Overcoming wakefulness -
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.
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. 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 nicotine as well as level and timing of physical activity should also be included. If excessive daytime sleepiness is the problem, severity should be quantified based on the propensity for falling asleep in different situations eg, resting comfortably versus when driving a car.
Snoring Snoring Snoring is a raspy noise produced in the nasopharynx during sleep. However, because a bed partner's read more , interrupted breathing patterns, witnessed apneic events, nocturnal gasping and choking, and nocturia sleep apnea Obstructive Sleep Apnea OSA Obstructive sleep apnea OSA consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation defined as a period of read more syndromes.
Restlessness in the legs, an irresistible desire to move them, and jerking leg movements restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may Cataplexy, sleep paralysis, and hypnagogic phenomena narcolepsy Narcolepsy Narcolepsy is characterized by chronic excessive daytime sleepiness, often with sudden loss of muscle tone cataplexy.
Past medical history should check for known disorders that can interfere with sleep, including chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease COPD Chronic obstructive pulmonary disease COPD is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke.
Alpha-1 antitrypsin deficiency and various occupational read more COPD , asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea read more , heart failure Heart Failure HF Heart failure HF is a syndrome of ventricular dysfunction.
Left ventricular LV failure causes shortness of breath and fatigue, and right ventricular RV failure causes peripheral and abdominal read more , hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones.
Symptoms include palpitations, fatigue, weight loss, heat intolerance, anxiety, and tremor read more , gastroesophageal reflux Gastroesophageal Reflux Disease GERD Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia read more , neurologic disorders particularly movement and degenerative disorders , urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem.
The disorder is greatly underrecognized and underreported. read more , other urinary disorders, and painful disorders eg, rheumatoid arthritis. 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 Some Drugs That Interfere With Sleep Some Drugs That Interfere With Sleep. The physical examination is useful mainly for identifying signs associated with obstructive sleep apnea:.
Enlarged tonsils palatine or lingual , adenoid, tongue, uvula, lateral walls of the pharynx or soft palate modified Mallampati score 3 or 4—see figure Modified Mallampati scoring Modified Mallampati scoring.
The chest should be examined for expiratory wheezes and kyphoscoliosis. Signs of right ventricular failure, including lower-extremity edema, should be noted. A thorough neurologic examination should be done. 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.
Difficulty falling asleep sleep-onset insomnia should be distinguished from difficulty maintaining sleep and early awakening sleep maintenance insomnia. Sleep-onset insomnia suggests delayed sleep phase syndrome Circadian rhythm sleep disorder, altered sleep phase types Circadian rhythm sleep disorders are caused by desynchronization between internal sleep-wake rhythms and the light-darkness cycle.
read more , chronic psychophysiologic insomnia, restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may read more , or childhood phobias.
Sleep maintenance insomnia suggests major depression Major depressive disorder unipolar depressive disorder Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. read more , central sleep apnea Central Sleep Apnea Central sleep apnea CSA is a heterogeneous group of conditions characterized by changes in ventilatory drive without airway obstruction.
read more , obstructive sleep apnea Obstructive Sleep Apnea OSA Obstructive sleep apnea OSA consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation defined as a period of read more , or aging.
Falling asleep early and awakening early suggest advanced sleep phase syndrome Circadian rhythm sleep disorder, altered sleep phase types Circadian rhythm sleep disorders are caused by desynchronization between internal sleep-wake rhythms and the light-darkness cycle.
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 STOP-BANG Risk Score for Obstructive Sleep Apnea STOP-BANG Risk Score for Obstructive Sleep Apnea.
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 are suspected. It also helps clinicians evaluate violent and potentially injurious sleep-related behaviors.
It monitors brain activity via EEG , eye movements, heart rate, respirations, oxygen 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; home sleep studies are now commonly used to diagnose obstructive sleep apnea, but not other sleep disorders 1 Evaluation reference Almost half of all people in the US report sleep-related problems.
Disordered sleep can cause emotional disturbance, memory difficulty, poor motor skills, decreased work efficiency, and increased 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. For the maintenance of wakefulness test , patients are asked to stay awake in a quiet room during 4 wakefulness opportunities 2 hours apart while they sit in a bed or a recliner.
Rosen IM, Kirsch DB, Chervin RD, et al : Clinical Use of a Home Sleep Apnea Test: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med 13 10 —, doi: Specific conditions are treated.
The primary treatment for insomnia is cognitive-behavioral therapy, which ideally should be done before hypnotics are prescribed. Good sleep hygiene Sleep Hygiene is a component of cognitive-behavioral therapy that is important whatever the cause and is often the only treatment patients with mild problems need.
Cognitive-behavioral therapy for insomnia focuses on managing the common thoughts, worries, and behaviors that interfere with sleep. It is typically done in 4 to 8 individual or group sessions but can be done remotely online or by telephone; however, evidence for the effectiveness of remote therapy is weaker.
Helping patients improve sleep hygiene Sleep Hygiene , particularly restricting time spent in bed, establishing a regular sleep schedule, and controlling stimuli. Teaching patients about the effects of sleeplessness and helping them identify inappropriate expectations about how much sleep they should get.
Restricting the amount of time spent in bed aims to limit the time patients spend lying in bed trying unsuccessfully to sleep. Patients are asked to get out of bed in the morning at a fixed time and then calculate a bed time based on total sleep time.
After a week, this approach typically improves quality of sleep. Then, the time spent in bed can be increased by gradually making bed time earlier, as long as awakenings in the middle of the night remain minimal.
General guidelines for use of hypnotics see table Guidelines for the Use of Hypnotics Guidelines for the Use of Hypnotics aim at minimizing abuse, misuse, and addiction. For commonly used hypnotics, see table Oral Hypnotics in Common Use Oral Hypnotics in Common Use.
All hypnotics except ramelteon , low-dose doxepin , and suvorexant act at the benzodiazepine recognition site on the gamma -aminobutyric GABA receptor and augment the inhibitory effects of GABA.
Hypnotics 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 doxepin , only for sleep maintenance insomnia.
New drugs with a very short duration of action eg, low-dose sublingual zolpidem can be taken in the middle of the night, during a nocturnal awakening, as long as patients stay in bed for at least 4 hours 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.
Falling is a significant risk with all hypnotics. Three dual orexin receptor antagonists daridorexant , lemborexant , suvorexant can be used to treat sleep-onset and maintenance insomnia.
They block orexin receptors in the brain, thereby blocking orexin-induced wakefulness signals and enabling sleep initiation. Dual orexin receptor antagonists block orexin receptors-1 and The orexin receptor-1 is involved in suppressing the onset of rapid eye movement REM sleep; the orexin receptor-2 is involved in suppressing non-REM sleep onset and, to some extent, in controlling REM sleep.
However, the mechanism of action for dual orexin receptor antagonists is not fully understood. For suvorexant , the recommended dose is 10 mg, taken no more than once a night and taken within 30 minutes of going to bed, with at least 7 hours before the planned time of awakening.
The dose can be increased but should not to exceed 20 mg once a day. The most common adverse effect is somnolence. Lemborexant 5 mg is taken once a day within 30 minutes of going to bed; the dose can be increased to 10 mg maximum dose based on patient response and tolerability.
Daridorexant 25 to 50 mg is taken once a day within 30 minutes of going to bed. Daridorexant has the shortest half-life 8 hours of the dual oxexin receptor antagonists. Hypnotics should be used cautiously in patients with pulmonary insufficiency.
In older patients, any hypnotic, even in small doses, can cause restlessness, excitement, falls, 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 of hypnotics Sedatives Sedatives include benzodiazepines, barbiturates, and related drugs.
High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical read more is typically discouraged because tolerance can develop and because abrupt discontinuation can cause rebound insomnia or even anxiety, tremor, and seizures.
These effects are more common with benzodiazepines particularly triazolam 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 Withdrawal and detoxification Withdrawal and detoxification Sedatives include benzodiazepines, barbiturates, and related drugs.
Alcohol is used by many patients to help with sleep, but alcohol is a poor choice because 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 chronic obstructive pulmonary disease COPD.
Over-the-counter OTC antihistamines eg, doxylamine , diphenhydramine can induce sleep. However, efficacy is unpredictable, and these drugs have long a half-life and have adverse effects such as daytime sedation, confusion, urinary retention, and other systemic anticholinergic effects, which are particularly worrisome in older people.
Over-the-counter antihistamines should not be used to treat insomnia. Antidepressants taken in low doses at bedtime eg, doxepin 25 to 50 mg, paroxetine 5 to 20 mg, trazodone 50 mg, trimipramine 75 to 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 doxepin 3 or 6 mg is 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. When used to treat this disorder, it must be taken at the appropriate time a few hours before the evening increase in endogenous melatonin secretion—in early evening for most people, typically 3 to 5 hours before the intended bedtime and at a low dose of 0.
For other forms of insomnia, melatonin 's efficacy is largely unproved. Melatonin can cause headache, dizziness, nausea, and drowsiness. However, after widespread use, no other worrisome adverse effects have been reported.
Available preparations of melatonin are unregulated, so content and purity cannot be ensured, and the effects of long-term use are unknown.
Cannabinoids Marijuana Cannabis Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent read more include the following:.
CBD oil cannabidiol , which causes sedation and reduced sleep latency but no euphoria. THC tetrahydrocannabinol , which causes euphoria, reduces pain and nausea, and has variable effects on sleep stages.
Dronabinol Cannabinoids, Synthetic Synthetic cannabinoids are manufactured drugs that are tetrahydrocannabinol THC receptor agonists. They are typically applied to dried plant material and smoked.
THC is the primary active read more , which is a synthetic analog. Poor sleep hygiene and situational disruptors eg, shift work, emotional stressors are common causes 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.
If you have a sleep disorder that causes daytime drowsiness, speak with a sleep specialist who may provide you with more appropriate and effective treatments. When you're feeling tired but need to stay awake, sipping a little caffeine, taking frequent breaks, or eating a light snack can help you fight sleepiness.
Exercising, power-napping, getting fresh air, enjoying natural light, and lowering the temperature in a room can also help you stay awake during the day. If you have a sleep disorder, your provider may prescribe medications to help you stay awake.
These medications come with risks, however, and are rarely used if daytime drowsiness is the only symptom. Murray BJ. A practical approach to excessive daytime sleepiness: a focused review. Can Respir J.
Centers for Disease Control and Prevention. How much sleep do I need? Staffe AT, Bech MW, Clemmensen SLK, et al. Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants.
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Physical exercise: a novel tool to protect mitochondrial health. Front Physiol. Balchin R, Linde J, Blackhurst D, Rauch HL, Schönbächler G. Sweating away depression? The impact of intensive exercise on depression.
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Drug Enforcement Agency. Drug fact sheet: stimulants. By Brandon Peters, MD Brandon Peters, MD, is a board-certified neurologist and sleep medicine specialist. Use limited data to select advertising. Create profiles for personalised advertising. Use profiles to select personalised advertising.
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List of Partners vendors. Sleep Disorders. Sleep Apnea. By Brandon Peters, MD. Medically reviewed by Smita Patel, DO. Table of Contents View All. Table of Contents. Improve Sleep. Take Breaks. Use Caffeine. Alter Activities. Get Sunlight.
Take a Nap. Have a Snack. Lower Temperatures. Discuss Medications. Group Age Hours of sleep needed Newborns months hours Infants months hours including naps Toddlers years hours including naps Preschoolers years hours including naps School-aged years hours Teens years hours Adults years 7 or more hours per night Older adults years hours per night 65 years and over hours per night.
Why Do I Get Sleepy in the Afternoon? How Much Caffeine Is Too Much? Is Focusing on Work Bad for Your Eyes? Why You Feel Sleepy All the Time.
Reviewed Overcomihg Psychology Today Staff. Overcoming wakefulness has wakefulnses Citrus fruit for cancer prevention asleep from time to wakefjlness indeed, evidence suggests Citrus fruit for cancer prevention percent of adults experience periods of sleeplessness High protein diet the course pvercoming their lifetime. Individuals with insomnia regularly struggle to fall asleep, stay asleep, or return to sleep upon waking prematurely. This can, in turn, trigger irritability, reduced cognitive abilities, anxiety, depression, and numerous physical health problems if left untreated. On the bright side, many cases of insomnia, regardless of severity, respond well to treatment. Self-help strategies, like improving sleep hygiene or implementing at-home behavioral techniques, can help in most mild to moderate cases.
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