Fast Fact and Concept #104: Non-pharmacological Therapy for Insomnia

Author(s): M Miller; R Arnold

NOTE : See Fast Fact #101 for discussion of insomnia assessment.

Non-Specific Treatments:

Improving Sleep Hygiene: Patients can be reminded that there is no rule for how much someone should sleep; older patients need less sleep. Patients should be advised to keep a regular sleep schedule; this means going to bed and getting up at the same time. Patients should avoid long daytime naps, alcohol, and caffeine. Vigorous exercise done at least six hours before bedtime or moderate exercise at least four hours before sleep improves sleep latency and quality.

Sleep hygiene can be particularly difficult for chronically or seriously ill patients. Exercise is often not possible, and a person may have difficulty getting out of bed without assistance. Avoiding daytime naps completely is often unrealistic for patients who are very ill; naps should be kept as short as possible, and there should be a prolonged period of awake time prior to bedtime.

Behavioral treatments:

• Relaxation therapies (e.g. progressive muscle relaxation, guided imagery or hypnosis) -- The patient can be taught to use various relaxation techniques just prior to bedtime.
• Sleep restriction therapy -- This therapy requires patient motivation as it involves a patient staying out of the bedroom until 3 am and then going to bed 15 minutes earlier every night until the target bedtime is achieved.
• Stimulus control therapy -- This focuses on establishing a connection between the bed and sleep. It emphasizes not watching TV or reading in bed.
• Cognitive behavioral therapy ? This is a form of psychotherapy that focuses on identifying unwanted feelings or thoughts and replacing them with more positive thoughts. It is effective in treating chronic insomnia in the general population and has also been effective in women with metastatic breast cancer.

Stimulus control therapy, relaxation therapy, cognitive behavioral therapy, and practicing good sleep hygiene are primary therapies for insomnia. Sleep hygiene education should be provided to anyone with insomnia. Choosing which therapy to use first depends mainly on provider experience and patient motivation. It is difficult to know how long non-pharmacologic therapy should be tried before attempting other measures. This may depend somewhat on the patient, the severity of their insomnia, or the severity of their illness. Many studies which showed cognitive behavioral therapy to be effective used a treatment regimen of 7-8 weeks.

Specific Treatments:

Obstructive sleep apnea is treated with Bi-level Positive Airway Pressure (BiPAP) ventilation at night. Though, some patients report difficulty becoming accustomed to sleeping with the BiPAP mask on, this therapy can dramatically improve symptoms. Surgery is sometimes indicated for obstructive sleep apnea.

Symptoms from an underlying medical disorder may also contribute to insomnia. Thus adequately treating a patients pain, nausea and vomiting (See FF#5), or dyspnea (See FF#27) may improve sleep.

Spiritual concerns can be an important cause of insomnia in palliative care patients. Patients may be able to avoid these concerns during the day through the distraction of daily activities but have difficulty ignoring them at night. Thus, it is important to directly address a patient ?s spiritual concerns, worries, and fears about dying during the day; brief psychotherapy may be helpful.

References

1. Montgomery, P; Dennis, J. Physical exercise for sleep problems in adults aged 60+ Cochrane Database of Systematic Reviews. 1, 2003.
2. Morin CM; Culbert JP; Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 1994 151(8):1172-80.
3. Quesnel C, et al: Efficacy of Cognitive-Behavioral Therapy for Insomnia in Women Treated for Nonmetastatic Breast Cancer. Journal of Consulting and Clinical Psychology Volume 71(1), p 189 ?200, February 2003.
4. Oxford Textbook of Palliative Medicine, third edition. Oxford Medical Publications, 2003. Derek Doyle et al., editors.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fast Facts and Concepts #104. Miller M and Arnold R. Insomnia: Non Pharmacological Treatments. January 2004. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2004

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes; psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders