Sleep problems

Insomnia can be a common problem for people when first changing a drug problem. Sleeping problems can be related to the rebound effects of the drugs, or may be related to rumination and regret. Since insomnia is common, therapists and counselors will likely want to teach their clients how they can reduce the duration of this potentially uncomfortable problem. To orient the client, the counselor or therapist will want to emphasize to the client that insomnia is not life threatening, and that eventually he or she will sleep. This orientation is meant to put the client at ease... 

Simple methods, often with proven benefits are forgotten such as stop smoking, lower weight, reduce sleeping problems, sour throat and constipation etcetera... 

Holmquist IB, Svensson B, Hoglund P (2005) Perceived anxiety, depression, and sleeping problems in relation to psychotropic drag use among elderly in assisted-living facilities. Eur J Clin Pharmacol 61(3) 215-224... 

Schneider DL (2002) Insomnia Safe and effective therapy for sleep problems in the older patient. Geriatrics 57(5) 24-26... 

The sleep disorders fall into four main categories (1) insomnia, (2) hypersomnia, (3) parasomnias, and (4) sleep schedule disorders. Insomnia is the most common sleep problem. It is simply defined as poor sleep and can be manifested by difficulty falling asleep, difficulty staying asleep, waking up too early, or waking up in the morning without feeling refreshed. 

Although we are focusing on the primary sleep disorders, sleep disturbance quite often occurs as a symptom of another illness. Depression, anxiety, and substance abuse can impair the quality of sleep, though in the setting of chronic insomnia, other psychiatric disorders account for less than 50% of cases. Nightmares are a frequent complication of post-traumatic stress disorder (PTSD), and pain, endocrine conditions, and a host of medical illnesses can produce sleep problems. Thus, when discussing insomnia or hypersomnia, we are well advised to remember that these can be either a symptom of a psychiatric syndrome, a medical illness, or a sleep disorder. 

In this chapter, we will not attempt to provide an exhaustive description of every sleep disorder. Medication therapy plays a minimal role in the treatment of many sleep disorders. In fact, we contend that medication, apart from being an integral component of a comprehensive multimodal treatment program, is seldom an effective treatment for any sleep problem with the possible exception of acute insomnia due to an identifiable and short-lived stressor. Nevertheless, medications do play a part in the treatment of some sleep disorders. 

Substance-Induced Insomnia. A variety of substances can cause or worsen sleep problems (see Table 9.2). Patients often miss the connection between the ingestion of a medication or caffeine and the onset of their insomnia, and they rarely spontaneously volunteer this information. 

Montgomery P. Treatments for sleep problems in elderly people. BMJ 2002 325(7372) 1049. 

A wide range of sleep disturbances has been documented in PD (Larsen, 2001). In a population-based survey of sleep disorders in PD, Tandberg et ah (1998) reported nocturnal sleeping problems in 60% of PD patients compared to 33% in healthy controls and 46% in elderly with diabetes mellitus. The most common problem reported was sleep fragmentation, which was found in 39% of PD and only 12% of normal elderly controls, whereas inability to fall asleep did not differ between the groups. 

Happe S, Berger K. The association of dopamine agonists with daytime sleepiness, sleep problems and quality of life in patients with Parkinson s disease prospective study. J Neurol 2001 248 1062-1067. 

Geriatric Considerations - Summary Eszopiclone is the only hypnotic which has been shown to maintain efficacy over long-term use (6 months) and may have a role in the management of chronic sleep problems in olderadults. Because eszopiclone is a substrate of CYP C3A, and 2E1, it should be used with caution, especially with drugs such as nefazodone, clarithromycin, and amiodarone. This agent has been newly approved for use in the US and has not been well studied in terms of falls or other geriatric side effects. 

Given its therapeutic profile, nefazadone might be useful in children with depression or anxiety who have prominent sleep problems, or who were activated or energized on SSRIs. 

Trazodone has been used therapeutically, but because of low potency and marked sedative effects, its use has been mostly restricted to a sleeping aid in doses of 50-100 mg at bedtime. It has been routinely used in adults on SSRIs, who develop sleep problems. The concern about priapism even at low doses may reduce enthusiasm for its use in male children and adolescents. 

St. John s wort has been used to treat a wide range of ailments for more than 2000 years, and is said to have been prescribed by Hippocrates himself. Apart from depression, St. John s wort is being promoted or used as a treatment for attention-deficit hyperactivity disorder (ADHD), anxiety, stress, obsessive-compulsive disorder, sleep problems, nocturnal enuresis, bacterial and viral infections such as HIV-AIDS, respiratory conditions, peptic ulceration, inflammatory arthritis, cancer, and skin wounds (Rey and Walter, 1998 Walter et ah, 2000). It is also said to increase libido, an application dating from the Middle Ages (Fletcher, 1996). No empirical evidence is currently available to support any of these uses. 

Preschoolers Child Behavior Checklist/ 2-3 100 items rated 0—2, 6 subscales social withdrawal, depressed, sleep problems, somatic problems, aggressive, destructive P Achenbach et ah, 1992... 

Sleep problems can cause considerable difficulty in and of themselves and can also exacerbate and be exacerbated by other psychiatric and behavioral problems in individuals with MR. The Expert Consensus Panel (Rush and Frances, 2000) recommended sleep hygiene... 

Benzodiazepines (such as clonazepam) are used widely to induce sleep, but they disrupt the normal sleep architecture. Children also have a tendency to become more irritable and hyperactive with hypnotics. In severe cases, benzodiazepines could be given for 3-5 days to facilitate a behavioral treatment program. Trazodone, though not specifically studied in children, may be a safer alternative for more chronic sleep problems if over-the-counter (OTC) diphenhydramine does not work. 

New-onset sleep problems may be a side effect of psychoactive or other medication, and the first intervention should be consideration of adjusting the dosage or time of day the medication is given. For example, sleep disruption from stimulants can generally be relieved by adjustments based on careful history of the time-action effects. 

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