Lifestyle, Medication, and Natural Therapies V. Treatment of Sleep Disorders: Nondrug therapies Nondrug interventions have been shown to improve sleep quality in people with sleep disorders. These treatment options include cognitive behavioral therapy, sleep restriction, sleep habits, and relaxation therapy.

1. General Lifestyle One of the most effective behavioral therapies for sleep disorders is to improve sleep habits. Examples include a consistent bedtime, limiting blue light exposure before bed, and limiting time spent in bed (nonsleep). Good sleep habits may help prevent sleep disorders. A prospective crosssectional analysis of 548 college students examined the association between sleep habits and the severity of sleep disorders.

Students complain of inconsistent sleepwake cycles and often worry in bed. Poor sleep arrangements, uncomfortable sleeping conditions, and behaviors that cause arousal before falling asleep are associated with the severity of sleep disorders. After controlling for other adverse factors, sleep arrangements were most associated with the severity of sleep disorders. A separate analysis of 130 patients admitted to a burn unit found that a sleep habit improvement programme was successful in helping patients fall asleep faster and with fewer sleep disruptions.

Consider the following sleep hygiene and general lifestyle measures:

(1) Keep your bedroom cool, dark, and quiet.

(2) Keep your sleep and wake times consistent throughout the week.

(3) Avoid eating large meals two to three hours before bed, as indigestion can make falling asleep difficult. Limit your intake of stimulants (e.g., caffeine, nicotine, and alcohol) during the day, especially near bedtime.

(5) Limit daytime sleep.

(6) Take a walk outside every day and feel the natural light.

(7) Engage in daily physical exercise, but avoid strenuous exercise within two hours before bed.

(8) Develop a bedtime routine (e.g., a warm bath and listening to light music) to improve relaxation. Addressing stress may help improve sleep quality. People with sleep disorders should also look at stress management programs.

(9) Avoid nonsleep related activities in the bedroom (e.g., watching TV, reading or listening to the radio). Use the bedroom only for sexual activity and sleep (stimulation control). If you're worried that the time will keep you awake, turn off your alarm.

2. Sleep Restriction to Restore Circadian Rhythms Sleep restriction therapy limits bed time (including naps) to increase the biological need for sleep at night. This process usually begins by limiting bed time to the estimated amount of sleep people should spend. For example, a person who lies in bed for nine hours but sleeps for only six hours initially limits their time in bed to six hours. At first, this leads to mild sleep deprivation, but the sleepiness it produces trains the body to fall asleep faster.

As the body ADAPTS, people can increase the amount of time they spend in bed by 15 to 20 minutes until they can get a full night's sleep without spending more time in bed. A study of sleep hygiene plus sleep restriction versus sleep hygiene alone found that sleep restriction improved sleep efficiency. Evidence of sleep restriction as a standalone treatment for sleep disorders suggests it can improve sleep efficiency and total sleep time, which researchers believe is an effective treatment for chronic sleep disorders.

3. Cognitive Behavioral Therapy In 2016, the American College of Internal Medicine recommended cognitive behavioral therapy as an initial treatment option for people with chronic sleep disorders. Cognitive behavioral therapy can help people develop more sleepfriendly behaviors. It involves regular visits to a clinician who will assess sleep patterns and work to change the patient's sleep patterns. Cognitive behavioral therapy works by teaching subjects to change their beliefs about sleep, develop good sleep habits and improve their sleep environment.

Cognitive behavioral therapy may involve sleep restriction and education on sleep habits. It may also involve biofeedback, which provides information about certain biological functions (such as respiration, heart rate, and muscle contraction) via electrical sensors. This information allows a person to make subtle changes (such as breathing rate or muscle relaxation) in an attempt to control bodily functions to better manage conditions such as anxiety, pain, and sleep disturbances. Stimulus control therapy focuses on eliminating factors that encourage people to resist sleep, such as inconsistent bedtimes or using the bedroom for activities other than sleep.

Cognitive behavioral therapy has been shown to be an effective treatment for both primary and secondary sleep disorders. A recent randomized controlled trial of 36 people followed for six months showed that cognitive behavioral therapy improved sleep disorder severity scores, sleep metrics, and dysfunctional sleep beliefs. A recent review concluded that cognitive behavioral therapy may be more effective than benzodiazepines and nonbenzodiazepines in the longterm treatment of sleep disorders; Other studies have shown that cognitive behavioral therapy can reduce depression, improve mental health, and treat sleep disorders more effectively than sleep AIDS.

4. Relaxation Therapy Some people with sleep disorders have higher levels of cognitive and physical arousal, as evidenced by increased glucose metabolism in the brain. Relaxation therapy (including meditation, visualization techniques, breathing exercises, and progressive muscle relaxation) aims to reach a more relaxed state before bedtime. Most of these techniques can be selfadministered with the initial guidance of a medical professional. Social support, stressreducing techniques (including meditation and yoga) and improved coping mechanisms for stress may be useful for some people with sleep disorders.

A study involving 30 adults with sleep disorders found that mindfulnessbased stress reduction, which included meditation training, resulted in significant improvements in sleep quality, including the time spent falling asleep and total sleep time. Another study of 44 postmenopausal women between the ages of 50 and 65 who were not taking hormone replacement therapy found that practicing yoga for four months reduced sleep disturbances and stress severity scores, and improved quality of life. There are many medications available to treat sleep disorders, including overthecounter medications, benzodiazepines, nonbenzodiazepines, and antidepressants.

These drugs are usually used sporadically or intermittently. Overthecounter (OTC) medications can be used safely and effectively to promote an occasional good night's sleep. Antihistamines are among the most common OTC sleep medications, such as doxylamine (Unisom) and Benadryl (Benadryl). Antihistamines block receptors that respond to histamine. This can reduce congestion, sneezing, coughing and allergies. The blockage of histamine receptors in the central nervous system causes a sedative effect; therefore, antihistamines can be used as sleep AIDS.

Side effects include daytime sleepiness, dry mouth and constipation. Few rigorously designed trials have been conducted to determine the efficacy of OTC sleep AIDS. Diphenhydramine can remain in the body for a long time, resulting in a sedative effect the next day. Be aware that some people may develop tolerance or dependence to these medications, and they may cause dangerous side effects when used with other medications. In addition, if taken for a long time and then stopped, it may exacerbate sleep problems. Older adults should take extra care when using OTC sleep AIDS. One reviefound that 50% to 65% of adults abuse OTC sleep medications.

Drugdrug interactions and drugage interactions were the most common. In 2015, the Beers Criteria for Potentially Inappropriate Medication for Older Adults recommended that people over 65 not use products containing ingredients such as benadryl and doxylamine. Talk to your doctor before using a sleep aid to make sure it won't interact with any medications you're currently taking or any medical conditions you have. Avoid alcohol; Do not engage in activities requiring vigilance after taking the drug, such as driving a vehicle; And don't use any sleep medication for more than two weeks.

Benzodiazepines Prior to the 1990s, benzodiazepines (e.g., Xanax, Klonopin, and diazepam) were the basis for the treatment of sleep disorders. These drugs enhance the effects of the neurotransmitter gammaaminobutyroacid (GABA), one of the major inhibitory neurotransmitters in the brain, by binding to multiple brain receptor sites. Benzodiazepines have been found to increase sleep duration, reduce the number of nighttime awakenings, and improve total sleep duration and sleep quality with shortterm use. Benzodiazepines can be classified based on their duration of action.

Shortacting benzodiazepines are more likely to cause withdrawal symptoms, while longacting benzodiazepines are more likely to make users feel sleepy. A recent longitudinal cohort study of more than 200 nursing home residents in Belgium found that longterm use of benzodiazepines actually reduced sleep quality over a oneyear period compared to people who did not use these drugs, suggesting that longterm use of these drugs does not maintain higher sleep quality.

3. Nonbenzodiazepines Nonbenzodiazepines, also known as benzodiazepines, such as zalepram (Sonata), zolpitham and dexzopicron, have fewer effects on brain receptors than benzodiazepines and therefore generally have fewer side effects.

(1) Zaleplon is one of the first nonbenzodiazepines developed to treat sleep disorders and has been shown to be effective in reducing the time to fall asleep. Its short halflife (1 hour) also reduces the risk of persistent effects the next morning, which may make it less useful for people who wake up during the night. Older people should not take Zareplon as it is not as safe or effective as other available medications. Note that while using Zareplon, some people experience sleep disturbances, such as getting up and performing some activities while half asleep, such as driving, having sex or eating. These people often do not remember what happened the next day. In addition, there may be unexpected changes in mental health with this drug, including aggression, hallucinations, memory problems, depression, confusion and suicidal ideation. Zareplon should only be taken under the guidance of a healthcare professional.

(2) Zolpitam The halflife of zolpitam (about 2.5 hours) may make it more effective in reducing the time required to fall asleep and help maintain sleep while reducing daytime sleepiness caused by residual drug effects. A review of the literature found that 10 mg of zolpidem in adults and 5 mg of zolpidem in people over 65 reduced sleep latency and prolonged sleep duration in people with sleep disorders. Residual effects during the day are uncommon, as long as people stay in bed for at least eight hours before getting up. Zolpidem is cleared more slowly in women than men. Blood levels may be higher in the morning, which may affect psychomotor ability. In 2013, the US Food and Drug Administration (FDA) asked manufacturers to lower the recommended dose from 10 mg to 5 mg for fastrelease formulations and from 12.5 mg to 6.5 mg for slowrelease formulations.

(3) Ezopicron Ezopicron has also been shown to be effective in improving sleep. This drug prolongs total sleep time and helps people fall asleep faster. It takes longer to act than other nonbenzodiazepines, but it also lasts longer. Due to adverse effects on driving, memory, and concentration the day after taking it, the FDA recently lowered the recommended starting dose of ezopicron to 1 mg. A doubleblind study involving 91 people ages 25 to 40 showed that taking ezopicron 3 mg was associated with psychomotor and memory impairments for 7.5 to 11 hours.

The dose may be increased to 2 to 3 mg under the guidance of a physician, but 3 mg has been associated with states of altered mental awareness. Note that recent studies have shown that hypnotic sleep AIDS may be associated with serious adverse events, including dependence/withdrawal, impaired driving, cognitive impairment and an increased risk of accidents or falls. There has also been an association between the use of hypnotic sleep AIDS and increased risk of depression, infection and mortality. These risks are most common in the elderly. In addition, in 2012, a wellcontrolled study showed an association between sleep AIDS (such as zolpitam, ezopicron and temazepam), with a more than threefold increased risk of death.

However, we should note that people who use hypnotic sleep AIDS generally have poorer sleep quality, which may be the factor contributing to the sharp increase in mortality risk. In a recent review, 43 out of 46 epidemiological studies found excess mortality with hypnotics use, while 45 of these studies found no survival benefit with hypnotics use. Results from two large cohort studies showed that benzodiazepines use was associated with increased allcause mortality. Some researchers believe that the risks associated with hypnotic sleep AIDS outweigh any minimal benefits. In fact in April 2019, the US FDA announced that the agency was requiring boxed warnings for eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (e.g. Ambien).

The crate warning is the most prominent warning required by the agency. The move is based on safety monitoring studies that have linked these drugs to an increased risk of engaging in potentially dangerous behaviors while not fully awake, such as driving. These drugs should only be used under the guidance and supervision of a physician.

Since many people with depression also suffer from sleep disorders, these medications may help relieve the symptoms of both disorders. Studies have shown that antidepressants can reduce the time it takes to fall asleep and help prevent waking up during the night. In addition, the sedative effect of these medications allows you to get the relaxation you need to fall asleep faster. Typically, antidepressants redue REM sleep, but seem to have little effect on deeper sleep cycles.