Approach Considerations
Treatment of sleep disorders is directed at the particular problem and includes behavioral and pharmacologic components, as well as implementation of a sleep hygiene program.
Continuous positive airway pressure (CPAP) therapy
The treatment of choice for SDB is CPAP therapy. This treatment uses forced air pressure to keep the upper airways open.
Oral appliance
Oral appliance therapy uses a dental device to effect advancement of the mandible and tongue in order to increase airway opening. Oral appliance therapy is indicated for mild-to-moderate sleep apnea and when individuals are unable to tolerate CPAP therapy. There are many types of oral appliances. Although not as effective as CPAP for the treatment for OSA, oral appliance treatment is less obtrusive and easier to tolerate than the CPAP device.
Cognitive behavioral therapy for insomnia (CBT-I)
Behavioral approaches to the treatment of insomnia are effective and should be used as first-line treatment for chronic insomnia. Specifically, in a study from the National Institutes of Health (NIH), CBT-I produced longer-lasting effects than medication. According to the 2005 NIH consensus statement, CBT-I is as effective a treatment for insomnia as sleeping pills for the short term and is more effective than hypnotics in the long term. CBT-I involves the modification of certain sleep-related maladaptive behaviors and the identification of dysfunctional perceptions and attitudes related to sleep patterns. CBT-I has also been found to be effective in special populations, including geriatric groups and patients with chronic pain conditions.
Medications
See Medication.
Surgical care
Uvulopalatopharyngoplasty (UPPP) is a surgical procedure performed to eliminate loud snoring. It involves surgical removal of excess tissues of the soft palate (including uvula) in order to enlarge the area of the upper airways for the purpose of improvement of air exchange.
Diet
In general, women should avoid eating heavy meals within 4 hours before bedtime, as this can have a stimulating effect on sleep. Pregnant women are prone to heartburn, particularly during the last trimester of pregnancy. Therefore, they should maintain a balanced diet and avoid eating spicy food at least 2-3 hours before bedtime.
Activity
For older women, maintaining long hours of sound sleep during the night and long hours of complete alertness during the day becomes increasingly difficult. This can result in waking periods during the night and increased daytime fatigue. In addition, decreased physical activity, an irregular sleep-wake schedule, and a lack of outdoor light exposure may be involved in changes of the circadian rhythm. Older women should be encouraged to maintain a structured daily schedule that includes physical activity and light exposure and that allows a daily afternoon nap at a regular time.
Menstruation-Related Sleep Disorder
Generally, premenstrual insomnia disappears a few days after menstruation begins. For some women, however, the associated tension and irritability can result in lingering sleep problems and even in chronic insomnia. These women should pay attention to their sleep needs, maintain a regular sleep-wake schedule, avoid stress when possible, and eat a healthy diet.
Because of underlying circadian disturbances in women with premenstrual symptoms, evening bright-light therapy has been reported to be effective in preventing early morning awakening in women with this complaint.
Women diagnosed with PMDD are more susceptible to major depressive disorder when their condition goes untreated. Studies have shown that, like patients with major depression, women with PMDD respond to treatment that incorporates sleep deprivation. Total and partial sleep deprivations have been shown to effectively reduce depressive symptoms, although these methods still are considered experimental.
Pregnancy-Related Sleep Disorder
Relatively little is known about the health significance of sleep disturbance in pregnancy. Pregnancy can pose a risk for developing SDB, [44] back pain, and leg cramps. It can also trigger episodes of sleepwalking and PLMD. [45]
In addition, sleep disturbance during pregnancy also can be associated with frightening dreams, postpartum blues, and sometimes even major depression and postnatal psychosis. [46]
Throughout their pregnancy, women need to pay extra attention to their sleep pattern by making sure that they get enough sleep, maintain a regular sleep-wake schedule, and avoid excessively stressful conditions.
Because sleeping pills and alcohol can harm the baby, other measures to improve sleep need to be considered. The practice of muscle relaxation technique prior to bedtime may be effective in promoting better sleep and reducing the discomfort of pregnancy.
To avoid exacerbating heartburn, women should maintain a balanced diet and avoid eating heavy meals and spicy food for at least 2-3 hours before bedtime.
After delivery, getting enough rest continues to be very important, as severely disturbed sleep may place women at risk for postpartum depression and child abuse. [47]
Narcolepsy
Most patients with narcolepsy rely on stimulant and antidepressant medication to maintain daytime alertness and to control cataplexy; therefore, cessation of medication during pregnancy can cause excessive sleepiness or cataplexy, which may result in injury. In addition, withdrawal from medications also may affect sleep patterns.
No adverse fetal outcome was described in 2 case reports on women with narcolepsy who continued to take amphetamine throughout pregnancy and during nursing. Despite these findings, caution must be used in the administration of these medications during pregnancy, because the long-term sequelae have not been fully assessed.
Menopause-Related Sleep Disorder
Women can alleviate their menopause-related sleep disturbances by paying attention to their sleep habits, controlling their bedroom temperature, adjusting the light, and using comfortable (preferably cotton) bed linen. In addition, they should eliminate caffeine, sugar, and alcohol from their diet.
Estrogen therapy has been found to be quite effective for women with severe sleep and mood disturbances who have no history of affective illness. Hormone replacement therapy (HRT) has also been the treatment of choice for sleep interruptions related to hot flashes. However, study results have caused the safety of this treatment to be questioned. [48]
A combination of antidepressant medications and supportive psychotherapy should be considered for women who have had long-standing difficulties with sleep, depression, and anxiety.
Sleep-Disordered Breathing
In the presence of SDB, nasal CPAP and/or an oral device should be offered, along with recommendations regarding weight management. Weight management also appears to be an important factor in the management of SDB in menopausal women.
HRT may be useful in the treatment of OSA in menopausal women. However, results from the Women's Health Initiative study have raised concerns about the safety of HRT.
Sleep Disorders in Elderly Women
Older women should be aware of sleep disturbances and not dismiss them as part of the aging process. In addition, the presence of significant daytime sleepiness should be investigated. A sleep study may be required to rule out major sleep disorders.
The physician should be aware of the patient's medical and psychiatric conditions and target the treatment at the cause of the disturbance rather than at the symptoms. General guidelines for better sleep habits should be provided.
Follow-Up
Compliance with nasal CPAP treatment has been estimated to be 50-73% in the first 6 months of treatment. It decreases sharply to less than 60% by 18 months of treatment; therefore, long-term follow-up is essential to maintain the efficacy of this treatment.
Treatment of primary insomnia typically consists of a short-term cognitive-behavioral treatment, with follow-up visits at 3 and 12 months. In the presence of comorbid psychiatric conditions, psychological treatment typically is combined with medication, and long-term follow-up treatment is needed.
Deterrence and Prevention
Strategies for preventing sleep dysfunction include the following:
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Good sleep hygiene - Maintaining good sleep hygiene improves the sleep of most women
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Stress management - Stress associated with daily life often contributes to sleep problems; learning stress management skills can help women to sleep better and prevent more serious sleep problems
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Body weight maintenance - Regular exercise and healthy diet promote good sleep; in addition, maintaining normal weight may prevent the development of obesity-associated SDB
Consultations
Because of the multidisciplinary nature of sleep disorders, consultation with various specialists often is needed, including the following:
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Psychiatrist - A psychiatric consultation often is needed when severe insomnia does not respond to behavioral treatment
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Behavioral sleep specialist (board-certified in behavioral sleep medicine) - This is typically a psychologist trained in behavioral therapy for insomnia
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Neurologist - In the differential diagnosis of parasomnias (eg, sleep terror, sleepwalking, REM sleep behavior disorder), consultation with a neurologist often is needed to rule out sleep-related seizure disorders
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Pulmonologist - SDB is suspected in the presence of loud snoring and daytime sleepiness; occasionally, a pulmonologist is consulted to rule out related respiratory disease such as alveolar hypoventilation syndrome
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Dentist - For patients who are unable to tolerate nasal CPAP, oral appliances may prove effective in the treatment of SDB
