In terms of treatment of insomnia,
I wouldn't rush right to a sleep study
or right to doing a bunch
of laboratory testing.
Start with a sleep diary to
actually document what's going on.
Think about those conditions
that can make insomnia worse.
Treat their depression,
treat pain before ordering a workup
and certainly before recommending
other hypnotic therapy for sleep, medications.
And start with some non-nonpharmacologic interventions.
These are effective.
and they can prove to be helpful in
other aspects of health beyond sleep.
So, moderate intensity exercise definitely
helps regulate your cycle and it helps you sleep,
but you want to complete that exercise
at least four hours before bedtime.
Avoiding sleep during the day,
if somebody is napping two-and-a-half
hours during the afternoon,
they're going to experience some awakenings and sleep latency.
And it has to be cut out if they ever
want to sleep fully through the night.
Of course, limiting caffeine, tobacco
and alcohol use is a good idea
and not eating at least four
hours before going to bed,
avoiding any meal
during that time as well.
Now, let’s talk about advice to give the patient
with insomnia and just general sleep hygiene.
First of all, just go to bed when tired.
The patients who –
again, who get into real trouble with insomnia are the ones
who really try to force the sleep upon themselves
and sleep just doesn't work like that.
And I think that promotes an anxiety.
Whether they had anxiety before or not,
it promotes an anxiety
in trying to sleep and
worrying about this problem,
such that it self-perpetuates and
you're guaranteed to have more insomnia.
So, use the bed only when tired.
Use the bedroom only for
sleep and for intimacy.
Try to settle down before bedtime.
So, do really boring things.
I don’t know if chess necessarily boring.
There’s a pawn there,
but maybe it’s reading.
It’s nothing crazy and active
and you’re not running around,
doing a million chores.
You do have a little time to settle down.
And if you wake up,
do more boring things.
And if you do get up,
and I think this is one of
the most critical things,
don't just lie and push
yourself to try to sleep.
That again doesn't work.
Get up, get out of bed,
do something for 20 minutes, 40 minutes
and then return when you feel sleepy.
That one really does work.
And usually, between these recommendations
and the lifestyle recommendations,
you’re going to manage about 80 to 90%
of insomnia cases effectively, just with these alone.
So, pharmacologic treatment,
limited to the short term.
The drugs can disturb
They have addictive potential.
And as well, among older adults,
they can promote falls
and more cognitive problems.
they have a higher risk of abuse.
I really use them for only
very limited periods of time,
no more than a week
generally speaking for those drugs.
Over-the-counter treatments like
diphenhydramine don't work very well,
but they can promote some
of that cognitive dysfunction,
somnolence and falls.
And finally, just a
quick word on melatonin.
It probably works particularly
for switching time zone,
but we’re talking about reducing sleep
latency by a few minutes on average.
So, it's probably not something patients
are really going to feel as a benefit.
But if it helps them relax and
makes them feel a little bit better,
There is a risk of daytime grogginess
afterwards as well with melatonin.
So, it's not a completely benign agent.
So, this gives you a
nice overview of sleep.
It helps, I think, you to discuss normal sleep and
changes with sleep as you age with your patients
and then that's a nice entrée for starting to talk about sleep hygiene
and how to how to set the right environment and tone for sleep.
And as I said,
that's going to help you
with the majority of your patients.
Thanks very much.