Insomnia and Excessive Daytime Sleepiness: A Merck Manual of Patient Symptoms podcast

The most commonly reported sleep-related symptoms are insomnia and excessive daytime sleepiness (EDS).

• Insomnia is difficulty falling or staying asleep or a sensation of unrefreshing sleep.
• EDS is the tendency to fall asleep during normal waking hours.

EDS is not a disorder but a symptom of various sleep-related disorders. Insomnia can be a disorder, even if it exists in the context of other disorders, or can be a symptom of other disorders. Parasomnias are abnormal sleep-related events.

Pathophysiology

There are 2 states of sleep, each marked by characteristic physiologic changes:

• Nonrapid eye movement (NREM): NREM sleep constitutes about 75 to 80% of total sleep time in adults. It consists of 3 stages (N1 to N3) in increasing depth of sleep. Slow, rolling eye movements, which characterize quiet wakefulness and early stage N1 sleep, disappear in deeper sleep stages. Muscle activity also decreases. Stage N3 is referred to as deep sleep because arousal threshold is high; people may perceive this stage as high-quality sleep.
• Rapid eye movement (REM): REM sleep follows each cycle of NREM sleep. It is characterized by low-voltage fast activity on the EEG and postural muscle atonia. Respiration rate and depth fluctuate dramatically. Most dreams occur during REM sleep.

Progression through the 3 stages, typically followed by a brief interval of REM sleep, occurs cyclically 5 to 6 times a night (see Fig. 1: Sleep and Wakefulness Disorders: Typical sleep pattern in young adults.). Brief periods of wakefulness (stage W) occur periodically.

Individual sleep requirements vary widely, ranging from 6 to 10 h/24 h. Infants sleep a large part of the day; with aging, total sleep time and deep sleep tend to decrease, and sleep becomes more interrupted. In the elderly, stage N3 may disappear. These changes may account for increasing EDS and fatigue with aging, but their clinical significance is unclear.

Fig. 1
Typical sleep pattern in young adults. Rapid eye movement (REM) sleep occurs cyclically throughout the night every 90–120 min. Brief periods of wakefulness (stage W) occur periodically. Sleep time is spent as follows: Stage N1: 2–5% Stage N2: 45–55% Stage N3: 13–23% REM: 20–25%

Etiology

Some disorders can cause either insomnia or EDS (sometimes both), and some cause one or the other (see Table 1: Sleep and Wakefulness Disorders: Some Causes of Insomnia and Excessive Daytime Sleepiness).

Table 1
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Some Causes of Insomnia and Excessive Daytime Sleepiness Disorder Insomnia Excessive Daytime Sleepiness Inadequate sleep hygiene √ √ Adjustment insomnia √ Psychophysiologic insomnia √ Physical or mental sleep disorders √ √ Insufficient sleep syndrome √ Drug-dependent and drug-induced sleep disorders √ √ Obstructive sleep apnea √ Central sleep apnea syndrome √ Circadian rhythm sleep disorders √ √ Narcolepsy √ Periodic limb movement disorder √ √ Restless legs syndrome √ √ = commonly present (but insomnia and/or excessive daytime sleepiness can occur in any of these disorders). Some Causes of Insomnia and Excessive Daytime Sleepiness Disorder Insomnia Excessive Daytime Sleepiness Inadequate sleep hygiene √ √ Adjustment insomnia √ Psychophysiologic insomnia √ Physical or mental sleep disorders √ √ Insufficient sleep syndrome √ Drug-dependent and drug-induced sleep disorders √ √ Obstructive sleep apnea √ Central sleep apnea syndrome √ Circadian rhythm sleep disorders √ √ Narcolepsy √ Periodic limb movement disorder √ √ Restless legs syndrome √ √ = commonly present (but insomnia and/or excessive daytime sleepiness can occur in any of these disorders).

Insomnia is most often caused by

• An insomnia disorder (eg, adjustment sleep disorder, psychophysiologic insomnia)
• Inadequate sleep hygiene
• Psychiatric disorders, particularly mood, anxiety, and substance use disorders
• Miscellaneous medical disorders such as cardiopulmonary disorders, musculoskeletal conditions, and chronic pain

EDS is most often caused by

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Miscellaneous medical, neurologic, and psychiatric disorders
• Circadian rhythm disorders such as jet lag and shift work sleep disorders

Inadequate sleep hygiene refers to behaviors that are not conducive to sleep. They include consumption of caffeine or sympathomimetic or other stimulant drugs (typically near bedtime, but even in the afternoon for people who are particularly sensitive), exercise or excitement (eg, a thrilling TV show) late in the evening, and an irregular sleep-wake schedule. Patients who compensate for lost sleep by sleeping late or by napping further fragment their nocturnal sleep.

Adjustment insomnia results from acute emotional stressors (eg, job loss, hospitalization) that disrupt sleep.

Psychophysiologic insomnia is insomnia (regardless of cause) that persists well beyond resolution of precipitating factors, usually because patients feel anticipatory anxiety about the prospect of another sleepless night followed by another day of fatigue. Typically, patients spend hours in bed focusing on and brooding about their sleeplessness, and they have greater difficulty falling asleep in their own bedroom than falling asleep away from home.

Physical disorders that cause pain or discomfort (eg, arthritis, cancer, herniated disks), particularly those that worsen with movement, can cause transient awakenings and poor sleep quality. Nocturnal seizures can also interfere with sleep.

Most major mental disorders are associated with EDS and insomnia. About 80% of patients with major depression report EDS and insomnia; conversely, 40% of chronic insomniacs have a major mental disorder, most commonly a mood disorder.

Insufficient sleep syndrome involves not sleeping enough at night despite adequate opportunity to do so, typically because of various social or employment commitments.

Drug-related sleep disorders result from chronic use of or withdrawal from various drugs (see Table 2: Sleep and Wakefulness Disorders: Some Drugs That Interfere With Sleep).

Table 2
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Some Drugs That Interfere With Sleep Cause Example Drug use Alcohol Anticonvulsants (eg, phenytoinSome Trade Names DILANTIN Click for Drug Monograph ) Antimetabolite chemotherapy Certain antidepressants of the SSRI, SNRI, MAOI, and TCA classes CNS stimulants (eg, amphetamines, caffeine) Oral contraceptives PropranololSome Trade Names INDERAL Click for Drug Monograph Steroids (anabolic steroids, corticosteroids) Thyroid hormone preparations Drug withdrawal Alcohol Certain antidepressants of the SSRI, SNRI, MAOI, and TCA classes CNS depressants (eg, barbiturates, opioids, sedatives) Illicit drugs (eg, cocaine, heroin, marijuana, phencyclidineSome Trade Names No US trade name ) MAOI = monoamine oxidase inhibitor; SNRI = serotonin-norepinephrineSome Trade Names LEVOPHED Click for Drug Monograph reuptake inhibitor; TCA = tricyclic antidepressant.

Circadian rhythm disorders result in misalignment between endogenous sleep-wake rhythms and environmental light-darkness cycle. The cause may be external (eg, jet lag disorder, shift work disorder) or internal (eg, delayed or advanced sleep phase disorder).

Central sleep apnea consists of repeated episodes of breathing cessation or shallow breathing during sleep, lasting at least 10 sec and caused by diminished respiratory effort. The disorder typically manifests as insomnia or as disturbed and unrefreshing sleep.

Obstructive sleep apnea consists of episodes of partial or complete closure of the upper airway during sleep, leading to cessation of breathing for ≥ 10 sec. Most patients snore, and sometimes patients awaken, gasping. These episodes disrupt sleep and result in a feeling of unrefreshing sleep and EDS.

Narcolepsy is characterized by chronic EDS, often with cataplexy, sleep paralysis, and hypnagogic or hypnopompic hallucinations. Cataplexy is momentary muscular weakness or paralysis without loss of consciousness that is evoked by sudden emotional reactions (eg, mirth, anger, fear, joy, surprise). Weakness may be confined to the limbs (eg, patients may drop the rod when a fish strikes their line) or may cause a limp fall during hearty laughter (as in “weak with laughter”) or sudden anger. Sleep paralysis is the momentary inability to move when just falling asleep or immediately after awakening. Hypnagogic and hypnopompic phenomena are vivid auditory or visual illusions or hallucinations that occur when just falling asleep (hypnagogic) or, less often, immediately after awakening (hypnopompic).

Periodic limb movement disorder is characterized by repetitive (usually every 20 to 40 sec) twitching or kicking of the lower extremities during sleep. Patients usually complain of interrupted nocturnal sleep or EDS. They are typically unaware of the movements and brief arousals that follow, and they have no abnormal sensations in the extremities.

Restless legs syndrome is characterized by an irresistible urge to move the legs and, less frequently, the arms, usually accompanied by paresthesias (eg, creeping or crawling sensations) in the limbs when reclining. To relieve symptoms, patients move the affected extremity by stretching, kicking, or walking. As a result, they have difficulty falling asleep, repeated nocturnal awakenings, or both.

Evaluation

History: History of present illness should include duration and age at onset of symptoms and any events (eg, a life or work change, new drug, new medical disorder) that coincided with onset. Symptoms during sleeping and waking hours should be noted. The quality and quantity of sleep are identified by determining bedtime, latency of sleep (time from bedtime to falling asleep), number and time of awakenings, final morning awakening and arising times, and frequency and duration of naps. Having patients keep a sleep log for several weeks is more accurate than questioning them. Bedtime events (eg, food or alcohol consumption, physical or mental activity) should be evaluated. Intake of and withdrawal from drugs, alcohol, caffeine, and nicotineSome Trade Names
COMMIT
NICORETTE
NICOTROL
Click for Drug Monograph
as well as level and timing of physical activity should also be included.

If EDS is the problem, severity should be quantified based on the propensity for falling asleep in different situations (eg, resting comfortably vs when driving a car). The Epworth Sleepiness Scale (see Table 3: Sleep and Wakefulness Disorders: Epworth Sleepiness Scale) may be used; a cumulative score ≥ 10 represents abnormal daytime sleepiness.

Table 3
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Epworth Sleepiness Scale Situation Sitting and reading Watching TV Sitting inactive in a public place Riding as a car passenger for 1 h continuously Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) Sitting in a car stopped for a few minutes in traffic For each situation, probability of dozing is self-rated as none (0), slight (1), moderate (2), or high (3). A score of ≥ 10 suggests abnormal daytime sleepiness.

Review of systems should check for symptoms of specific sleep disorders, including snoring, interrupted breathing patterns, and other nocturnal respiratory disturbances (sleep apnea syndromes); depression, anxiety, mania, and hypomania (mental sleep disorders); restlessness in the legs, an irresistible desire to move them, and jerking leg movements (restless legs syndrome); and cataplexy, sleep paralysis, and hypnagogic phenomena (narcolepsy). Bed partners or other family members can best identify some of these symptoms.

Past medical history should check for known disorders that can interfere with sleep, including COPD, asthma, heart failure, hyperthyroidism, gastroesophageal reflux, neurologic disorders (particularly movement and degenerative disorders), and painful disorders (eg, RA). Risk factors for obstructive sleep apnea include obesity, heart disorders, hypertension, stroke, smoking, snoring, and nasal trauma. Drug history should include questions about use of any drugs associated with sleep disturbance (see Table 2: Sleep and Wakefulness Disorders: Some Drugs That Interfere With Sleep).

Physical examination: The physical examination is useful mainly for identifying signs associated with obstructive sleep apnea. Signs include obesity with fat distributed around the neck or midriff; large neck circumference (≥ 43.2 cm in males, ≥ 40.6 cm in females); mandibular hypoplasia and retrognathia; nasal obstruction; enlarged tonsils, tongue, uvula, or soft palate (Mallampati score 3 or 4 —see Fig. 2: Sleep and Wakefulness Disorders: Mallampati scoring.); decreased pharyngeal patency; increased obstruction of uvula and soft palate by the tongue; and redundant pharyngeal mucosa. The chest should be examined for expiratory wheezes and kyphoscoliosis. Signs of right ventricular failure should be noted. A thorough neurologic examination should be done.

Red flags: The following findings are of particular concern:

• Falling asleep while driving or other potentially dangerous situations
• Repeated sleep attacks (falling asleep without warning)
• Breathing interruptions or awakening with gasping reported by bed partner
• Unstable cardiac or pulmonary status
• Recent stroke
• Status cataplecticus (continuous cataplexy attacks)
• History of violent behaviors or injury to self or others during asleep
• Frequent sleepwalking or other out-of-bed behavior

Interpretation of findings: Inadequate sleep hygiene and situational stressors are usually apparent in the history. EDS that disappears when sleep time is increased (eg, on weekends or vacations) suggests inadequate sleep syndrome. EDS that is accompanied by cataplexy, hypnagogic/hypnopompic hallucinations, or sleep paralysis suggests narcolepsy.

Difficulty falling asleep (sleep-onset insomnia) should be distinguished from difficulty maintaining sleep (sleep maintenance insomnia). Sleep-onset insomnia suggests delayed sleep phase syndrome, chronic psychophysiologic insomnia, or childhood phobias. Sleep maintenance insomnia suggests major depression, central or obstructive sleep apnea, periodic limb movement disorder, or aging. Falling asleep early and awakening early suggests advanced sleep phase syndrome. Clinicians should suspect obstructive sleep apnea in patients with significant snoring, frequent awakenings, and other risk factors. The STOP-BANG score can help predict risk of obstructive sleep apnea (see Table 4: Sleep and Wakefulness Disorders: STOP-BANG Risk Score for Obstructive Sleep Apnea).

Table 4
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STOP-BANG Risk Score for Obstructive Sleep Apnea Item Evaluated Finding Snoring Loud snoring (louder than talking or loud enough to be heard through closed door) Tired Often fatigue or sleepiness during the daytime Observed Observed to stop breathing during sleep BP High BP or current treatment for hypertension BMI > 35 kg/m2 Age > 50 yr Neck circumference > 40 cm (> 15 3/4 in) Gender Male ≥ 3 findings = high risk of OSA. < 3 findings = low risk of OSA. BMI = body mass index; OSA = obstructive sleep apnea.

Testing: Tests are usually done when specific symptoms or signs suggest obstructive sleep apnea, nocturnal seizures, narcolepsy, periodic limb movement disorder, or other disorders whose diagnosis relies on identification of characteristic polysomnographic findings. Tests are also done when the clinical diagnosis is in doubt or when response to initial presumptive treatment is inadequate. If symptoms or signs strongly suggest certain causes (eg, restless legs syndrome, poor sleep habits, transient stress, shift work disorder), testing is not required.

Polysomnography is particularly useful when obstructive sleep apnea, narcolepsy, nocturnal seizures, periodic limb movement disorder, or parasomnias is suspected. It also helps clinicians evaluate violent and potentially injurious sleep-related behaviors. It monitors brain activity (via EEG), eye movements, heart rate, respirations, O₂ saturation, and muscle tone and activity during sleep. Video recording may be used to identify abnormal movements during sleep. Polysomnography is typically done in a sleep laboratory; equipment for home use has been devised but is not widely used and is intended to help diagnose only obstructive sleep apnea, not any other sleep disorders.

The multiple sleep latency test assesses speed of sleep onset in 5 daytime nap opportunities 2 h apart during the patient's typical daytime. Patients lie in a darkened room and are asked to sleep. Onset and stage of sleep (including REM) are monitored by polysomnography to determine the degree of sleepiness. This test's main use is in the diagnosis of narcolepsy.

For the maintenance of wakefulness test, patients are asked to stay awake in a quiet room during 4 wakefulness opportunities 2 h apart while they sit in a bed or a recliner. This test is probably a more accurate measure of ability to remain awake in everyday situations.

Patients with EDS may require laboratory tests of renal, liver, and thyroid function.

Treatment

Specific conditions are treated. Good sleep hygiene (see Table 5: Sleep and Wakefulness Disorders: Sleep Hygiene) is important whatever the cause and is often the only treatment patients with mild problems need.

Table 5
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Sleep Hygiene Measure Implementation Regular sleep/wake schedule Bedtime and particularly wake-up time should be the same each day, including weekends. Patients should not spend excessive time in bed. Appropriate use of the bed Limiting time in bed improves sleep continuity. If unable to fall sleep within 20 min, patients should get out of bed and return when sleepy. The bed should not be used for activities other than sleep or sex (eg, for reading, eating, watching television, or paying bills). Avoidance of daytime naps, except by shift workers, the elderly, and patients with narcolepsy Daytime naps may aggravate sleeplessness in patients with insomnia. However, naps decrease the need for stimulants in patients with narcolepsy and improve performance in shift workers. Naps should be taken at the same time each day and limited to 30 min. Regular routine before bedtime A pattern of activities—brushing teeth, washing, setting the alarm clock—can set the mood for sleep. Bright lights should be avoided before bedtime and during nocturnal awakenings. Sleep-conducive environment The bedroom should be dark, quiet, and reasonably cool; it should be used only for sleep and sexual activity. Heavy curtains or a sleep mask can eliminate light, and earplugs, fans, or white-noise devices can help eliminate disturbing noise. Pillows Pillows between the knees or under the waist can increase comfort. For patients with back problems, lying supine with a large pillow under the knees can help. Regular exercise Exercise promotes sleep and reduces stress, but if done in the late evening, it can stimulate the nervous system and interfere with falling asleep. Relaxation Stress and worry interfere with sleep. Reading or taking a warm bath before bedtime can aid relaxation. Techniques such as visual imagery, progressive muscle relaxation, and breathing exercises can be used. Patients should not watch the clock. Avoidance of stimulants and diuretics Drinking alcoholic or caffeinated beverages, smoking, eating caffeinated foods (eg, chocolate), and taking appetite suppressants, or prescription diuretics—especially near bedtime—should be avoided. Bright light exposure while awake Light exposure during the day can help rectify circadian rhythms.

Hypnotics: General guidelines for use of hypnotics (see Table 6: Sleep and Wakefulness Disorders: Guidelines for the Use of Hypnotics) aim at minimizing abuse, misuse, and addiction.

Table 6
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Guidelines for the Use of Hypnotics Define a clear indication and treatment goal. Prescribe the lowest effective dose. Except for specific hypnotics and patients, limit duration of use to a few weeks. Individualize the dose for each patient. Use lower doses in patients also taking a CNS depressant, in the elderly, and in patients with hepatic or renal disorders. Avoid* if patients have sleep apnea or respiratory disorders or a history of sedative abuse, if they are drinking alcohol, or if they are pregnant. For patients who need longer-term treatment, consider intermittent therapy. Avoid abruptly stopping the drug if possible (ie, taper it). Re-evaluate drug treatment regularly; assess efficacy and adverse events. *Ramelteon is an exception; it can be given to patients with mild to moderate obstructive sleep apnea or COPD or a history of sedative abuse.

For commonly used hypnotics, see Table 7: Sleep and Wakefulness Disorders: Oral Hypnotics in Common Use. All hypnotics, except ramelteon and low-dose doxepinSome Trade Names
SINEQUAN
ZONALON
Click for Drug Monograph
, act at the benzodiazepine recognition site on the γ-aminobutyric (GABA) receptor and augment the inhibitory effects of GABA. The drugs differ primarily in elimination half-life and onset of action. Drugs with a short half-life are used for sleep-onset insomnia. Drugs with a longer half-life are useful for both sleep-onset and sleep maintenance insomnia, or, in the case of low-dose doxepinSome Trade Names
SINEQUAN
ZONALON
Click for Drug Monograph
, only for sleep maintenance insomnia; some hypnotics (eg, older benzodiazepines) have greater potential for daytime carryover effects, especially after prolonged use and/or in the elderly. New drugs with a very short duration of action (low-dose sublingual zolpidemSome Trade Names
AMBIEN
Click for Drug Monograph
) can be taken in the middle of the night, during a nocturnal awakening, as long as patients stay in bed for at least 4 h after use. Patients who experience daytime sedation, incoordination, or other daytime effects should avoid activities requiring alertness (eg, driving), and the dose should be reduced, the drug stopped, or, if needed, another drug used. Other adverse effects include amnesia, hallucinations, incoordination, and falls.

Table 7
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Oral Hypnotics in Common Use Drug Half Life* (h) Dose (mg)† Comments Benzodiazepine receptor agonists: Benzodiazepines EstazolamSome Trade Names PROSOM Click for Drug Monograph 10–24 0.5–2 Effective for sleep induction and maintenance FlurazepamSome Trade Names DALMANE Click for Drug Monograph 47–100 15–30 High risk of next-day residual sedation; not recommended for the elderly QuazepamSome Trade Names DORAL Click for Drug Monograph 39–100 7.5–15 High lipophilicity, which may mitigate residual sedation in first 7–10 days of continuous use TemazepamSome Trade Names RESTORIL Click for Drug Monograph 9.5–12.4 7.5–15 Longest latency for sleep induction TriazolamSome Trade Names HALCION Click for Drug Monograph 1.5−5.5 0.25–0.5 May cause anterograde amnesia; high likelihood of tolerance and rebound after repeated use Benzodiazepine receptor agonists: Nonbenzodiazepines Eszopiclone 6 1–3 Effective for sleep-onset insomnia and sleep maintenance insomnia; no tolerance with up to 6 mo nightly use ZaleplonSome Trade Names SONATA Click for Drug Monograph 1 5–20 Ultrashort-acting; can be given for sleep-onset insomnia or after nocturnal awakening (if patients can spend at least 4 h in bed after taking the drug) When given at normal bedtime, least likely to have residual effects ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , tablets 2.5 5–10 Effective for sleep-onset insomnia only ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , extended-release 2.8 6.25–12.5 Effective for sleep-onset insomnia and sleep maintenance insomnia; no tolerance with up to 6 mo of use 3 to 7 nights/wk ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , sublingual‡ 2.9 5, 10 Men: 3.5 Women: 1.75 More rapid onset of action than zolpidemSome Trade Names AMBIEN Click for Drug Monograph tablets Higher doses used for sleep-onset insomnia Lower doses used for early awakening (should not be taken unless patients can spend at least 4 h in bed after taking the drug) ZolpidemSome Trade Names AMBIEN Click for Drug Monograph oral spray‡ 2.7 5, 10 Used for sleep-onset insomnia Melatonin receptor agonists Ramelteon 1–5 8 Useful only for sleep-onset insomnia; one of 2 hypnotics that is not associated with abuse liability Can be safely given to patients with mild to moderate obstructive sleep apnea or COPD No difficulties with long-term use Tricylic antidepressants DoxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph , ultra low dose 3, 6 Indicated for sleep maintenance insomnia *Includes parent and active metabolites. Arranged in order from longest to shortest half-life. †Dose given at bedtime. ‡Newer forms of zolpidemSome Trade Names AMBIEN Click for Drug Monograph . Oral Hypnotics in Common Use Drug Half Life* (h) Dose (mg)† Comments Benzodiazepine receptor agonists: Benzodiazepines EstazolamSome Trade Names PROSOM Click for Drug Monograph 10–24 0.5–2 Effective for sleep induction and maintenance FlurazepamSome Trade Names DALMANE Click for Drug Monograph 47–100 15–30 High risk of next-day residual sedation; not recommended for the elderly QuazepamSome Trade Names DORAL Click for Drug Monograph 39–100 7.5–15 High lipophilicity, which may mitigate residual sedation in first 7–10 days of continuous use TemazepamSome Trade Names RESTORIL Click for Drug Monograph 9.5–12.4 7.5–15 Longest latency for sleep induction TriazolamSome Trade Names HALCION Click for Drug Monograph 1.5−5.5 0.25–0.5 May cause anterograde amnesia; high likelihood of tolerance and rebound after repeated use Benzodiazepine receptor agonists: Nonbenzodiazepines Eszopiclone 6 1–3 Effective for sleep-onset insomnia and sleep maintenance insomnia; no tolerance with up to 6 mo nightly use ZaleplonSome Trade Names SONATA Click for Drug Monograph 1 5–20 Ultrashort-acting; can be given for sleep-onset insomnia or after nocturnal awakening (if patients can spend at least 4 h in bed after taking the drug) When given at normal bedtime, least likely to have residual effects ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , tablets 2.5 5–10 Effective for sleep-onset insomnia only ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , extended-release 2.8 6.25–12.5 Effective for sleep-onset insomnia and sleep maintenance insomnia; no tolerance with up to 6 mo of use 3 to 7 nights/wk ZolpidemSome Trade Names AMBIEN Click for Drug Monograph , sublingual‡ 2.9 5, 10 Men: 3.5 Women: 1.75 More rapid onset of action than zolpidemSome Trade Names AMBIEN Click for Drug Monograph tablets Higher doses used for sleep-onset insomnia Lower doses used for early awakening (should not be taken unless patients can spend at least 4 h in bed after taking the drug) ZolpidemSome Trade Names AMBIEN Click for Drug Monograph oral spray‡ 2.7 5, 10 Used for sleep-onset insomnia Melatonin receptor agonists Ramelteon 1–5 8 Useful only for sleep-onset insomnia; one of 2 hypnotics that is not associated with abuse liability Can be safely given to patients with mild to moderate obstructive sleep apnea or COPD No difficulties with long-term use Tricylic antidepressants DoxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph , ultra low dose 3, 6 Indicated for sleep maintenance insomnia *Includes parent and active metabolites. Arranged in order from longest to shortest half-life. †Dose given at bedtime. ‡Newer forms of zolpidemSome Trade Names AMBIEN Click for Drug Monograph .

Hypnotics should be used cautiously in patients with pulmonary insufficiency. In the elderly, any hypnotic, even in small doses, can cause restlessness, excitement, or exacerbation of delirium and dementia. Rarely, hypnotics can cause complex sleep-related behaviors, such as sleepwalking and even sleep driving; use of higher-than-recommended doses and concurrent consumption of alcoholic beverages may increase risk of such behaviors. Rarely, severe allergic reactions occur.

Prolonged use is typically discouraged because tolerance can develop (see Drug Use and Dependence: Chronic effects) and because abrupt discontinuation can cause rebound insomnia or even anxiety, tremor, and seizures. These effects are more common with benzodiazepines (particularly triazolamSome Trade Names
HALCION
Click for Drug Monograph
) and less common with nonbenzodiazepines. Difficulties can be minimized by using the lowest effective dose for brief periods and by tapering the dose before stopping the drug (see also Drug Use and Dependence: Withdrawal and detoxification). Nevertheless, many patients with chronic insomnia require long-term treatment with hypnotics; such treatment should not be withheld because chronic sleeplessness by itself can disrupt emotional and physical well-being.

Other sedatives: Many drugs not specifically indicated for insomnia are used to induce and maintain sleep.

Many patients use alcohol to help them sleep, but alcohol is a poor choice because after prolonged use and at higher doses, it produces unrefreshing, disturbed sleep with frequent nocturnal awakenings, often increasing daytime sleepiness. Alcohol can further impair respiration during sleep in patients with obstructive sleep apnea and other pulmonary disorders such as COPD.

OTC antihistamines (eg, doxylamineSome Trade Names
GOOD SENSE SLEEP AID
UNISOM SLEEPTABS
Click for Drug Monograph
, diphenhydramineSome Trade Names
BENADRYL
NYTOL
Click for Drug Monograph
) can induce sleep. However, efficacy is unpredictable, and these drugs have adverse effects such as daytime sedation, confusion, and systemic anticholinergic effects, which are particularly worrisome in the elderly.

Low doses of some antidepressants at bedtime (eg, doxepinSome Trade Names
SINEQUAN
ZONALON
Click for Drug Monograph
25 to 50 mg, paroxetineSome Trade Names
PAXIL
Click for Drug Monograph
5 to 20 mg, trazodoneSome Trade Names
DESYREL
Click for Drug Monograph
50 mg, trimipramineSome Trade Names
SURMONTIL
Click for Drug Monograph
75 to 200 mg) may improve sleep. However, antidepressants should be used in these low doses mainly when standard hypnotics are not tolerated (rare) or in higher (antidepressant) doses when depression is present. Ultra low dose doxepinSome Trade Names
SINEQUAN
ZONALON
Click for Drug Monograph
(3 or 6 mg) is now indicated for sleep maintenance insomnia.

Melatonin is a hormone that is secreted by the pineal gland (and that occurs naturally in some foods). Darkness stimulates secretion, and light inhibits it. By binding with melatonin receptors in the suprachiasmatic nucleus, melatonin mediates circadian rhythms, especially during physiologic sleep onset. Oral melatonin (typically 0.5 to 5 mg at bedtime) may be effective for sleep problems due to delayed sleep phase syndrome. When used to treat this disorder, it must be taken at the appropriate time (when endogenous melatonin is normally secreted, in early evening for most people, typically 3 to 5 h before the intended bedtime) and at a low dose of 0.5 to 1 mg; taken at the wrong time, it can aggravate sleep problems. For other forms of insomnia, melatonin's efficacy is largely unproved, and its safety is in question because it appears to stimulate coronary artery changes in animals. Nevertheless, worrisome adverse effects have not been reported after widespread use. Available preparations of melatonin are unregulated, so content and purity cannot be ensured, and the effects of long-term use are unknown. Its use should be supervised by a physician.

Key Points

• Poor sleep hygiene and situational disruptors (eg, shift work, emotional stressors) cause many cases of insomnia.
• Consider medical disorders (eg, sleep apnea syndromes, pain disorders) and psychiatric disorders (eg, mood disorders) as possible causes.
• Usually, consider sleep studies (eg, polysomnography) when sleep apnea syndromes, periodic limb movements, or other sleep disorders are suspected, when the clinical diagnosis is in doubt, or when response to initial presumptive treatment is inadequate.
• Use hypnotics and sedatives with caution in the elderly.
• Good sleep hygiene may be the only treatment needed by patients with mild insomnia problems.

Last full review/revision November 2012 by Karl Doghramji, MD

Content last modified January 2013