Sleep restriction therapy

Acute Phase Treatment. Hypnotic medications are useful for short-term treatment of insomnia, but they should always be accompanied by behavioral and psychoeducational treatments, including a review of good sleep hygiene practices. It may also include more aggressive measures such as relaxation training, sleep restriction therapy, and stimulus control therapy. 

Wohlgemuth WK, Edinger JD. Sleep restriction therapy. In Lichstein KL, Morin CM, eds. Treatment of Late-Life Insomnia. Sage London, 2000 147-165. 

Anderson MW, Zendell SM, Rosa DP, Rubinstein ML, Herrera CO, Simons O, Caruso L, Spielman AJ. Comparison of sleep restriction therapy and stimulus control in older insomniacs an update. Sleep Res 1988 17 141. 

Glovinsky PB, Spielman AJ. Sleep restriction therapy. In Hauri PJ, ed. Case Studies in Insomnia. New York Plenum Press, 1988. 

Behavioral and educational interventions that may help include shortterm cognitive behavioral therapy, relaxation therapy, stimulus control therapy, cognitive therapy, sleep restriction, paradoxical intention, and sleep hygiene education (Table 72-3). 

Some clinicians believe that sleep restriction is an effective form of treatment for chronic insomnia. Evidence from studies varies, and use of sleep restriction in many studies was part of combination therapy, and the specific contribution of sleep restriction toward sleep improvement was unclear. 

As for most behavioral therapies, the success of SRT is entirely dependent on the patient s compliance with the prescribed sleep window (7,22). Despite the apparent simplicity of this clinical procedure, therapist guidance is often essential to optimize compliance with the clinical recommendations (16). The first hurdle is making it clear to the patient what is expected and why. Indeed, the idea of curtailing even further the sleep of someone who presents with insomnia is somewhat paradoxical. For many patients, it is counterintuitive when sleep quality is unsatisfactory—from their vantage point, time in bed should be increased to obtain more satisfactory sleep. Thus, it is essential to explain the basic principles of sleep homeostasis and the rationale behind SRT, which should help patients better understand why time in bed should be restricted (27). The addition of sleep education is also useful for elderly individuals to explain the nature and extent of sleep changes associated with aging (16,18,22,25). 

Tablets, 1 mg, may be crushed before swallowing with water. Initially 1-2 tablets should be taken and thereafter, not more than 4 tablets should be taken in 24 h, the sequence should not be repeated for 4 days, and not more than 8 tablets should be taken in a week. Suppositories, 2 mg, are now preferred as part of stepped therapy (above) they are subject to the same maximum dose restrictions. Caffeine enhances both the speed of absorption and peak concentration of ergotamine and is often combined with it (though it may prevent sleep).

The intravenous route is used to deliver larger volumes (e.g. replacement and hyperalimentation solutions). Positioning catheters in a central vein s blood flow avoids multiple injections in seriously ill patients. Rapid dilution occurs compared to injection in peripheral veins. In the latter, infiltration, phlebitis due to osmolarity, pH and the characteristic of the drug and excipients can damage the vessels and lead to the loss of veins for therapy. Other common risks encountered with intravenous administration include activity restriction, impact of normal fluctuations in feeding, activity and sleeping patterns, the pulling out of intravenous lines by the patient, infection and extravasion. 

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