00:01
In terms of treatment of insomnia,
I wouldn't rush right to a sleep study
or right to doing a bunch
of laboratory testing.
00:10
Start with a sleep diary to
actually document what's going on.
00:13
Think about those conditions
that can make insomnia worse.
00:16
Treat their depression,
treat pain before ordering a workup
and certainly before recommending
other hypnotic therapy for sleep, medications.
00:28
And start with some non-nonpharmacologic interventions.
00:32
These are effective.
00:33
They’re safe
and they can prove to be helpful in
other aspects of health beyond sleep.
00:39
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.
00:48
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.
00:58
That's normal.
00:59
And it has to be cut out if they ever
want to sleep fully through the night.
01:03
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.
01:15
Now, let’s talk about advice to give the patient
with insomnia and just general sleep hygiene.
01:20
First of all, just go to bed when tired.
01:22
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.
01:33
And I think that promotes an anxiety.
01:35
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.
01:45
So, use the bed only when tired.
01:49
Use the bedroom only for
sleep and for intimacy.
01:51
That's it.
01:52
Try to settle down before bedtime.
01:55
So, do really boring things.
01:56
I don’t know if chess necessarily boring.
01:58
There’s a pawn there,
but maybe it’s reading.
02:01
It’s nothing crazy and active
and you’re not running around,
doing a million chores.
02:06
You do have a little time to settle down.
02:09
And if you wake up,
do more boring things.
02:12
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.
02:18
That again doesn't work.
02:19
Get up, get out of bed,
do something for 20 minutes, 40 minutes
and then return when you feel sleepy.
02:26
That one really does work.
02:28
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.
02:42
So, pharmacologic treatment,
limited to the short term.
02:45
The drugs can disturb
sleep architecture.
02:49
They have addictive potential.
02:51
And as well, among older adults,
they can promote falls
and more cognitive problems.
02:57
So, benzodiazepines,
they have a higher risk of abuse.
03:00
I really use them for only
very limited periods of time,
no more than a week
generally speaking for those drugs.
03:09
Over-the-counter treatments like
diphenhydramine don't work very well,
but they can promote some
of that cognitive dysfunction,
somnolence and falls.
03:18
And finally, just a
quick word on melatonin.
03:21
It probably works particularly
for switching time zone,
but we’re talking about reducing sleep
latency by a few minutes on average.
03:29
So, it's probably not something patients
are really going to feel as a benefit.
03:33
But if it helps them relax and
makes them feel a little bit better,
that's great.
03:38
There is a risk of daytime grogginess
afterwards as well with melatonin.
03:42
So, it's not a completely benign agent.
03:46
So, this gives you a
nice overview of sleep.
03:50
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.
04:06
And as I said,
that's going to help you
with the majority of your patients.
04:09
Thanks very much.