What treatment options are available for a patient with sleep disturbances?

Treatment of Sleep Disturbances

Start with sleep hygiene education and cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, reserving pharmacological interventions only when behavioral approaches fail after 4-8 weeks. 1

Initial Assessment and Diagnosis

Before initiating treatment, identify the specific type of sleep disturbance:

• Insomnia: Difficulty falling asleep and/or maintaining sleep at least 3 times per week for at least 4 weeks, accompanied by distress 2
• Excessive sleepiness with snoring/apneas: Screen with STOP questionnaire for obstructive sleep apnea (OSA); confirm with polysomnography if positive 2
• Leg discomfort worse at night, relieved by movement: Check ferritin levels; levels <45-50 ng/mL indicate treatable restless legs syndrome (RLS) 2
• Excessive sleepiness with cataplexy, frequent short naps, vivid dreams, or sleep paralysis: Consider narcolepsy; confirm with polysomnography and multiple sleep latency test 2

First-Line Treatment: Non-Pharmacological Interventions

Sleep Hygiene Education (Essential for All Patients)

Implement these specific measures 2:

• Regular morning or afternoon exercise (not evening)
• Daytime exposure to bright light
• Keep bedroom dark, quiet, and comfortable
• Avoid heavy meals, alcohol, and nicotine near bedtime
• Go to bed only when sleepy
• Get out of bed if unable to sleep within 20 minutes
• Use bed only for sleep and sex

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is the gold standard for chronic insomnia and should be implemented before any medication trial. 1

Key components include 1:

• Sleep restriction therapy: Limit time in bed to match actual sleep duration based on sleep logs; this enhances sleep drive and consolidates sleep
• Stimulus control: Break the association between bed and wakefulness using the sleep hygiene principles above
• Cognitive therapy: Address maladaptive thoughts about sleep
• Relaxation techniques: Consider adding if insufficient improvement after 4 weeks

Evidence: A randomized trial in 150 cancer survivors showed CBT-I (5 weekly group sessions) reduced mean wakefulness by almost 1 hour per night, while usual care had no effect 2

Physical Activity

• Yoga: A randomized trial of 410 survivors showed standardized yoga improved global sleep quality, subjective sleep quality, daytime functioning, and sleep efficiency (all P≤0.05), with decreased sleep medication use 2
• Exercise: Meta-analysis showed exercise improved sleep at 12-week follow-up in cancer survivors 2

Second-Line Treatment: Pharmacological Options

Consider pharmacological treatment only after behavioral interventions have been unsuccessful for 4-8 weeks. 1

For Insomnia (Sleep Maintenance Problems)

FDA-approved options 1:

• Eszopiclone
• Temazepam

Low-dose sedating antidepressants 1:

• Trazodone: Initial dose 150 mg/day in divided doses, can be increased by 50 mg every 3-4 days; maximum 400 mg/day for outpatients; take shortly after meal or light snack 3
• Doxepin (low-dose)

Important caveat: One small study found mirtazapine increased total nighttime sleep in cancer patients, but overall data on pharmacologic interventions for sleep in cancer patients are lacking 2

For Restless Legs Syndrome

Treat with 2:

• Dopamine agonists (first-line)
• Gabapentin (calcium channel alpha-2-delta ligand; meta-analyses show effectiveness)
• Benzodiazepines
• Opioids
• Refer to sleep specialist

For Obstructive Sleep Apnea

• Continuous positive airway pressure (CPAP) is primary treatment 2
• Surgery or oral appliances as alternatives
• Weight loss and exercise
• Refer to sleep specialist

For Narcolepsy

• Psychostimulants: Modafinil, methylphenidate 2

Critical Pitfalls to Avoid

• Never prescribe sleep medications without concurrent behavioral therapy, as this leads to dependence without addressing underlying sleep architecture problems 1
• Avoid long-term benzodiazepines due to risk of dependence, tolerance, and cognitive impairment 1
• Avoid antihistamines (diphenhydramine, doxylamine) due to anticholinergic effects, daytime sedation, and delirium risk, especially in older adults 1
• Avoid antipsychotics as first-line treatment due to metabolic side effects 1
• Screen for underlying causes before assuming primary insomnia: sleep apnea, restless legs syndrome, medication side effects, pain, nocturia, or psychiatric conditions 1
• Antidepressants, antihistamines, antiepileptics, and antipsychotics are often used off-label for insomnia with limited efficacy data and significant risks; use with caution 2

Treatment Algorithm

1. Weeks 0-2: Implement sleep hygiene education and document sleep patterns with sleep logs 1
2. Weeks 2-6: Focus on CBT-I with stimulus control and sleep restriction therapy 1
3. Weeks 6-8: Add relaxation techniques or biofeedback if insufficient improvement 1
4. Week 8+: Evaluate for contributing medical conditions or medications; consider short-term pharmacological therapy if still insufficient 1
5. Ongoing: Attempt medication tapering after 4-8 weeks when sleep consolidates; continue behavioral interventions 1

Special Considerations

• Melatonin: Results are inconclusive, but lower doses may be more effective; it is drug-free and non-habit forming 4, 5
• Referral to sleep specialist: Indicated for persistent sleep disturbances despite adequate treatment, suspected OSA, RLS, narcolepsy, or complex cases 2, 1
• Regular reassessment: Essential to evaluate treatment efficacy and monitor for medication side effects such as residual daytime sedation and complex sleep behaviors 1