Suggested Guidelines for Prescribing Medications
It is often clinically useful to provide patients with information on good sleep hygiene practices. Certain elements are particu-larly important (e.g., going to another room and waiting until drowsy or looking for clues about waking life events, and issues that may be keeping one awake). Behavioral techniques such as stimulus control and progressive muscle relaxation are quite use-ful. When a hypnotic agent is prescribed, it is helpful to advise patients to take the medication on an empty stomach and with ample fluids (e.g., a full glass of water) to promote rapid disso-lution and absorption, and onset of effect. For patients prone to nocturia the amount of fluids should be lessened substantially. One should always caution patients about potential impairments in memory, coordination, or driving skills and about unsteadi-ness if they are awakened after having taken a sleep aid. It is also important to remind them that if they use the medication for more than a few nights, some pattern of tapering should be followed when they stop. It is reinforcing to work out a discon-tinuation schedule at the time of the first prescription. Patients should also be cautioned to avoid the use of alcohol when taking a hypnotic as the effects are additive in nature. Medications such as the benzodiazepines that have a propensity to be abused should be avoided in those patients with drug or alcohol problems.
Universally accepted guidelines for dosing and duration of use for hypnotics are not established. Both dose and duration must be individualized with the goal of finding the lowest dose and the shortest duration. Short-term treatment (i.e., from 1 or 2 nights to 1 or 2 weeks) is reasonable for most patients. However, some patients with chronic insomnia may benefit from longer-term use provided that there is careful monitoring by the pre-scribing physician. No criteria are presently available to identify this subpopulation. It seems reasonable to consider several short-term trials, with gradual tapering at the end of each period and a drug-free interval between each period, to establish the patient’s need for and the appropriateness and value of continued therapy. The drug-free time interval between the initial periods should range from 1 to 3 weeks, depending on the half-life of the agent and its active metabolites and the rapidity of the taper schedule. Reevaluation of such a patient’s continued need for hypnotic medication at 3- to 6-month intervals is also reasonable. Because the elderly are particularly susceptible to falls or confusion from hypnotic medication, use of the lowest available dosage strength is advisable. The elderly should also avoid the use of longer half-life agents or those with active metabolites with long half-lives because such medications tend to accumulate over time in older patients due to pharmacodynamic differences in drug metabo-lism in the elderly.
For those individuals who hope to benefit from behavioral and nonpharmacological approaches to their insomnia, prescrib-ing hypnotics two or three times per week while they are work-ing out such modifications may be beneficial. Because there are few predictable central tendencies that characterize patients with primary insomnia, individual variation is likely.