Sleep restriction therapy 25 consists of curtailing the amount of time spent in bed to increase the percentage of time spent asleep. Poor sleepers often increase their time in bed in an effort to provide more opportunity for sleep, a strategy that is more likely to result in fragmented and poor-quality sleep. What daytime consequences does the patient report? (Daytime consequences may be significant)ĭoes the patient report dozing off or having difficulty staying awake during routine tasks, especially while driving? (This is a serious problem that should be dealt with promptly) What are the bedtimes and rise times on weekdays and weekends? (May relate to poor sleep hygiene)ĭoes the patient use caffeine, tobacco or alcohol? Does the patient take over-the-counter or prescription medications (such as stimulating antidepressants, steroids, decongestants, beta blockers)? (May relate to substance-induced insomnia) Is the patient a shift worker? What are the work hours? Is the patient an adolescent? (May relate to circadian sleep disorders/sleep deprivation) Is the sleep environment conducive to sleep? (Noise, interruptions, temperature, light)ĭoes the patient report “creeping, crawling or uncomfortable feelings” in the legs that are relieved by moving the legs? (May relate to restless legs syndrome)ĭoes the bed partner report that the patient's legs or arms jerk during sleep? (May relate to periodic limb movements in sleep)ĭoes the patient snore loudly, gasp, choke or stop breathing during sleep? (May relate to obstructive sleep apnea) When did the problem begin? (To differentiate between acute and chronic insomnia)ĭoes the patient have a psychiatric or medical condition that may cause insomnia? (May relate to an underlying condition that should be treated first) How has the patient been sleeping recently? Circadian rhythm sleep disorders are characterized by an inability to sleep because of a mismatch between the circadian sleep rhythm and the desired or required sleep schedule ( Table 1). Obstructive sleep apnea is most commonly associated with snoring, daytime sleepiness and obesity but occasionally presents with insomnia. This condition and restless legs syndrome are more common in older patients. Characteristically, the bed partner is more likely to report the movement problem. Rather, the patient reports that sleep is not refreshing. These movements occur every 20 to 90 seconds and can lead to arousals, which are usually not perceived by the patient. Periodic limb movement disorder is characterized by bilateral repeated, rhythmic, small-amplitude jerking or twitching movements in the lower extremities and, less frequently, in the arms. The dysesthesias cause difficulty falling asleep and are often accompanied by periodic limb movements. Symptoms increase in the evening, especially when a person is lying down and remaining still. Restless legs syndrome is characterized by unpleasant sensations in the legs or feet that are temporarily relieved by moving the limbs. Effective treatment of insomnia may improve the quality of life for many patients. Hypnotic medications are safe and effective in inducing, maintaining and consolidating sleep. Behavior approaches take a few weeks to improve sleep but continue to provide relief even after training sessions have ended. Behavior and pharmacologic therapies are used in treating insomnia. Asking sleep-related questions during the general review of systems and asking patients with sleep complaints to keep a sleep diary are helpful approaches in detecting insomnia. Approximately 10 percent of adults experience persistent insomnia, although most patients do not mention it during routine office visits. In addition, daytime consequences such as fatigue, lack of energy, difficulty concentrating and irritability are often present. Patients with insomnia may experience one or more of the following problems: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning and nonrefreshing sleep.
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