What are the recommended medications and treatments for patients with sleep disturbances?

Recommended Medications and Treatments for Sleep Disturbances

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the foundation of treatment for most sleep disturbances, with pharmacologic interventions used as adjunctive therapy when necessary. 1

Assessment and Classification of Sleep Disorders

• Sleep disorders are generally categorized into two main types: insomnia (difficulty falling asleep and/or maintaining sleep) and sleep disturbance/excessive sleepiness 2
• Insomnia is diagnosed when patients have difficulty falling asleep and/or maintaining sleep at least 3 times per week for at least 4 weeks, accompanied by distress 2
• Excessive sleepiness may be associated with obstructive sleep apnea (OSA), narcolepsy, or restless legs syndrome (RLS) 2

First-Line Non-Pharmacologic Interventions

Sleep Hygiene Education

• Educate patients about proper sleep hygiene including regular morning/afternoon exercise, daytime exposure to bright light, keeping sleep environment dark/quiet/comfortable, and avoiding heavy meals, alcohol, and nicotine near bedtime 2
• Sleep hygiene education is especially recommended for the treatment of insomnia 2

Cognitive Behavioral Therapy (CBT)

• CBT is strongly recommended as first-line treatment for insomnia, with multiple randomized controlled trials showing significant improvement in sleep quality 2, 1
• Components include stimulus control therapy, sleep restriction, relaxation techniques, and cognitive restructuring 1
• One randomized controlled trial found that 5 weekly group CBT sessions reduced mean wakefulness by almost 1 hour per night 2

Physical Activity

• Regular exercise may improve sleep quality in patients with sleep disturbances 2
• A randomized controlled trial showed that yoga intervention plus standard care resulted in greater improvements in global and subjective sleep quality, daytime functioning, and sleep efficiency compared to standard care alone 2

Pharmacologic Interventions for Specific Sleep Disorders

For Insomnia

• Short-term use of hypnotics may be considered when non-pharmacologic interventions are insufficient 2
• Zolpidem is indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation, shown to decrease sleep latency for up to 35 days in controlled clinical studies 3
• Important cautions with zolpidem include:
  • Do not take more than prescribed
  • Take only when able to stay in bed for 7-8 hours
  • Risk of complex sleep behaviors that can cause serious injury (sleep-driving, sleep-eating, etc.)
  • Potential for next-day residual effects, especially at doses above 10mg 3
• Low-dose doxepin (3-6mg) may be considered for sleep maintenance issues 1
• Ramelteon (8mg) may be considered for sleep onset issues 1

For Restless Legs Syndrome (RLS)

• Check ferritin levels; levels less than 45-50 ng/mL indicate a treatable cause of RLS 2
• Treatment options include:
  • Dopamine agonists (first-line) 2
  • Gabapentin or other calcium channel alpha-2-delta ligands 2
  • Benzodiazepines (with caution) 2
  • Opioids (for refractory cases) 2

For Obstructive Sleep Apnea (OSA)

• Primary treatments include:
  • Continuous positive airway pressure (CPAP) 2
  • Weight loss and exercise 2
  • Oral appliances or surgery in selected cases 2
  • Referral to a sleep specialist 2

Special Considerations

Elderly Patients

• Lower doses of medications are recommended (e.g., 5mg zolpidem instead of 10mg) 2
• Avoid benzodiazepines in older patients and those with cognitive impairment due to risk of decreased cognitive performance 2

Refractory Insomnia

• For patients with persistent insomnia unresponsive to multiple medications, reevaluation is necessary 1
• Consider a sleep study to rule out other sleep disorders 1
• Evaluate for psychiatric comorbidities and medical conditions that could be contributing to insomnia 1
• Avoid combining multiple sedative medications due to increased risk of adverse effects 1
• Antipsychotics like quetiapine are not recommended as first-line treatments for insomnia due to metabolic side effects 1

Common Pitfalls to Avoid

• Using pharmacologic treatments as first-line therapy instead of non-pharmacologic approaches 2, 1
• Long-term use of hypnotic medications, which can lead to dependence 2
• Inadequate dosing or inappropriate timing of medication administration 3
• Failure to address underlying causes of sleep disturbances 1
• Using antipsychotics as first-line treatment for insomnia 2, 1

By following this evidence-based approach to managing sleep disturbances, clinicians can help improve sleep quality and overall quality of life for their patients while minimizing potential adverse effects from medications.