Insomnia: Therapeutic Approach

* Sleep apnea: Transient periods of breathing cessation during sleep. Two primary types exist: Central sleep apnea results from failure of stimulation by the respiratory centers in the medulla. Obstructive sleep apnea is caused by collapse or obstruction of the airway due to the inhibition of muscle tone during REM sleep.
^† Periodic limb movement disorder: Repetitive leg-jerking movements during sleep, 2 to 3 times per minute, with awakening periods.
** Restless leg syndrome: An uncomfortable sensation in the leg musculature causing changes of position during sleep, with recurrent arousals.
^ý Narcolepsy: Recurrent, irresistible brief episodes of sleep, often associated with hypnogogic or hypnopompic hallucinations, and cataplexy.

* Aim: Correct chronobiologic rhythm to more normal patterns.
^† May be related to jet lag, shift changes, or endogenous patterns.

• Regular bedtime

• Regular time for arousal

• Avoid naps

• Exercise several times each week (best not at bedtime)

• Participate in relaxing activities (eg, yoga, hobbies, etc)

• No caffeine (coffee, tea, cola) after noon

• No late evening alcohol

• Make bedroom comfortable, quiet, and dark

• Do calm activities before bedtime

• Mask background noise, if needed

• Sleep mask or earplugs, if needed

• Use bed only for sleeping, reading, or sex

• Limit challenging activities in the evening

• Avoid unpleasant tasks in the evening

• Consciously relax your muscles when going to bed

• Read or think about pleasant matters when trying to sleep

• Listening to music or watching television in bed is helpful for some people

• If unable to sleep after 30 minutes, get out of bed and do something calmative.

* The time involved for one half of an administered drug to be lost via metabolism and/or excretion.

* Half-lives highly variable between specific drugs in this class: eg, doxepine (Sinequan) = 8 hours; amitriptyline (Elavil, Endep) = 1 day; nortriptyline (Aventyl, Pamelor) = 1 day.
^† Half-lives extremely variable between specific drugs in this class: eg, paroxetine (Paxil) = 1 day; mirtazapine (Remeron) = 1-2 days.