What are the causes of difficulty maintaining sleep (DMS) or insomnia with middle-of-the-night awakenings?

From the Guidelines

To address sleep issues with staying asleep, cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment, as it improves sleep quality and reduces symptoms of insomnia, according to the American College of Physicians 1.

Key Recommendations

• Establish a consistent sleep schedule by going to bed and waking up at the same time every day, even on weekends.
• Create a relaxing bedtime routine that includes activities like reading, gentle stretching, or meditation about 30-60 minutes before bed.
• Ensure your sleep environment is cool (around 65-68°F), dark, and quiet.
• Limit exposure to screens at least one hour before bedtime as blue light suppresses melatonin production.
• Avoid caffeine after noon and alcohol close to bedtime, as both can disrupt sleep architecture.

Treatment Options

• For persistent issues, short-term use of medications like melatonin (0.5-5mg taken 1-2 hours before bed) may help reset your sleep cycle 1.
• If problems persist beyond 2-3 weeks, consult a healthcare provider who might recommend CBT-I or prescription medications like trazodone (25-100mg) or low-dose doxepin (3-6mg) for short-term use 1.

Important Considerations

• Insomnia can be managed with psychological therapy, pharmacologic therapy, or a combination of both 1.
• Cognitive behavioral therapy for insomnia is multimodal cognitive behavioral therapy targeted specifically to insomnia, and it consists of a combination of cognitive therapy, behavioral interventions, and educational interventions 1.

From the FDA Drug Label

Sleep disturbance may be the presenting manifestation of an underlying physical and/or psychiatric disorder The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated Worsening of insomnia may be the consequence of an unrecognized psychiatric or physical disorder

Temazepam is used for the short-term treatment of insomnia, including issues with staying asleep. However, the FDA drug label does not provide direct information on the effectiveness of temazepam in addressing sleep issues with staying asleep. The label emphasizes the importance of evaluating the underlying cause of insomnia and monitoring for potential adverse effects, including worsening of insomnia or emergence of new abnormalities of thinking or behavior 2.

• Key considerations:
  • Evaluate the patient for underlying physical and/or psychiatric disorders
  • Monitor for worsening of insomnia or emergence of new abnormalities
  • Use the lowest possible effective dose, especially in elderly patients
  • Discontinuation of temazepam should be strongly considered for patients who report complex behaviors, such as "sleep-driving" 2.

From the Research

Sleep Issues with Staying Asleep

• Sleep maintenance insomnia is a common problem where individuals have difficulty staying asleep throughout the night 3.
• Current pharmacologic therapies for insomnia have limitations, including next-day sedation, risk of tolerance, and dependence 3.
• Cognitive Behavioral Therapy for Insomnia (CBT-i) is a recommended treatment for chronic insomnia, with benefits including improved sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 4, 5.
• CBT-i has been shown to be effective in adults with chronic insomnia, with sustained benefits and no reported adverse outcomes 4.
• Trazodone, a pharmacologic agent, has been compared to CBT-i in patients with insomnia and short sleep duration, with results suggesting that trazodone may be more effective in improving total sleep time and reducing salivary cortisol levels in this population 6.
• Sleep hygiene practices, such as maintaining a consistent sleep schedule, regular bedtime routine, and avoiding substances that can disrupt sleep, can also help improve sleep quality and duration 7.
• Recommendations for improving sleep include achieving 7-9 hours of sleep, engaging in regular exercise, and adopting a contemplative practice, as well as avoiding caffeine, alcohol, and heavy meals close to bedtime 7.