Treatment Options for Nighttime Awakenings
The most effective approach to treating nighttime awakenings is a multicomponent strategy that includes behavioral interventions, light therapy, and structured physical activity during the day, while avoiding pharmacological interventions particularly in elderly patients with dementia. 1, 2
Behavioral Interventions
- Establish good sleep hygiene techniques and maintain a regular sleep-wake schedule that allows adequate time for nocturnal sleep 1
- Implement a consistent bedtime routine, which has shown a dose-dependent relationship with better sleep outcomes including reduced night wakings 3
- Reduce time spent in bed during daytime hours to minimize daytime napping and consolidate nighttime sleep 1, 2
- Schedule two short 15-20 minute naps, one around noon and another around 4:00-5:00 pm, which may help alleviate sleepiness without disrupting nighttime sleep 1, 4
- Create a sleep-conducive environment by reducing nighttime light and noise, which can minimize awakenings, particularly in nursing home residents 1, 2
Light Therapy
- Increase both duration and intensity of light exposure throughout the daytime (2,500-5,000 lux for 1-2 hours in the morning) and avoid exposure to bright light in the evening 1, 2
- Morning bright light exposure delivered for 2 hours at 3,000 to 5,000 lux over 4 weeks has been found to decrease daytime napping and increase nighttime sleep in patients with dementia 1
- Light therapy helps consolidate nighttime sleep, decrease agitated behavior, and increase the amplitude of circadian rhythms 1, 2
Physical and Social Activity
- Structured physical and social activity provides temporal cues needed to increase the regularity of the sleep-wake schedule 1
- Encourage at least 30 minutes of daily sunlight exposure combined with increased physical activity 1, 2
- Increase participation in social activities and conversation, which has been shown to help elderly subjects with disrupted sleep-wake patterns sleep less during the day 1
Pharmacological Considerations
- Melatonin has yielded inconsistent results in treating irregular sleep-wake rhythm disorder, with inconclusive evidence for efficacy 1
- For shift work-related sleep disturbances, modafinil (200-400 mg) may be considered as first-line therapy for excessive sleepiness, with common side effects including nausea, headaches, and nervousness 4
- Avoid benzodiazepines in elderly patients or those with cognitive impairment due to risk of falls, confusion, and worsening cognitive impairment 4
- Exercise caution when using zolpidem due to risk of next-morning impairment; lower doses are recommended by the FDA (5 mg for immediate-release products) 4, 5
Special Considerations for Different Populations
For Elderly Patients with Dementia:
- The American Academy of Sleep Medicine suggests treating ISWD with light therapy (weak recommendation) 2
- Strongly avoid sleep-promoting medications due to increased risks of falls and other adverse outcomes 2
- Improve incontinence care to minimize nighttime awakenings in nursing home residents 1, 2
For Patients with Shift Work Disorder:
- Maintain good sleep hygiene and a regular sleep-wake schedule 1, 4
- Consider modafinil as first-line therapy for excessive sleepiness 4
- Judicious use of caffeine, with the last dose given no later than 4:00 pm 4
Common Pitfalls and Caveats
- Sleep restriction therapy may initially result in decreased total sleep time before improvements are seen 1, 6
- Light therapy may be labor-intensive depending on the method and setting of delivery 2
- Always assess for potential contraindications to light therapy, including preexisting mania, retinal photosensitivity, and migraine 2
- When using medications like modafinil, more frequent follow-up is necessary when starting or adjusting doses to monitor for adverse effects 1, 4
- Nocturnal awakenings affect about one-third of the general population and are associated with a wide variety of organic diseases and psychiatric disorders that warrant appropriate treatment 7