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worked and tired out These people sink into bed and sleep through sheer exhaustion, but they awaken early with their worries and are unable to get back to sleep In states of mania and acute agitation, sleep diminishes and REM sleep may be abolished Chronic and even short-term use of alcohol, barbiturates, and certain nonbarbiturate sedative-hypnotic drugs markedly reduces REM sleep as well as stages 3 and 4 of NREM sleep Following withdrawal of these drugs, there is a rapid and marked increase of REM sleep, sometimes with vivid dreams and nightmares Rebound insomnia, a worsening of sleep compared with pretreatment levels, has also been reported upon discontinuation of short-half-life benzodiazepine hypnotics, notably triazolam (Gillin et al) Furthermore, a form of drug-withdrawal or rebound insomnia may actually occur during the night in which the drug is administered The drug produces its hypnotic effect in the rst half of the night and a worsening of sleep during the latter half of the night, as the effects of the drug wear off; the patient and the physician may be misled into thinking that these latter symptoms require more of the hypnotic drug or a different one Alcohol taken in the evening acts in the same way A wide variety of other pharmacologic agents may give rise to sporadic or persistent disturbances of sleep Caffeine-containing beverages, corticosteroids, bronchodilators, central adrenergic blocking agents, amphetamines, certain activating antidepressants such as uoxetine, and cigarettes are the most common offenders Others are listed in the extensive review of Kupfer and Reynolds The sleep rhythm may be totally deranged in acute confusional states and especially in delirium, and the patient may doze for only short periods, both day and night, the total amount and depth of sleep in a 24-h period being reduced Frightening hallucinations may prevent sleep The senile patient tends to catnap during the day and to remain alert for progressively longer periods during the night, until sleep is obtained in a series of short naps throughout the 24 h; the total amount of sleep may be increased or decreased Treatment of Insomnia In general, a sedative-hypnotic drug for the management of insomnia should be prescribed only as a shortterm adjuvant during an illness or some unusual circumstance For patients who have dif culty falling asleep, staying asleep, or both, a quick-acting, fairly rapidly metabolized hypnotic is useful The ones most commonly used have been urazepam (Dalmane), 15 to 30 mg; triazolam (Halcion), 025 to 05 mg; lorazepam (Ativan) 05 mg; and the nonbenzodiazepine hypnotic zolpidem (Ambien), 10 mg Barbiturates are no longer used because they so often produce dependence and, after a few consecutive nights, unpleasant aftereffects Chloral hydrate occupies a position between these two groups All of these drugs are more or less equally effective in inducing and maintaining sleep, although they affect sleep stages somewhat differently Flurazepam reduces stage 4 but not REM sleep, whereas the barbiturates reduce both stage 4 and REM sleep If urazepam or triazolam are given for longer than a week or two, they may have a cumulative effect and lead to daytime drowsiness and dependence or withdrawal symptoms including anxiety attacks Melatonin (300 to 900 mg) is sometimes as effective as the sedative-hypnotics and may cause fewer short-term side effects Amitriptyline (25 to 50 mg at bedtime) appears to be a sleep-enhancing drug even in those who are not anxious or depressed When pain is a factor in insomnia, the sedative may be combined with a suitable analgesic Nonprescription drugs, such as Nytol and Sleepeze,
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contain diphenhydramine (Benadryl) or doxylamine, which are minimally effective in inducing sleep but may impair the quality of sleep and lead to drowsiness the following morning The chronic insomniac who has no other symptoms should not be permitted to use sedative drugs as a crutch on which to limp through life The solution of this problem is rarely to be found in medication One should search out and correct, if possible, any underlying situational or psychologic dif culty, using medication only as a temporary measure Patients should be encouraged to regularize their daily schedules, including their bedtimes, and to be physically active during the day but to avoid strenuous physical and mental activity before bedtime It has been suggested that illumination from broad-spectrum light (television) in the late evening is detrimental Dietary excesses must be corrected and all nonessential medications interdicted Coffee and alcohol should be avoided A number of simple behavioral modi cations may be useful, such as using the bedroom only for sleeping, arising at the same time each morning regardless of the duration of sleep, avoiding daytime naps, and limiting the time spent in bed strictly to the duration of sleep A helpful approach is to lessen the patient s concern about sleeplessness by pointing out that the human organism will always get as much sleep as needed and that there is pleasure to be derived from staying awake and reading a good book
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