Sleep Disorders — Therapeutic Armamentarium
We spend a third of our lives asleep and yet sleep remains an enigma. The numerous and complex disorders of sleep have been dealt with in several previous chapters. The most common complaint is that of insufficient and unsatisfying sleep. Problems with excessive sleep are much less common. Abnormal sleep is also noted on occasion, usually manifested as aberrant behaviour such as night terrors or sleepwalking.
A range of medications is available to treat insomnia, ranging from folk remedies such as valerian to the most recently introduced compound, zaleplon. Many medications possess sedative and sleep-inducing properties as a side effect, such as many tricyclic antidepressants and the first-generation antihistamines. Fewer remedies exist to treat excessive or qualitatively abnormal sleep, but progress is being made.
The purpose of this chapter is to review the available remedies, concentrating on the newest introductions that are of both theoretical interest and practical utility. The emphasis will be on the remedies for insufficient sleep — the hypnotic drugs — as these are among the most-widely prescribed medications, particularly by primary care practitioners (Simon and VonKorff, 1997).
Before dealing with hypnotic medication, it is useful to outline the stratagems that people use to induce and maintain sleep (Table XXIV-11.1). A regular bedtime routine is conducive to sleep, and many people follow a time-hallowed sequence of events, almost a ritual, before they retire at night. Regular hours for going to bed and for rising in the morning help consolidate sleep, and this routine should be maintained at the weekends and during vacations as well. Many people read before going to sleep, but arousing or disturbing material should be avoided. Rehearsing the next day's agenda or worrying about finances, family, etc. is unhelpful.
Exercise late at night is used by many people to hasten the onset of sleep although it is probably the routine that is most important. However, the optimum is moderate exercise in the afternoon or early evening, as anyone taking a vigorous sport-oriented vacation can testify. By contrast, heavy, exhausting exercise may be unhelpful (Home, 1981).
The bedroom should be quiet, so that sound-attenuation may be needed if it abuts on a noisy street or lies under the flight path to an all-night airport. The room should not be too hot nor too cold. Many people take a milky drink at bedtime and there are many on the market. Tea and coffee may induce insomnia (Stradling, 1993). Coffee was once dubbed an 'antihypnotic' (Miller, 1722). Tolerance to the effects of the active principles, caffeine and, to a lesser extent, theobromine, tends to get lost as the individual ages.
|A.||Regular bedtime routine|
|B.||Standard hours of retiring and getting up|
|D.||Exercise in late afternoon/early, but not late, evening|
|E.||Quiet, warm, comfortable bedroom|
|F.||Avoid caffeine-containing drinks and too much alcohol|
|c.||Sleep hygiene education|
|E.||Attention-focusing procedures: thought-stopping, imagery training, meditation, yoga|
|F.||Relaxation: progressive muscular relaxation, autogenic training, biofeedback|
Alcohol is also used by many people, the traditional 'nightcap'. However, too much may disturb sleep due to its diuretic effect and to rebound insomnia later on.
Some people find formal relaxation techniques very helpful, especially if meditation techniques have been learnt for daytime use (Table XXIV-11.2). Nevertheless, meditation and the induction of sleep are distinct physiological and psychological processes, and it is the muscular relaxation that is most relevant. Simple relaxation exercises in which the person relaxes muscle groups progressively from toes to legs, trunk, arms, neck and head are appropriate.
More elaborate behavioural techniques have been advocated (Bootzin and Perlis, 1992; Sloan and Shapiro, 1993). Although not widely available, a variety of techniques have been developed. Morin and his colleagues evaluated 59 treatment studies involving over 2000 patients. These were predominantly women, and the mean age was 44. Most suffered from chronic primary insomnia, on average, of 11 years' duration. Most subjects received sleepfocused interventions with an average treatment time of 5 h. Followup lasted a mean of 6 months.
Of four outcome variables assessed, two in the metaanalysis— sleep-onset latency and time awake after sleep onset—were significantly improved following behavioural interventions. The absolute number of awakenings and total sleep time