Sleep Initiation And Maintenance Disorders

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In medicine, sleep initiation and maintenance disorders, including insomnia, are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."[1][2]

Epidemiology/causes[edit]

There are many underlying associations[3][4] including psychiatric disorders[5][4].

Diagnosis[edit]

While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a polysomnogram is often needed for the differential diagnosis.

Treatment[edit]

Randomized controlled trial of treatment options for insomnia.[6]
Treatment Outcome at 6 months
Responders Remitters
6 weeks of CBT 55% 40%
6 months of CBT 63% 44%
6 months of CBT
6 weeks of zolpidem		 81% 68%
6 months of CBT
6 months of zolpidem		 65% 42%
Adapted from Table 4 of Morin et al.[6]

Treatment options for geriatric patients have been reviewed.[7]

Non-drug treatment[edit]

No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.[8]

A combination of education, sleep hygiene, exercise, and light therapy helped patients with Alzheimer's disease in the NITE-AD randomized controlled trial.[9]

Indirect evidence suggests a warm bath may help.[10]

Exercise, perhaps by raising body temperature, may help.[10]

Medications[edit]

Pharmacological interventions for sleepiness and sleep disturbances caused by shift work has been reviewed by the Cochrane Collaboration.[11]

GABA agonists[edit]

These medications are agonists of the gamma aminobutyric acid.

Nonselective BZ1 and BZ2 agonists[edit]
For more information, see: Benzodiazepine.
BZ1 selective agonists[edit]

These medications include zopiclone, eszopiclone, zolpidem, and zaleplon. Overall, the benefit of these medications is small.[12]

In treating persistent insomnia in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of cognitive behavioral therapy followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a randomized controlled trial.[6]

In geriatrics, the benefits of zolpidem for insomnia to not clearly exceed the drug toxicity.[13][14]

The benefit of eszopiclone may not be strong.[15]

Melatonin agonists[edit]

These may increase sleep by less than 30 minutes.[11]

Ramelteon is one available agonist. Its magnitude of benefit may be small among outpatients.[15]

Tasimelteon can help transient insomnia due to shift changes related to employment.[16]

References[edit]

  1. ↑ Anonymous (2025), Sleep initiation and maintenance disorders (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Silber MH (2005). "Clinical practice. Chronic insomnia.". N Engl J Med 353 (8): 803-10. DOI:10.1056/NEJMcp043762. PMID 16120860. Research Blogging.
  3. ↑ Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake C, Warman G (2012). "Prevalence of causes of insomnia in primary care: a cross-sectional study.". Br J Gen Pract 62 (595): e99-103. DOI:10.3399/bjgp12X625157. PMID 22520782. PMC PMC3268500. Research Blogging.
  4. ↑ 4.0 4.1 Maggi S, Langlois JA, Minicuci N, Grigoletto F, Pavan M, Foley DJ et al. (1998). "Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes.". J Am Geriatr Soc 46 (2): 161-8. PMID 9475443. [e]
  5. ↑ Ford DE, Kamerow DB (1989). "Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?". JAMA 262 (11): 1479-84. PMID 2769898. [e]
  6. ↑ 6.0 6.1 6.2 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.". JAMA 301 (19): 2005-15. DOI:10.1001/jama.2009.682. PMID 19454639. Research Blogging.
  7. ↑ Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al. (2009). "Evidence-based recommendations for the assessment and management of sleep disorders in older persons.". J Am Geriatr Soc 57 (5): 761-89. PMID 19484833. PMC PMC2748127.
  8. ↑ Shub D, Darvishi R, Kunik ME (2009). "Non-pharmacologic treatment of insomnia in persons with dementia.". Geriatrics 64 (2): 22-6. PMID 19256583.
  9. ↑ McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L (2005). "Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial.". J Am Geriatr Soc 53 (5): 793-802. DOI:10.1111/j.1532-5415.2005.53252.x. PMID 15877554. Research Blogging.
  10. ↑ 10.0 10.1 Horne JA, Moore VJ (1985). "Sleep EEG effects of exercise with and without additional body cooling.". Electroencephalogr Clin Neurophysiol 60 (1): 33-8. PMID 2578352.
  11. ↑ 11.0 11.1 Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo LK et al. (2014). "Pharmacological interventions for sleepiness and sleep disturbances caused by shift work.". Cochrane Database Syst Rev 8: CD009776. DOI:10.1002/14651858.CD009776.pub2. PMID 25113164. Research Blogging.
  12. ↑ Huedo-Medina, T. B.; I. Kirsch, J. Middlemass, M. Klonizakis, A. N. Siriwardena (2012-12-17). "Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration". BMJ 345 (dec17 6): e8343-e8343. DOI:10.1136/bmj.e8343. ISSN 1756-1833. Retrieved on 2012-12-19. Research Blogging.
  13. ↑ Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE (2005). "Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.". BMJ 331 (7526): 1169. DOI:10.1136/bmj.38623.768588.47. PMID 16284208. PMC PMC1285093. Research Blogging. Review in: ACP J Club. 2006 Jul-Aug;145(1):14 Review in: Evid Based Med. 2006 Aug;11(4):110 Review in: Evid Based Nurs. 2006 Jul;9(3):87
  14. ↑ Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ (1997 Dec 24-31). "Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.". JAMA 278 (24): 2170-7. PMID 9417012.
  15. ↑ 15.0 15.1 Schwartz LM, Woloshin S (2009). "Lost in transmission--FDA drug information that never reaches clinicians.". N Engl J Med 361 (18): 1717-20. DOI:10.1056/NEJMp0907708. PMID 19846841. Research Blogging.
  16. ↑ Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al. (2009). "Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials.". Lancet 373 (9662): 482-91. DOI:10.1016/S0140-6736(08)61812-7. PMID 19054552. Research Blogging.

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