When presented with a youth experiencing sleep problems, a provider must first take a comprehensive, developmentally appropriate sleep history. Using the “BEARS” acronym can be helpful in remembering to ask about Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity of evening sleep time and morning awakenings, and Sleep-related breathing problems or Snoring. Asking youth and their families to maintain a sleep log, including sleep and wake times, caffeine intake, exercise, and any other associated behaviors, for at least two consecutive weeks can provide valuable information (see this link for an example: Sleep Diary). Questionnaires, such as the Epworth Sleepiness Scale for Children and Adolescents, School Sleep Habits Survey, and Children’s Sleep Habits Questionnaire, can provide additional insights. If there are concerns about organic causes of insomnia, such as narcolepsy or obstructive sleep apnea, consider ordering polysomnography and/or referring to a sleep specialist.

The first step in addressing pediatric insomnia is to implement behavioral interventions aimed at improving sleep hygiene. Key tips include reducing substance use (including caffeine), limiting screen time before bed, creating a healthy sleep environment, maintaining a regular sleep/wake schedule, practicing a consistent bedtime routine, avoiding naps, and exercising regularly (though not immediately before bed). It is essential to enlist the support of a parent or caregiver to help implement these behavioral changes. Such interventions alone can be highly effective in improving sleep.

If further intervention is needed, consider referring the youth to a therapist trained in Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I is a 4-6 session, evidence-based program that can help children and adolescents with sleep onset latency, the number and duration of awakenings, and total sleep time. About 70-80% of patients experience a therapeutic response, and 40% achieve clinical remission. CBT-I involves the following components: sleep education, stimulus control, sleep restriction therapy, cognitive behavioral therapy, and relaxation techniques.

• Sleep education provides youth and their families with information on how sleep works.
• Stimulus control encourages going to bed only when sleepy, leaving the bedroom if awake for more than 20 minutes, avoiding naps, maintaining a regular wake-up time, and other strategies to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness.
• Sleep restriction therapy involves systematically limiting the time spent in bed to increase sleep efficiency, or the ratio of time asleep to time in bed.
• Cognitive behavioral therapy targets restructuring maladaptive thoughts that interfere with sleep, such as worries about sleep loss.
• Relaxation training involves learning techniques like diaphragmatic breathing, progressive muscle relaxation, imagery, and other strategies to improve sleep.

Overall, behavioral interventions are preferred over pharmacological treatments for sleep issues, especially in youth. Currently, no medications are FDA-approved for pediatric insomnia. Medications, such as melatonin, antihistamines, and alpha agonists, can be trialed off-label on a short-term basis in conjunction with behavioral interventions, but most are not evidence-based, have limited effectiveness, and may cause adverse side effects. Psychotropic medications may be warranted if comorbid psychiatric conditions are contributing to sleep difficulties.

References

Lunsford-Avery JR, Bidopia T, Jackson L, Sloan JS. Behavioral treatment of insomnia and sleep disturbances in school-aged children and adolescents. Child Adolesc Psychiatr Clin N Am. 2021 Jan;30(1):101-116. doi: 10.1016/j.chc.2020.08.006.

Moturi S, Avis K. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010;7(6):24-37.

Shatkin, J, Ivanenko A, Gruber R. Cognitive behavior therapy for insomnia. Presented as part of AACAP’s 2024 Annual Meeting; October 19, 2024; Seattle, WA.

Sleep disorders: Parents’ medication guide. Available at: https://www.aacap.org/App_Themes/AACAP/Docs/families_and_youth/med_guides/SleepDisorders_Parents-Medication-Guide-web.pdf (Accessed: 13 November 2024).

AUTHOR:

Dr. Kristen Kim, MD, Psychiatrist

Vista Hill Foundation

A good assessment of onset, extent, duration, onset, severity, triggers of the sleep problem, in conjunction with the standard review of systems, is the first step.  Once done, treatment options can be considered.

Cognitive Behavioral Therapy (CBT) interventions have a high rate of long-term efficacy, and CBT should be employed with all patients, even those with health care issues and medication needs.   When using CBT, the complications and risks associated with sleep aid medications can be avoided or minimized and for intractable cases, doses may be able to be contained.

CBT has been shown to be helpful as an adjunctive treatment for insomnia in depression when used with antidepressant medication. It has also been helpful with other co-morbid concerns, like chronic pain, fibromyalgia, substance abuse, and anxiety disorders. Some patients may be able to taper off of sleep medications after participating in CBT treatment for insomnia.   The central focus of CBT treatment is on improving the patient’s sleep hygiene.

Predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep difficulties. Some individuals may be particularly predisposed or vulnerable to sleep difficulties because of a dysfunctional biological sleep system. When such individuals are confronted with precipitating circumstances (for example: a stressful life event), they can develop an acute sleep disturbance. This sleep disturbance can be perpetuated if the patient develops poor sleep hygiene practices (for example: daytime napping, spending excessive time in bed, etc) to try to cope with the sleep difficulty.

Therefore, although predisposing and precipitating factors contribute to insomnia, poor sleep hygiene is seen as a critical sustaining element in the sleep disturbance. One key element of CBT for insomnia is to correct those sleep habits that ostensibly sustain or add to the patients’ sleep problems.

Modified CBT intervention can be provided in the primary care office, though referral to a formal program is appropriate for most as well.   CBT requires a discussion about the rationale for the treatment and some basic education about sleep norms, circadian rhythms, effects of aging, of medications and drugs and the effects of sleep deprivation.   Typical CBT techniques include sleep scheduling, stimulus control, relaxation, cognitive restructuring, sleep hygiene, and medication tapering techniques.   Typically the behavioral treatment uses stimulus control and sleep restriction strategies to normalize standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep profile and pattern. It is important to maintain and review sleep logs to help with troubleshooting problems that may occur along the way.

Here is a case example to illustrate the role that CBT for insomnia can play in the primary care setting:

35yo male with a history of Type I Diabetes well controlled on insulin and no previous psychiatric history who presents with longstanding (since high school) difficulty with initiating and maintaining sleep. Various medication trials (Benadryl, Ambien, Elavil, OTC agents) have worked for short periods of time but then cease to be helpful. He has been stable, denies other mood or anxiety symptoms and has been able to maintain working.   Education and guidance on sleep hygiene is helpful in some respects but medication requests recur.   A referral for a sleep study is made with normal findings and a recommendation for referral to a formal CBT sleep treatment group.

If you are interested in more information, here are some websites that might be useful:

http://www.med.unc.edu/neurology/sleepclin/jdedingrCBTManual.pdf

http://www.journalsleep.org/Articles/260209.pdf

https://adaa.org/sites/default/files/Runko_177.pdf

Pharmacological options include benzodiazepines, non-benzodiazepines, antidepressants and antihistamines. There is limited evidence on their long-term safety particularly with cognitively-impaired older adults. For this reason, it is important to use these medications with caution, for the shortest period of time as needed, and to follow the motto “start low and go slow”. Benzodiazepines are commonly used, but they have little effect on the sleep maintenance problems that are most commonly seen in older adults with dementia. In addition, they can have problematic side effects, including sedation, confusion, anterograde amnesia, and rebound insomnia, which can make the behavioral disturbance seen with dementia worse. The newer generation non-benzodiazepines have shorter half-lives and fewer side effects, but there is limited data on their use in older patients with dementia.

Antidepressants, including Trazodone, the SSRIs and Remeron, are sometimes used to help with sleep problems, in some cases to take advantage of their side effect of sedation and in other cases because there is concern about co-morbid depression. Trazodone has been found in small studies to be helpful short-term with improving total sleep time and sleep efficiency. Antihistamines are commonly used in this situation, partly because of the availability over-the-counter, but there are side effect concerns, including sedation, cognitive impairment, and anticholinergic responses. Because of these side effect risks, they should be avoided as first-like agents in older patients. Supplemental melatonin has not been found to be helpful as a stand-alone treatment for insomnia in patients with dementia in studies, but ramelteon, a melatonin agonist, has been shown some promising results in general studies, to improve sleep efficiency and increase total sleep time. In addition, it is not associated with side effects that are seen with other medications used for sleep disturbance, like cognitive impairment and daytime sleepiness. It would be helpful for more studies to be done with this agent in older patients.

It is our hope that this article has been helpful in addressing the common issue of sleep disturbance in patients with dementia, to begin thinking about how to determine the cause and the best treatment approach.

Reference: Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.

In order to discuss appropriate treatment, it is first important to understand the causes of sleep disturbance in this population. The causes of sleep disturbance in patients with dementia include: (1) physiologic changes that occur as part of dementia as well as normal aging; (2) primary sleep disorders such as sleep apnea and restless leg syndrome that can occur co-morbidly; (3) medication side effects; (4) environmental and behavioral factors, including poor sleep hygiene practices; and (5) a combination of the above.  With Alzheimer’s dementia, the sleep disturbance is thought to be a result of a progressive deterioration and decrease in the number of neurons in the suprachiasmatic nucleus (SCN), which lead to fluctuations in neurohormones that are important in the homeostatic stability of the circadian rhythm.

It is often difficult to determine the exact cause for an older patient presenting with insomnia. Older adults are at risk for a variety of age-related comorbid conditions, such as ischemic heart disease, diabetes, depression, renal failure, arthritis and pulmonary disorder, which can

further exacerbate sleep disturbances. To make things more complicated, many of the medications used to treat these chronic diseases can have varying effects on sleep. For example, narcotic analgesics that are used to treat chronic pain can cause excessive daytime somnolence, and bronchodilators that are used commonly for pulmonary disorders can have nighttime stimulating effects.

Often, patients with dementia need medication to manage their behavioral symptoms. Medications that are commonly used to treat the behavioral disturbances seen in dementia can have a negative impact on a patient’s sleep. Acetylcholinesterase inhibitors can cause nighttime activation and dream disturbances. Antipsychotic medications can cause daytime sleepiness and somnolence. When using these medications, it is important to individualize the treatment and assess for risks and benefits related to a medication.

Part 2 of this article will discuss treatment options, both non-pharmacological and pharmacological, for patients with insomnia related to dementia.

Reference:
Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.

Prescription Meds: In general the most studied and effective medications for short term and/or intermittent treatment of insomnia are the benzodiazepines and the hypnotic “Z” drugs (zolpidem, zaleplon, eszopiclone). Risks include dependency, excessive sedation, cognitive impairment and complex sleep related behaviors. Sleep onset insomnia will typically benefit more from short acting medications such as zolpidem, zaleplon, or triazolam. If there are issues with maintenance of sleep a longer acting choice such as eszopiclone, zolpidem ER, lorazepam, or temazepam may be more beneficial, but these may carry an additional risk of morning sedation.

Other options that could be used when there are concerns about abuse of these medications or addictive risk, include low doses of sedating antidepressants such as trazodone, mirtazapine, amitriptyline and doxepin. These agents are not infrequently used as long-term agents, when effective. Use of quetiapine (Seroquel) or clonidine may also be an option.

OTC: Over the counter options for insomnia typically have antihistamines as their active ingredient. Generally these are fairly safe and a viable option though the research has not supported their use for treatment of primary insomnia. Nonetheless, these agents are popular and readily accessible.

Herbals: Herbal products are also frequently used even though studies of effectiveness are limited or inconclusive. It is important to inform patients of possible negative effects of these substances along with information about their potential benefits. The most common alternative remedies used for insomnia include melatonin, valerian, kava, chamomile, St. John’s wort, and 5-Hydroxytryptophan (5-HTP).

Melatonin has some of the best research supporting its use in sleep disorders, mainly for disorders of the circadian rhythm. There are few side effects associated with melatonin and it may help with both sleep onset and maintenance. Research only supports the use of doses between 0.3-0.6 mg, higher doses will raise blood levels of melatonin throughout the day with risk of daytime sedation as well the potential of hyperprolactinemia. A melatonin agonist (ramelteon) is also now available.

St. John’s wort has been used for depression, anxiety and sleep. It is believed to work on the GABA and serotonin systems. In general it is probably safe to use for insomnia but the patients should be warned about various interactions with other medications as St. John’s wort affects the p450 system and thus can increase the risk of serotonin syndrome if taken along with an SSRI medication.

Other Herbals: Valerian appears to work on the GABA system through benzodiazepine-like activity. It should not be used by pregnant or breast feeding women and there has been some reports of possible liver failure. Three or more weeks of daily use may be required for efficacy to become apparent. Kava has also been frequently used for insomnia and it too appears to work through the GABA system. There have also been some reports of liver failure with its use. Chamomile is generally used in a tea for insomnia. It has very little research supporting its use in insomnia but has very few potential adverse effects so there is no reason to discourage its use if the patient desires. Finally 5-HTP is a serotonin precursor that may have some benefit for insomnia, though the evidence is weak. It may take 6-12 weeks of use to see any benefit and because it raises serotonin levels use with other serotonergic medications may increase the risk of serotonin syndrome.

In summary behavioral treatments for insomnia should always be used first but if ineffective then use of a medication or herbal supplement could be tried. First line treatment for short term use should probably be a benzodiazepine or a “Z” drug. Use of herbal supplements while lacking rigorous studies, do seem to have some benefit and in general low side effects profiles so they could be recommended as possible treatment options. Patients should be advised that these substance are not intrinsically safe because they are “natural” and that they can have side effects and drug interactions. Additionally, they are unregulated and can be subject to contaminates that may be harmful. Patients should try to obtain these substances from reputable sources. If the patient does not respond to sleep aid options or they are unable to be tapered off the prescription meds after 1-2 months, then it would be recommended refer to a sleep clinic for further evaluation and treatment.

Insomnia Defined: ―trouble with either falling asleep, staying asleep or early awakenings at least 3 nights a week for at least a month associated with significant functional impairment or distress.

The major causes of insomnia include medical conditions and psychiatric disorders, yet about 6% of adults will present with a primary insomnia for which no underlying illness or condition can be identified.

Both physical and psychiatric causes of poor sleep should be evaluated when a patients presents with complaints of insomnia.

– Common medical issues to assess include problems with pain, restless leg syndrome, sleep apnea, thyroid or other endocrine/metabolic disorders and any drug/medication use that could be affecting sleep.

– Psychiatric conditions can affect sleep as well and treatment of the underlying psychiatric issues, particularly anxiety and mood disorders, will frequently lead to improved sleep.

Assessment of the sleep problem should include a history of what the sleep problem is like– is it mainly trouble initiating sleep, staying asleep, early awakening or a combination of these. Sleep onset insomnia is the most common complaint but each case has its own profile and determining when a patient goes to bed, how long it takes to fall asleep, the number of times they awaken at night, when and how they finally arise and if they take naps during the day is important.

Additional information to review includes any routines the patient has prior to going to bed, any other activities they do in bed (eating, TV, reading, etc), use of caffeine, alcohol, or other substances and what they do when they are not falling asleep (toss and turn, trying to force the sleep to come, watching TV, reading, etc.

The first step in treating the insomnia should be to address issues of sleep hygiene. This includes having a set bed time, minimizing napping during the day, avoiding caffeine, alcohol or other stimulating substances at night, not eating large meals close to bed time, and having a sleep routine.

Establishing a nightly sleep routine of sleep preparation can be suggested, with the goal of winding things down—this may include terminating ―screen time (TV, computers, phones) and using relaxation techniques (deep breathing, muscle relaxation) for 30 – 60 minutes prior to the chosen and established bedtime.

A problem arises for many people when the bed and bedroom becomes paired with behaviors that are not conducive or compatible with sleep– such as watching TV in bed, eating in bed, and/or discussing the day’s anxieties and frustrations. Good sleep hygiene limits activities such as these.

Patients who have not fallen asleep within 15-30 min of going to bed should be advised to get up rather than to toss and turn restlessly. For some, efforts to relax, listening to quiet music, reading with limited light exposure may be more helpful than staying in bed tossing and turning or worrying as these behaviors can become paired to being in the bed.

If serious efforts to implement sleep hygiene do not prove helpful, use of a medication may be appropriate. Next week’s e-Weekly will discuss the various pharmacologic approaches including both OTC and prescription medication options.