What are the recommendations for managing sleep difficulties?

Managing Sleep Difficulties: Evidence-Based Recommendations

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for chronic sleep difficulties, with pharmacotherapy reserved only for cases where CBT-I has failed, using the lowest effective doses for the shortest duration possible. 1, 2

Initial Assessment

Before initiating treatment, conduct a targeted evaluation to identify underlying causes and contributing factors:

• Review all medications that commonly disrupt sleep, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1, 2
• Screen for primary sleep disorders such as obstructive sleep apnea (24% prevalence in older adults), restless legs syndrome (12% prevalence), and periodic limb movements (45% prevalence) 2
• Identify sleep-impairing behaviors including excessive daytime napping (especially after 2 PM), prolonged time in bed, insufficient physical activity, evening alcohol consumption, caffeine use, and late heavy meals 3, 4
• Assess medical comorbidities such as pain, nocturia, gastroesophageal reflux, depression, anxiety, and neurodegenerative disorders that exacerbate sleep disruption 3, 2

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

The American College of Physicians and American Academy of Sleep Medicine recommend CBT-I as initial therapy due to proven efficacy with sustained effects for up to 2 years and minimal side effects compared to medications 1, 4. CBT-I combines multiple evidence-based components:

Sleep Restriction/Compression Therapy

• Limit time in bed to match actual sleep time (e.g., if sleeping only 5.5 hours while spending 8.5 hours in bed, restrict bed time to 5.5-6 hours initially) 3
• Gradually increase time in bed by 15-20 minute increments approximately every 5 days as sleep efficiency improves, until optimal sleep time is achieved 3
• Sleep compression variant allows gradual decrease in time in bed rather than immediate restriction, which is better tolerated by older adults 3, 1

Stimulus Control Therapy

Strengthen the association between the bedroom and sleep by implementing these specific instructions 3:

• Use the bedroom only for sleep and sex—no television, work, or other activities in bed 3
• Go to bed only when sleepy, not based on clock time 3
• Leave the bedroom if unable to fall asleep within 20 minutes and return only when sleepy 3
• Maintain consistent sleep and wake times—arise at the same time each morning regardless of sleep obtained 3
• Avoid daytime napping, or if necessary, limit to 30 minutes before 2 PM 3

Sleep Hygiene Education

While insufficient as standalone treatment, sleep hygiene is effective when combined with other CBT-I modalities 1, 2:

• Develop a 30-minute relaxation period before bedtime or take a hot bath 90 minutes before bed 3
• Ensure the bedroom is restful and comfortable—cool, dark, and quiet 3, 1
• Avoid heavy exercise within 2 hours of bedtime 3
• Eliminate sleep-fragmenting substances: caffeine, nicotine, and alcohol, especially in the evening 3, 5
• Avoid late heavy meals 3

Relaxation Techniques

• Progressive muscle relaxation (tensing and relaxing each muscle group) 3, 1
• Guided imagery and diaphragmatic breathing 3, 1
• Meditation and biofeedback 3

Cognitive Restructuring

• Address unrealistic sleep expectations and anxiety about sleep 1
• Provide education about normal sleep requirements (7-9 hours for adults) and age-related sleep changes 3

Pharmacological Treatment (Second-Line Only)

Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term medication use 1, 2.

Preferred First-Line Medications

Start all medications at the lowest available dose due to reduced drug clearance and increased sensitivity in older adults 1, 2:

• For sleep onset insomnia: Ramelteon (melatonin receptor agonist) is preferred due to safer profile and minimal adverse effects 1, 2
• For sleep maintenance insomnia: Low-dose doxepin (3-6 mg) is effective with minimal side effects 1, 2
• For both onset and maintenance: Eszopiclone or extended-release zolpidem 1

Medications to AVOID

The American Geriatrics Society strongly recommends avoiding the following due to unfavorable risk-benefit profiles 1, 2:

• Benzodiazepines (including temazepam)—higher risk of falls, cognitive impairment, dependence, and worsening dementia 1, 2
• Over-the-counter antihistamines (diphenhydramine)—anticholinergic effects and lack of efficacy data in elderly 1, 2
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine)—should only be used when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia 1, 2
• Barbiturates, chloral hydrate, and herbal supplements—lack of efficacy and safety data 1

Monitoring and Follow-Up

• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Employ the lowest effective maintenance dosage and taper when conditions allow 1
• For chronic hypnotic use: Administration may be nightly, intermittent (three nights per week), or as needed, with consistent follow-up 1
• Medication tapering is facilitated by concurrent CBT-I 1

Special Considerations

Environmental Modifications

• Decrease nighttime noise and light disruption to reduce nighttime arousals 1
• Increase daytime bright light exposure and physical activity to regulate circadian rhythms 2
• For nursing home residents: Implement multicomponent interventions combining increased daytime activity, sunlight exposure, decreased time in bed during the day, and minimized nighttime interruptions 1, 4

Combination Therapy

Combining CBT-I with pharmacotherapy may provide better short-term outcomes than either modality alone, with medications providing rapid onset relief and behavioral therapy providing longer-term sustained benefit 1.

Critical Pitfalls to Avoid

• Do not prescribe hypnotics before attempting CBT-I—behavioral interventions are more effective long-term and avoid polypharmacy risks 1
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities for chronic insomnia 3, 1
• Do not overlook medication-induced insomnia—SSRIs and other drugs commonly cause or worsen sleep disturbances 1
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1
• Avoid zolpidem in patients at risk for complex sleep behaviors—serious injuries and death have occurred during sleep-walking and sleep-driving episodes 6
• Ensure patients taking zolpidem have 7-8 hours available for sleep before being active again to minimize next-day impairment and driving risk 6

Optimal Sleep Duration

Adults should aim for 7-9 hours of sleep per 24-hour period for optimal health at a population level, although individual variability exists 3. Short sleep duration (<6 hours) is associated with adverse outcomes including mortality, while long sleep duration (>9-10 hours) may also be associated with adverse health outcomes and warrants investigation for underlying causes 3.