxation techniques such as PDMR 4

3. Third Line: If non-pharmacological approaches are insufficient:

   • For short-term use: Consider BzRAs based on specific sleep complaint 4
   • For patients with comorbid depression: Consider low-dose sedating antidepressants 4, 6

4. Monitoring and Follow-up:

   • Maintain sleep logs to track progress 4
   • Assess for residual daytime impairments 4
   • Adjust treatment based on response 4

Special Considerations

• Sleep disturbances often have bidirectional relationships with other mental health conditions, with disrupted sleep frequently being a causal factor in other psychiatric problems 5
• Treating sleep disturbances may help prevent or reduce other mental health difficulties 5
• In older adults, special attention should be paid to medication side effects, particularly with sedating medications 4
• Regular monitoring for adverse effects is essential when using pharmacological interventions 4