What treatment options are available for a patient with maintenance insomnia, characterized by difficulty staying asleep but no trouble falling asleep?

Treatment of Maintenance Insomnia (Difficulty Staying Asleep)

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as your first-line treatment—specifically emphasizing sleep restriction therapy and stimulus control, which directly target sleep maintenance problems. 1, 2

Initial Treatment: CBT-I Components

Sleep Restriction Therapy (Most Critical for Maintenance Insomnia)

• Have the patient keep a sleep log for 1-2 weeks to calculate actual total sleep time 1, 3
• Restrict time in bed to match only the actual sleep duration (minimum 5 hours allowed), which consolidates sleep by increasing sleep drive 1, 2
• Set a consistent wake time every morning regardless of sleep quality, and calculate bedtime backward from this wake time 3, 2
• Once sleep efficiency exceeds 85%, gradually increase time in bed by 15-30 minutes weekly 4, 3
• This approach specifically addresses the fragmented sleep pattern characteristic of maintenance insomnia 1

Stimulus Control Instructions

• Go to bed only when genuinely sleepy, not just tired 3, 2
• If unable to fall back asleep within approximately 20 minutes after waking, leave the bedroom and do a quiet, non-stimulating activity in dim light until sleepy, then return 3, 2
• Use the bed only for sleep and sex—no television, reading, or working in bed 4, 3
• Maintain the same wake time every day, even on weekends 3
• Avoid daytime napping, or if necessary, limit to 30 minutes before 2 PM 4, 3

Sleep Hygiene Modifications

• Eliminate all caffeine after noon 1, 3
• Avoid alcohol in the evening (causes sleep fragmentation) 4, 3
• Stop smoking, especially in the evening 4
• Avoid heavy exercise within 2 hours of bedtime 4
• Keep the bedroom dark, cool (around 65-68°F), and quiet 4, 1
• Avoid heavy meals close to bedtime 4, 3
• Remove clocks from view to prevent clock-watching, which increases anxiety 4, 3

Relaxation Techniques

• Practice progressive muscle relaxation, deep breathing exercises, or guided imagery 30 minutes before bed 4, 3
• Consider biofeedback or meditation if initial techniques are insufficient 4

Timeline and Reassessment

• Implement CBT-I consistently for 4-6 weeks before considering it unsuccessful 1, 3
• Reassess every 2-4 weeks initially to evaluate treatment effectiveness 3
• Counsel patients that initial mild sleepiness and fatigue typically resolve quickly as sleep consolidates 2

Second-Line: Pharmacological Treatment

Only consider medications if CBT-I has been attempted for 4-6 weeks without sufficient improvement, and always continue CBT-I alongside any medication 1, 2

Medication Options for Sleep Maintenance

• For sleep maintenance insomnia specifically: low-dose doxepin 3-6 mg 2
• For combined sleep onset and maintenance problems: eszopiclone 2-3 mg or zolpidem 10 mg 2, 5
• Eszopiclone is FDA-approved specifically for improving sleep maintenance and has been studied up to 6 months 5

Medications to Avoid

• Avoid benzodiazepines due to dependence risk, tolerance, cognitive impairment, and fall risk 1, 2
• 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

Medication Management

• Use the lowest effective dose 6
• Attempt medication tapering after 4-8 weeks when sleep consolidates 1, 3
• Never prescribe medications without concurrent behavioral therapy 1, 2

Critical Screening Before Treatment

Screen for underlying causes that may present as maintenance insomnia: 1, 2

• Obstructive sleep apnea (frequent awakenings, snoring, witnessed apneas)
• Restless legs syndrome (uncomfortable leg sensations at night)
• Medication side effects (diuretics causing nocturia, stimulating antidepressants, corticosteroids)
• Pain conditions
• Nocturia from prostate issues or diabetes
• Psychiatric conditions (depression, anxiety)

Common Pitfalls to Avoid

• Do NOT prescribe medications before attempting CBT-I—this is the most common error 2
• Do NOT rely on sleep hygiene education alone—it lacks efficacy as a single intervention 2, 7, 8
• Do NOT let patients stay in bed "trying to sleep" for hours—this worsens conditioned arousal and perpetuates the problem 2
• Do NOT prescribe sleep medications without concurrent behavioral therapy, as this leads to dependence without addressing underlying sleep architecture problems 1

Referral Considerations

• Consider referral to a sleep medicine specialist if insomnia persists despite 8-12 weeks of combined CBT-I and appropriate pharmacotherapy 3
• Refer if screening suggests underlying sleep disorders requiring polysomnography 1, 2