Insomnia: Management

00:01 In terms of treatment of insomnia, I wouldn't rush right to a sleep study or right to doing a bunch of laboratory testing.

00:10 Start with a sleep diary to actually document what's going on.

00:13 Think about those conditions that can make insomnia worse.

00:16 Treat their depression, treat pain before ordering a workup and certainly before recommending other hypnotic therapy for sleep, medications.

00:28 And start with some non-nonpharmacologic interventions.

00:32 These are effective.

00:33 They’re safe and they can prove to be helpful in other aspects of health beyond sleep.

00:39 So, moderate intensity exercise definitely helps regulate your cycle and it helps you sleep, but you want to complete that exercise at least four hours before bedtime.

00:48 Avoiding sleep during the day, if somebody is napping two-and-a-half hours during the afternoon, they're going to experience some awakenings and sleep latency.

00:58 That's normal.

00:59 And it has to be cut out if they ever want to sleep fully through the night.

01:03 Of course, limiting caffeine, tobacco and alcohol use is a good idea and not eating at least four hours before going to bed, avoiding any meal during that time as well.

01:15 Now, let’s talk about advice to give the patient with insomnia and just general sleep hygiene.

01:20 First of all, just go to bed when tired.

01:22 The patients who – again, who get into real trouble with insomnia are the ones who really try to force the sleep upon themselves and sleep just doesn't work like that.

01:33 And I think that promotes an anxiety.

01:35 Whether they had anxiety before or not, it promotes an anxiety in trying to sleep and worrying about this problem, such that it self-perpetuates and you're guaranteed to have more insomnia.

01:45 So, use the bed only when tired.

01:49 Use the bedroom only for sleep and for intimacy.

01:51 That's it.

01:52 Try to settle down before bedtime.

01:55 So, do really boring things.

01:56 I don’t know if chess necessarily boring.

01:58 There’s a pawn there, but maybe it’s reading.

02:01 It’s nothing crazy and active and you’re not running around, doing a million chores.

02:06 You do have a little time to settle down.

02:09 And if you wake up, do more boring things.

02:12 And if you do get up, and I think this is one of the most critical things, don't just lie and push yourself to try to sleep.

02:18 That again doesn't work.

02:19 Get up, get out of bed, do something for 20 minutes, 40 minutes and then return when you feel sleepy.

02:26 That one really does work.

02:28 And usually, between these recommendations and the lifestyle recommendations, you’re going to manage about 80 to 90% of insomnia cases effectively, just with these alone.

02:42 So, pharmacologic treatment, limited to the short term.

02:45 The drugs can disturb sleep architecture.

02:49 They have addictive potential.

02:51 And as well, among older adults, they can promote falls and more cognitive problems.

02:57 So, benzodiazepines, they have a higher risk of abuse.

03:00 I really use them for only very limited periods of time, no more than a week generally speaking for those drugs.

03:09 Over-the-counter treatments like diphenhydramine don't work very well, but they can promote some of that cognitive dysfunction, somnolence and falls.

03:18 And finally, just a quick word on melatonin.

03:21 It probably works particularly for switching time zone, but we’re talking about reducing sleep latency by a few minutes on average.

03:29 So, it's probably not something patients are really going to feel as a benefit.

03:33 But if it helps them relax and makes them feel a little bit better, that's great.

03:38 There is a risk of daytime grogginess afterwards as well with melatonin.

03:42 So, it's not a completely benign agent.

03:46 So, this gives you a nice overview of sleep.

03:50 It helps, I think, you to discuss normal sleep and changes with sleep as you age with your patients and then that's a nice entrée for starting to talk about sleep hygiene and how to how to set the right environment and tone for sleep.

04:06 And as I said, that's going to help you with the majority of your patients.

04:09 Thanks very much.