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Establishing a regular sleep–wake schedule
is very important, especially a regular time to awaken in the morning,
with no more than 1-hour deviation from day to day, including weekends.
Arousal time is perhaps the most important synchronizer of circadian
rhythms. Awakening at 6:00 a.m. on
weekdays to go to work and then sleeping until noon on weekends
should be discouraged.
Sleep interruptions should be minimized. The bedroom
should be cool, dark, and quiet. The clinician needs to inquire
specifically about noise, because patients may habituate to a noisy
sleep environment and may not remember the noise, even though it
continues to disrupt their sleep pattern. Patients who have convinced
themselves that they can sleep only with the radio or television
on should be discouraged from this practice. Attention to the radio
or television may prevent their minds from wandering, or may keep
them from beginning to worry about other matters, and thus assist
with sleep latency, but the continuing noise will be a disruptive
factor during the course of the night. Clock radios that automatically
turn off may be useful.
Time to wind down before sleep is important. The clinician
should advise patients to stop work at least 30 minutes before sleep-onset
time and to change their activities to something different and non-stressful,
such as reading or listening to music.
This procedure, an important component of sleep hygiene,
involves removing from the bedroom all stimuli that are not associated
with sleep. The bedroom should be used for sleep and, of course,
sexual activity (which is often conducive to sleep). Activities
such as eating, drinking, arguing, discussing the day's
problems, and paying bills should be done elsewhere, because their
associated arousal may interfere with sleep onset.
Caffeine is quite disruptive of nocturnal sleep in
many patients, and it has a long half-life. Thus, caffeine consumption
should be limited to the forenoon and in some individuals not be
continued after noon. A glass of wine or beer in the evening may
help some individuals relax, but regularly having several drinks
before bedtime for the express purpose of using the alcohol as a
sedative should be discouraged. Alcohol in large doses can substantially
disrupt and fragment sleep. Cigarette smoking may produce or aggravate
insomnia in some patients.
A bedtime snack such as a glass of milk, a cookie,
a banana, or a similar high-tryptophan food may help promote sleep
onset in some patients.
Periods of exercise for 20–30 minutes at least
3–4 days a week should be encouraged. Improved aerobic fitness
has been shown experimentally to promote slow-wave sleep. Exercise
should not occur within 3 hours of bedtime, however, because the
autonomic arousal accompanying the exercise may serve to delay sleep
Zolpidem ER (Ambien CR)