Chapter 71: Sleep disorders

Sleep is one of the five great innate drives in humans. Disorder of this basic function is one of the most common health-related problems presenting to the GP. It may represent the clue to some very important disorders, such as depression, anxiety, adverse drug reactions, drug abuse and obstructive sleep apnoea (OSA). About half of the population report having some sleep-related problem in a year, with 25% of the Australian population reporting trouble getting enough sleep.¹ Normal sleep requirement varies considerably.

Sleep is divided into rapid eye movement (REM—also called dream sleep), as shown by EEG studies, and non-rapid REM sleep (NREM), which is subdivided into stages 1, 2, 3 and 4. Most stage 4 sleep (deepest) occurs in the first hours. REM sleep is accompanied by dreaming and physiological arousals; some dreaming occurs in NREM.

Disorders of the sleep-wake cycle, which are invariably caused by a disruption of the body’s endogenous time clock, can result in insomnia or hypersomnolence (excessive sleepiness) or a combination of both. This is a feature of people experiencing the jet lag of international travel and shift workers.

Disorders of sleep are a common and significant contribution to community illness and death. For example, it is known that untreated moderate to severe OSA has an 11–13% 5-year mortality and a 37% 8-year mortality, mainly from cardiovascular and motor vehicle accident related deaths.^3,4 A classification of sleep disorders is presented in TABLE 71.1.⁵

Many conditions may disturb breathing during the night (see FIG. 71.1). Nocturnal dyspnoea may result from cardiac causes (mitral stenosis, ischaemic cardiomyopathy, cardiac arrhythmias, fluid overload or retention), which usually present with orthopnoea, pulmonary crepitations and peripheral oedema. Asthma is another common cause of nocturnal dyspnoea, cough (with or without wheeze) occurring classically between 2 am and 5 am. Gastro-oesophageal reflux with or without aspiration may disturb respiration at night, but it usually presents with daytime or postural reflux. All these conditions can usually be differentiated from sleep apnoea clinically or with further investigation.

The sleep apnoea syndromes are a common group of disorders that result in periodic hypoventilation during sleep. They occur in about 2% of the general population in all age groups, and in about 10% of middle-aged men.

Insomnia

Insomnia is defined as the inability to initiate or maintain sleep. Insomniac patients may complain of difficulty getting to sleep or staying asleep, of frequent intermittent nocturnal arousals, early morning awakening or combinations of these.

A careful history is required because some patients have unrealistic expectations about the required amount of sleep they need or have misperceptions of how long they have slept.

When taking the history, explore lifestyle factors, especially psychological reasons, painful conditions, drug use and abuse, appetite, energy, sexual issues and physical factors. Check thyroid status, especially hyperthyroidism.

Basic principles for managing insomnia^5,6

• Address anxiety about sleep.

• Address maladaptive behaviours around sleep.

• Address fear of further sleep disruption.

• Consider predisposing dispositions.

• Consider comorbidities.

• Assess pharmacological options, but consider hypnotics only as a short-term measure.

• Refer to a specialist if there are ongoing symptoms despite the above considerations.

Management⁶

1. Contract with the patient: discuss and agree to the therapeutic objective with the patient (e.g. to reinstate sleep without medication).

2. Sleep–wake history: take a sleep–wake history (preferably with a sleep diary) and evaluate daytime functioning.

3. Exclude and treat any underlying problem (see TABLE 71.2).

4. Explanation and reassurance, including patient education handout.

5. Sleep hygiene advice:

   • Try to recognise what helps patient to settle best (e.g. warm bath, listening to music).

   • Establish a routine before going to bed.

   • Regular daytime exercise.

   • Regular time of arising.

   • Avoid daytime naps.

   • Avoid strenuous exercise close to bedtime.

   • Avoid alcohol and drinks containing caffeine in the evening, especially close to retiring.

   • Avoid a heavy evening meal within 3 hours of bedtime.

   • Avoid smoking, especially in the evening.

   • Remove pets from the bedroom.

   • Use a suitable mattress and pillow for comfort and support.

   • Ensure a dark, quiet room for sleeping.

   • Avoid lights, including poorly screened windows and highly illuminated clocks in the room.

   Sleep-promoting adjuvants:

   • Try a drink of warm milk before retiring.

   • Organise a comfortable, quiet sleep setting with the right temperature.

   • Try a warm bath before bed.

6. Non-pharmacological treatment: various techniques should be adopted according to patient personality and preference, the clinician’s expertise and the available resources. These include relaxation therapy, meditation and stress management, which are all highly recommended. Other measures include cognitive behaviour therapy (first-line treatment), structured problem-solving and electromyographic feedback. Hypnosis is also worth considering.

7. Pharmacological treatment:⁶ it is advisable to avoid hypnotic agents as first-line treatment. If any form of continuous agent is necessary, it is best to limit it to 2 weeks.

   Options:

   • temazepam 10 mg tablets (o) nocte

   • or

   • zopiclone 3.75 mg (o) nocte

   • or

   • zolpidem 5 mg (o) or CR 6.25 mg nocte

   • or

   • melatonin prolonged release 2 mg (o) 1–2 hrs before bedtime (best >55 years). Long-term safety and efficacy not clearly evaluated.

Note:

• The cyclopyrrolone derivative zopiclone and the imidazopyridine derivative, zolpidem, are non-benzodiazepine hypnotics with a similar action to the benzodiazepines represented by temazepam. However, warnings have been issued about adverse neurological and psychiatric reactions.⁴

• Tricyclic antidepressants with sedative effects (e.g. amitriptyline) are often used as hypnotics but should generally be avoided in the absence of depressive disorders, especially in older people.

The term ‘sleep apnoea’ is used to describe cyclical brief interruptions of ventilation, each cycle lasting 15–90 seconds and resulting in hypoxaemia, hypercapnia and respiratory acidosis, terminating in an arousal from sleep (often not recognised by the patient). The interruption is then followed by the resumption of normal ventilation, a return to sleep, and further interruption of ventilation.

Sleep apnoea is broadly classified into obstructive and central types.

Obstructive sleep apnoea (OSA) refers to the presence of apnoeas and hypopnoeas during sleep together with daytime dysfunction, predominantly excessive daytime sleepiness. The effects include snoring (see FIG. 71.2).

Predisposing causes include:

• diminished airway size (e.g. macroglossia obesity, tonsillar-adenoidal hypertrophy)

• upper airway muscle hypotonia (e.g. alcohol hypnotics, neurological disorders; see FIG. 71.3)

• nasal obstruction

Central sleep apnoea (CSA), which occurs when there is either brief or prolonged loss of breathing during sleep, is less common (accounts for <10% of sleep-disordered breathing). It is due mainly to neurological conditions such as brain stem disorders leading to reduced ventilatory drive, and neuromuscular disorders such as motor neurone disease. Cardiorespiratory disease is also a risk factor. It requires specialist referral. Treatment of CSA is based on optimal therapy for these underlying conditions and attending to lifestyle modification as outlined below.

Clinical effects of sleep apnoea syndromes^5,7

Important clinical presentations include:

• excessive daytime sleepiness and tiredness

• nocturnal problems (e.g. loud snoring, thrashing, ‘seizures’, choking, pain reactions)

• morning headache

• subtle neuropsychiatric disturbance—learning difficulties, loss of concentration, personality change, depression

• sexual dysfunction

• occupational and driving problems

Causes of excessive daytime sleepiness are presented in TABLE 71.3. In OSA, sleepiness results from repeated arousals during sleep and the effects of hypoxaemia and hypercapnia on the brain. Physical examination may reveal few or no signs.

Management of sleep apnoea⁷

Referral to a comprehensive sleep disorder centre especially for sleep polysomnography (the gold standard diagnostic test) is advisable if this disorder is diagnosed or suspected. Consider also the Berlin questionnaire⁸ or the Epworth sleepiness scale.⁹

The general principles are as follows:

1. Lifestyle modification

   • Weight loss (e.g. loss of 10–15%, e.g. 7–10 kg can significantly reduce severity).

   • Achieve physical fitness with regular exercise.

   • Good sleep hygiene and adequate sleep hours (increase time in bed).

   • Reduce or cease sedatives/hypnotics.

   • Avoid alcohol for up to 3 hours before going to sleep and drugs in general.

   • Cease cigarette smoking (increases nasal resistance).

   • Medical management of nasal obstruction (e.g. short-course nasal decongestants) or 6-week trial intranasal topical corticosteroids.

   • Obtain positional therapy, avoid supine sleep—sleeping on side is best. Consider neck support.

2. Continuous positive airway pressure (CPAP)

   • CPAP is currently the most effective treatment for OSA (consider it for CSA)—the gold standard treatment.

   • Delivered by nasal (or facial) mask.

   • Provides an air splint to the upper airway and prevents pharyngeal collapse.

   • Sleepiness and neurocognitive function improved.

   • Not tolerated by all patients.

3. Surgery

   In children, OSA is usually due to tonsillar and/or adenoid hypertrophy and is relieved by surgery (see FIG. 71.4). In adults, depending on the cause, the options are:

   FIGURE 71.4

   Influence of tonsils and adenoids on airways

   Graphic Jump Location

   

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   • correction of the specific upper airway anatomical problem—up to 2% of problems

   • correction of nasal obstruction (improves snoring and OSA)

   • palatal surgery: uvulopalatopharyngoplasty for carefully selected patients—conventional or laser assisted

   • nasal polypectomy

   • tonsillectomy

   • base of tongue surgery

   • radiofrequency treatment to soft palate and base of tongue (‘somnoplasty’)

4. Oral appliances

   • The mandibular advancement splint—a custom-made dental device that supports the mandible and tongue during sleep to increase pharyngeal dimensions. An effective alternative to CPAP.

5. Medication

   There are no reliable drug treatment options for OSA. Consider:

   • amitriptyline 25–100 mg (o) nocte, in severe cases during REM sleep and intolerance of CPAP

   • trial of corticosteroid sprays in children with mild OSA

Obesity hypoventilation syndrome (OHS)—Pickwickian syndrome

OHS may occur alone or secondary to OSA. The main features of the OHS patient are:

• marked/morbid obesity

• cyanosis or plethora

• excessive daytime sleepiness

• right heart failure

There is impaired breathing leading to hypercapnia (↑ PaCO₂) and hypoxia. Diagnosis is by sleep studies. Treatment is weight loss plus CPAP. It is a complex problem with a risk of premature death.

Narcolepsy

Narcolepsy is a specific, permanent neurological disorder that is characterised by brief spells of irresistible sleep during daytime hours in inappropriate circumstances, even during activity and usually at times when the average person simply feels sleepy. It is uncommon with an incidence of two to five per 100 000.

Features

Usual onset between adolescence and 30 years of age—in teens and 20s (but has been reported in children as young as 2 years).

Tetrad of symptoms

• Daytime hypersomnolence: sudden brief sleep attacks (15–20 minutes).

• Cataplexy: a sudden decrease or loss of muscle tone in the lower limbs that may cause the person to slump to the floor, unable to move. These attacks are usually triggered by sudden surprise or emotional upset.

• Sleep paralysis: a frightening feeling of inability to move while drowsy (between sleep and waking).

• Hypnagogic (terrifying) hallucinations on falling asleep or waking up (hypnopompic hallucination).

Several attacks per day are possible.

Diagnosis

The diagnosis is clinical through the taking of an appropriate history. If doubtful, include:

• EEG monitoring

• sleep laboratory studies (sleep latency test—rapid eye movement is a hallmark)

Treatment⁶

Treatment is mainly symptomatic and initiated by a consultant. Central nervous system psychostimulants are of proven effectiveness in increasing alertness:

• dexamphetamine 5–10 mg (o), half an hour before breakfast and lunchtime; up to 40 mg daily may be required in slowly increasing doses

• or

• methylphenidate (Ritalin) 10–20 mg (o) half an hour before breakfast and lunchtime; up to 60 mg daily may be required

Drug holidays from these drugs may be necessary.

• Tricyclic antidepressants are used to treat cataplexy, sleep paralysis and hypnagogic hallucinations (e.g. clomipramine 20–100 mg (o) daily).

• Modafinil is used successfully in some countries.

Reflect on driving licence issues as appropriate.

Idiopathic hypersomnia¹⁰

This type of excessive daytime sleepiness (EDS) can present similarly to narcolepsy without cataplexy. The condition, which accounts for 5–10% of patients in sleep clinics with EDS, is diagnosed despite adequate sleep and exclusion of other causes. They usually have non-refreshing deep nocturnal sleep but, unlike narcolepsy, naps are not refreshing. The onset is usually insidious before 30 years and persists for life. Treatment is usually based on psychostimulant therapy to improve EDS.

Snoring

Definition

Snoring is a sonorous sound with breathing during sleep, caused by vibrations in the upper airways from the nose to the back of the throat. It is caused by partially obstructed breathing during sleep (see FIG. 71.5).

Features

• Sometimes indicates OSA, especially in perimenopausal women⁷

• Three times more common in obese persons

• Generally harmless, but if very severe, unusual or associated with periods of no breathing (>10 s) assessment is advisable

Aggravating factors^9,11

• Obesity

• Old age

• Sleeping on the back

• Sleep deprivation

• Excess alcohol

• Neck problems, especially a ‘thick’, inflexible neck

• Various drugs, especially sedatives and sleeping pills

• Hay fever and other causes of nasal congestion

• Problems in the upper airways, such as nasal polyps, enlarged tonsils or a foreign body (e.g. a piece of plastic or metal)

• Endocrine abnormalities (e.g. acromegaly, hypothyroidism)

Management

If an examination rules out a physical problem causing obstruction in the back of the nose and OSA, then the following simple advice can be given to patients.

• Obtain and keep to ideal weight.

• Avoid drugs (including sedatives and sleeping tablets), alcohol in excess and smoking.

• Treat nasal congestion (including hay fever) but avoid the overuse of nasal decongestants.

• For neck problems, keep the neck extended at night by wearing a soft collar.

• Consider a trial of an intranasal device such as the Breathing Wonder, which is a hollow intranasal plastic insert. Pharmacists can advise about the range of such devices.

• Try to sleep on your side. If you tend to roll on to your back at night, a maverick method is to consider sewing ping pong balls or tennis balls on the back of the nightwear. Others wear a bra (with tennis balls) back to front.

Periodic limb movements (nocturnal myoclonus)

Periodic limb movements (PLMs) and restless legs syndrome are important causes of insomnia and excessive daytime sleepiness. They may coexist in the same patient. Periodic limb movements, which are also referred to as nocturnal myoclonus or ‘leg jerks’, tend to occur usually in the anterior tibialis muscles of the leg but can occur in the upper limbs. The prevalence increases with age. Most people with PLMs are completely asymptomatic. The diagnosis is often made during sleep studies.¹² If troublesome, referral to a sleep clinic or neurologist may be appropriate.¹²

Medication

Medication that may help includes:

• levodopa plus carbidopa (e.g. Sinemet 100/25, tablets before bedtime)

• or

• clonazepam 1 mg (o) nocte increasing to 3 mg (o) nocte

• or

• sodium valproate 100 mg (o) nocte

Sleep paralysis

This is the temporary inability to move or speak when falling asleep or upon awakening, with intact consciousness. It is REM atonia. It can occur in the general population (8%) and about 30% of those with narcolepsy. It can be terrifying but is not dangerous.

Treatment is educational and preventive with optimal sleep hygiene.

Restless legs syndrome (RLS)

RLS, also known as periodic limb disorder or Ekbom syndrome, is a rather common movement disorder of the nervous system where the legs feel as though they want to exercise or move when the body is trying to rest. Sensations that may be experienced include ‘twitching’, ‘prickling’ and ‘creeping’.^11,13 The major complaint of sufferers is of disruption both to sleep and of relaxing activities, such as watching television or reading a book. Prolonged car or airplane travel can be difficult.

RLS is frequently an undiagnosed disorder because people often don’t complain about it to their doctor. A Canadian study reported that 15% of people sampled reported ‘leg restlessness’ at bedtime.

The diagnosis is made from the history—there are no special diagnostic tests.

Its prevalence increases with age so it mainly affects elderly people. Women are more prone to get RLS and it is aggravated by pregnancy. The exact cause of primary RLS is not clear. It is not related to exercise and does not appear to follow strenuous exercise.

Symptoms

There is an urge to move legs upon resting, particularly after retiring to bed. This urge is a response to unpleasant sensations in the legs, especially in the calves. The sensations are commonly and variously described as crawling, creeping, prickly, tingling, itching, contractions, burning, pulling or tugging, electric shock-like. However, sometimes patients are unable to describe the sensation or refer to it as simply a compulsion to move the legs.

In some patients the arms are affected in a similar way. The symptoms seem to be aggravated by warmth or heat. Many patients with RLS also experience nocturnal myoclonus.

Secondary (medical) causes include:

• anaemia (common)

• iron deficiency (common)

• uraemia

• hypothyroidism

• pregnancy (usually ceases within weeks of delivery)

• drugs (e.g. antihistamines, anti-emetics, selective antidepressants, lithium, selective major tranquillisers and antihypertensives)

Management

Iron studies should be performed and, if low, treat with iron and vitamin C tablets. Advise patients that although RLS can come and go for years, it usually responds well to treatment.

• Perform activities that can reduce symptoms, for example, a modest amount of walking before bedtime, massage or prescribed exercises (see FIG. 71.6).

  Note: getting out of bed and going for a walk or run does not seem to help RLS.

• Good sleep hygiene, namely regular sleeping hours, gradual relaxation at bedtime, avoidance of non-sleep activities in bed (e.g. reading, eating).

• Diet: follow a very healthy diet. Avoid caffeine drinks, smoking and alcohol.

• Try keeping the legs cooler than the body for sleeping.

• Exercises: a popular treatment is gentle stretching of the legs, particularly of the hamstring and calf muscles, for at least 5 minutes before retiring. This can be done by using a wide crepe bandage, scarf or other length of material around the foot to stretch and then relax the legs.

The following may be effective if simple measures fail: (taken before bedtime)

• clonazepam 0.5–1 mg (o) 1 hour before retiring

• or

• levodopa (+ benserazide or carbidopa) 100–200 mg (o) (especially if limb movements at sleep onset are infrequent)

For more severe symptoms consider low-dose dopamine agonists:

• pramipexole 0.125 mg (o) daily, increasing as tolerated to 0.75 mg

• or

• ropinirole 0.5 mg (o) → 4 mg daily

Cabergoline, gabapentin, codeine, baclofen and propranolol may be helpful. Carbamazepine, quinine, antipsychotics (avoid), antihistamines (avoid) and antidepressants are generally unhelpful.

Bruxism (teeth grinding)

Bruxism is the habit of grinding, clenching or tapping teeth, which may occur while awake (especially in children) or more commonly while asleep. The usual symptom is annoying, teeth-grinding noises during sleep that disturb family members. It may result in headaches and TMJ dysfunction in the person during the day. The cause may be a habit or a response to subconsciously correct a faulty bite by making contact between the upper and lower teeth when the jaws are closed. It is aggravated by stress and is more common in heavy alcohol drinkers and SSRI users.

Management

• Educate the patient to recognise, understand and try to overcome the habit.

• Practise keeping the jaws (and teeth) apart.

• Slowly munch an apple before retiring.

• Practise relaxation techniques, including meditation, before retiring.

• Consider other stress-management techniques (e.g. counselling, relaxation exercises, yoga and tai chi).

• Place a hot towel against the sides of the face before retiring to achieve relaxation.

• If this fails and bruxism is socially unacceptable, a plastic night-guard mouthpiece can be fashioned by a dentist to wear at night.

Parasomnias are defined as dysfunctional episodes associated with sleep, sleep stages or partial arousal. They are more common in children. Diagnosis is clinical.

Nightmares (dream anxiety)

These dream-related anxiety episodes usually occur later in the REM sleep period and are accompanied by unconscious body movements, which usually cause the person to awaken.

Associations include traumatic stress disorders, fever, drug withdrawal (e.g. alcohol, barbiturates, drugs such as zolpidem, SSRIs, beta blockers, benzodiazepines, mirtazepine). Violent behaviour can occur during these dreams due to a REM behaviour disorder and this requires a sleep study and specialist evaluation.

Psychological evaluation with cognitive behaviour therapy (CBT) is appropriate. Medications that may help include phenytoin, clonazepam or diazepam.

REM sleep behaviour disorder

A feature is complex and elaborate motor activity associated with dreams. The behaviour may be violent with profane verbalisation. It is more common in older males and among those with CNS degeneration disorders (e.g. dementia, Parkinson disease). Diagnosis is by sleep studies and treatment is low-dose clonazepam.

Somnambulism (sleepwalking)²

This is a complex motor activity in which the person performs some repetitive activity in bed or walks around freely while still asleep. There is amnesia for the event. No treatment is usually required but, if it is repetitive and potentially dangerous, then the sleeping environment should be rendered safe. Psychological assistance is required for recurring episodes. Benzodiazepines such as clonazepam 0.5–2 mg (o) nocte may be useful, but withdrawal usually leads to rebound problems.

Sleep-related leg cramps

Prevention is by stretching the affected muscles for several minutes before sleep. Consider magnesium. Refer to CHAPTER 68.

Sleep terrors

These are part of the same non-REM sleep cycle disorder as somnambulism. Characteristics of night terrors are sharp screams, violent thrashing movements and autonomic overactivity, including sweating and tachycardia. The sufferers, usually preadolescent, may or may not wake and usually cannot recall the event. They also require psychological evaluation and therapy. Similar medication as used for nightmares may help (e.g. a 6-week trial of phenytoin, diazepam or clonazepam).

Sleep disorders in children are very common in late infancy, toddlerhood and early preschool age groups. By 3 months 70% begin to sleep through the night. The majority do not sleep throughout the night until 6 months of age. Over 50% of toddlers and preschool children resist going to bed.¹² At least 30% of infants and toddlers wake at least once during the night every night. Toddlers begin to have dreams coinciding with language development in the second year of life.¹⁴

The child who wakes during the night needs reassurance, protection and the parent’s presence, but it must be given discreetly. Although psychosocial stresses can trigger sleep problems, serious psychological problems in children with sleep disorders are uncommon.¹⁵

Management¹⁴

Aim to see both parents together and get them to agree on the approach, including sharing the workload. Advice to parents:

• Resist taking the child into bed during the night unless they are happy to encourage this.

• Avoid giving attention to the child in the middle of the night—it encourages attention seeking.

• Avoid extra feeding or other pacifiers during the night.

• Return the child to bed promptly and spend only a brief time to give reassurance.

• A rigid series of rituals performed before bedtime helps the child to develop a routine. Settling to sleep may be assisted by soft music, a soft toy and a gentle night light.

• Take the child into the bedroom while still awake.

• Encourage the parents to keep a sleep diary.

Sedative medication has a minimal place in the management of sleep disturbances,⁶ and is not recommended for children <2 years although the judicious use of a sedative/hypnotic for a short term may break the sleepless cycle. Such drugs include promethazine 0.5 mg/kg (max. 10 mg) and trimeprazine (Vallergan) 1–2 mg/kg per dose (not for infants under 6 months).¹⁴

Parasomnias (sleep terrors, sleep walking and sleep talking)²

These are not true sleep disorders or night-time arousals. They occur in deep non-REM sleep. With sleep terrors, which usually develop within 2 hours of sleep and last 1–2 minutes, the child is usually inconsolable and has no memory of the event. These events cluster in age ranges:

• sleep terrors 4–8 years

• sleep walking 8–12 years

• sleep talking 6–10 years

• nightmares 3–6 years

They are self-limiting over a period of months. Usually, no active treatment is needed but for persistent, severe problems a 6-week trial of phenytoin, diazepam or imipramine is worthwhile.

The elderly constitute the bulk of long-term users of hypnotics and benzodiazepines. Two key issues to consider are sleep in the elderly and confusion in the elderly. Problems associated with long-term benzodiazepine use are dependence, confusion, memory impairment and falls.

A study of elderly patients with insomnia showed that:¹⁶

• 25% had insomnia either coexisting with or related to other sleep disorders, such as sleep apnoea or periodic limb movement disorder

• 10% had insomnia related to medical or psychiatric conditions

• 13% had insomnia associated with an inability to stop taking sedative-hypnotic agents

Principles of management in the elderly

• Exclude underlying causes of sleep disturbance.

• Educate patients and carers about the changing needs with ageing and the rational use of medicines.

• Avoid hypnotics if possible.

• Avoid hypnotics combined with alcohol.

• Beware of risks of long-term use and drug accumulation.

• Consider non-drug measures where possible (e.g. CBT).

• Avoid the ‘why bother’ factor when carers and patients are comfortable with hypnotics.

• In nursing homes, practise ‘bothering’ and use team effort to encourage less prescribing.

Medication⁶

If medication is necessary, prescribe a short-acting benzodiazepine for as limited a time as possible. An alternative non-benzodiazepine hypnotic (e.g. zopiclone or zolpidem) taken just before retiring may be useful in the elderly (beware of adverse effects). Consider melatonin prolonged release medication. Tricyclic antidepressants with a sedative action are frequently used, especially if there is coexistent depression, but side effects limit their use. However, commonsense prescribing needs to be used and the best option may be to continue the long-term prescribing of hypnotics in those with chronic medical problems or long-term dependents on a low effective dose.

Hand-out sheets from Murtagh’s Patient Education 6th edition:

• Sleep problems: insomnia

• Restless legs syndrome

• Sleep problems in children