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Chapter: Medicine Study Notes : Pharmacology

Treatment of Insomnia

Normal aging increases wakefulness during last 4 hours of sleep (reassure patient insomnia is „normal‟).

Treatment of Insomnia


·        A distressing complaint – not an illness 

·   Normal aging increases wakefulness during last 4 hours of sleep (reassure patient insomnia is „normal‟)

·        Non-drug management:

o   First check for: anxiety, depression, comfort, incontinence (eg diuretics), dementia, and treat these

o   Obtain careful sleep history, note factors improving/worsening sleep

o   Good explanation

o   Good Sleep Habits (Sleep Hygiene):

§  Reduce light, noise and extremes of temperature

§  Ensure physical security

§  Avoid caffeine, nicotine and alcohol before bedtime

§  No heavy meal for 2 hours beforehand, but have a light snack if hungry 

§  Regular exercise last in the afternoon/early evening, but nothing vigorous for 3 hours beforehand

§  Allow one hour of quiet activity before bedtime (reading, TV, music)

§  Develop a bedtime ritual, cleaning teeth, reading, etc

§  Don‟t go too early (ie before you feel sleepy) 

§  Don‟t stay in bed if you are awake. If not asleep within 15 – 20 minutes (estimate – don‟t use a clock), get up, go elsewhere and do something mundane until you feel sleepy again 

§  Get up at the same time in the morning: don‟t sleep in in weekends or after late nights. This helps train your body clock

§  Don‟t nap during the day

§  Don‟t worry if you can‟t get to sleep at night: worry will delay sleep even more

·        Drug management:

o   30% over 65 take sleeping pills 

o   Not for persistent insomnia (common in personality disorders, depression, sleep apnoea, pain, gastro-oesophageal reflux – treat primary cause).

·        Hypnotics should only be prescribed for symptomatic temporary insomnia (no more than 2 – 3 weeks) and should only be part of an overall management strategy

·        If used, for defined period, perhaps intermittently, and should sustain sleep

·        Not: 

o   Short acting (eg midazolam) get them off to sleep – but don‟t sustain sleep. Don‟t have any impact on early morning wakefulness. So will wake, and take another – then hangover in the morning, ­falls, etc 

o   Long acting (triazolam/Halcyon) - which leads to daytime anxiety

·        Use intermediate-acting hypnotics (eg zoplicone and temazepam)

·        Risk of addiction

·        Shift workers should avoid them


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