• Definition and Prevalence
• Clinical Presentation
• Risk Factors
• Diagnosis and Differential Diagnosis
• Treatment and Management
• Pharmacologic Treatment

Treatment and Management
As many factors may contribute to the insomnia complaint, identifying and treating the underlying cause is the key for a successful outcome. If insomnia is caused by a painful medical problem, successful treatment of the medical disorder will improve the insomnia as well. If depression is causing the insomnia, treatment of the depression will help resolve the insomnia.

Changing the timing of medication administration may be important for resolving the insomnia. Ideally, stimulating medications should be taken early in the day, while sedating medications should be taken near bedtime.

Some behavioral modification techniques have proven successful for the alleviation of psychophysiologic or primary insomnia. In a recent review by Morin et al., 70% to 80% of patients with primary chronic insomnia benefited from nonpharmacologic treatments.

Sleep hygiene is a set of guidelines aimed at maintaining healthy sleep habits. Commonsense rules include avoiding or limiting naps, particularly late in the day, as daytime napping may interfere with nighttime sleep; avoiding substances that interfere with sleep, such as alcohol, caffeine, and nicotine; maintaining a stable sleep-wake pattern throughout the week; and exercising regularly, but not late in the day (physical or mental stimulation at night may interfere with sleep). For a summary of sleep hygiene rules for the elderly,

see Table 70.2.

Stimulus control therapy is another behavioral technique designed to remove all negative associations from the bedroom environment. The patient is instructed to go to bed only when sleepy. If unable to fall asleep in 15 to 20 min, the patient must leave the bedroom and engage in a relaxing activity, such as reading a magazine or writing a letter. Only when patients feel sleepy again can they return to bed. This procedure should be re-peated as needed, until sleep is achieved in less than 15 min. For a summary of stimulus control therapy,

see Table 70.3. Stimulus control therapy is appropriate for patients who feel stress, tension, or anxiety that are conditioned to the bedroom or the bed. They are caught in a vicious cycle, in which negative thoughts and feelings disrupt their ability to fall asleep, leading to more intensified adverse thoughts and feelings associated with the bed-room. Learning to associate the bedroom with relaxing feelings of sleepiness breaks the cycle and allows the patient to regain control over their sleep.

Sleep restriction therapy is based on reducing time in bed to improve sleep efficiency. Many insomniacs try to get more sleep by going to bed early and spending more time in bed, when in fact this only worsens the problem. Thus, patients are instructed to stay in bed only for the amount of time that they actually sleep, plus 15 min. Actual sleep time is assessed by a subjective sleep log or an actigraph. When sleep efficiency reaches 85% or above, time in bed may be increased by 15 min. The procedure is repeated until the desired amount of time in bed is reached.

Sleep restriction therapy was found to be superior to relaxation techniques and comparable to sleep hygiene therapy for the treatment of insomnia in community-residing elderly after a 3-month follow-up.

Bright light therapy is an effective treatment for circadian rhythm sleep disorders. The light-dark cycle is the most important synchronizer of our internal biologic clock, and changes in the timing of bright light exposure effectively shift altered circadian rhythms to a more appropriate phase.

In the elderly, who most commonly have advanced sleep phase syndrome, exposure to bright light in the evening hours on a daily basis delays the sleep episode to a later phase, so that they no longer experience the early morning awakenings that often present as an insomnia complaint. Avoidance of bright light in the early morning hours is also important, as light exposure early in the day causes an advancement of the sleep episode.

There is growing evidence that institutionalized elderly patients receive disturbingly low levels of illumination during the day, and this has been associated with poor sleep at night.