Treatment of sleep disorders

In the treatment of insomnia there are two approaches: drug therapy and psychotherapeutic techniques. A large number of drugs of different classes have a hypnotic effect. In acute insomnia, when pronounced sleep disturbances are associated with a stressful event that is relevant for a person, a short course of sleeping pills (zopiclone, zolpidem, zaleplon) or antihistamines (doxylamine) is prescribed. When insomnia is combined with increased anxiety during the day, panic attacks, anxiolytics are prescribed (alprazolam, bromdihydrochlorophenylbenzodiazepine, hydroxyzine, alimemazine). Despite the fact that insomnia is a condition that requires the close attention of a specialist, most patients, especially those over 55 years of age, prefer to use the usual and affordable ways to normalize sleep - the use of traditional alcohol-based drugs containing phenobarbital. However, compared with next-generation sleeping pills, barbiturates have the highest potential for developing addiction and drug dependence, change the natural structure of sleep, and have a negative effect on cognitive (cognitive toxicity) and motor functions (behavioral toxicity).

With mild sleep disorders, therapy with herbal preparations of mint, valerian, nootropics with a sedative effect (aminophenylbutyric acid) can be started.

Separately, it is worth noting an independent class of sedatives, which includes bromine preparations - sodium bromide and potassium bromide, camphor bromide. Bromides began to be used in medicine a very long time ago, back in the 19th century. The effect of bromine salts on higher nervous activity was studied in detail by IP Pavlov and his students in experimentally induced neurosis in dogs, as well as in healthy animals. According to the school of IP Pavlov, the main effect of bromides is associated with the ability to concentrate and enhance the processes of inhibition in the cerebral cortex, restoring the disturbed balance between the processes of inhibition and excitation, especially with increased excitability of the central nervous system.

It should be noted that there is no scientific evidence of the effectiveness of drugs for the correction of sleep disorders in acute insomnia, since clinical studies that meet the criteria of evidence-based medicine have not been conducted in this nosological group. Medicines are prescribed on the basis of physiological ideas about the role of the limbicoreticular system in the organization of a systemic response to stress, which is manifested, in particular, by an increase in the level of anxiety, a violation of night sleep.

The treatment of choice for chronic insomnia according to clinical guidelines is cognitive behavioral therapy (LE: 1A). In a patient with chronic insomnia, false (dysfunctional) ideas about sleep are formed, which lead to a violation of his hygiene (the desire to spend more time in bed), restrictive behavior (a decrease in physical and mental activity due to insufficient sleep). While patients may feel that these behaviors may help improve sleep, the effect appears to be the opposite, so sleep hygiene should be explained: set daily bedtimes and wakeup times, stay out of bed if you are not drowsy, and stay out of bed during the day. It may be useful to keep a sleep diary in which the patient notes the time of going to bed and waking up, falling asleep, the number of nightly awakenings and the time to fall asleep after them, the time and amount of medication, alcohol, caffeinated products, physical activity during the day, well-being . Psychotherapy helps to overcome fear and anxiety about the upcoming painful night and negative associations associated with bedtime and bedtime. After stopping the main manifestations of insomnia, it is necessary to prepare the patient for the possibility of a relapse of insomnia against the background of another stress.

The problem that virtually excludes the use of cognitive-behavioral therapy for chronic insomnia in real clinical practice is the need for special training in this area and the duration of work with the patient (the standard method for treating insomnia includes 6 therapeutic sessions). Therefore, most often in the chronic course of insomnia, the choice is made in favor of drugs. The duration of use of GABAergic hypnotics is limited to 2-4 weeks, after which it is believed (but not confirmed by clinical studies) that the risk of addiction to these drugs increases.

Somnolent effect have tricyclic antidepressants (amitriptyline, pipofezin), four-cyclic antidepressants (mianserin, mirtazapine), serotonin reuptake inhibitors (trazodone). In chronic insomnia, neuroleptics with a sedative effect (chlorprothixen, quetiapine, alimemazine, clozapine) are used. The hypnotic effect of these drugs is associated primarily with the blockade of the central histaminergic H1 receptors. The antiepileptic drugs pregabalin and gabapentin are also used. The effectiveness of all the above drugs does not exceed the level of evidence 2B.

With OSAS, the universal recommendation is to reduce body weight, since 3/4 of OSAS patients are obese. A 10% weight loss has been shown to reduce AHI by 50% on average.

Mild OSAS or isolated snoring can be corrected surgically. Depending on the structural features of the laryngopharynx, an otorhinolaryngologist may prescribe a uvulotomy, tonsillectomy, or uvulopalatopharyngoplasty. An operation is considered effective if it reduces the number of apnea/hypopnea by 50%. The structural features of the oropharynx can be compensated with the help of oral applicators - tongue holders, mandibular splint (cap), external nasal dilators, orthoses that raise the soft palate.

In moderate and severe OSAS the effect of surgery is insufficient (50% improvement is achieved in 50% of cases). In this situation, CPAP therapy (creation of continuous positive pressure in the upper airways) is indicated with a device that creates positive air pressure, in which the upper airways remain open. This method of treatment has an extremely high efficacy in relation to the symptoms of OSA. To maintain the effect, the device must be used regularly at least 5 days a week for at least 4 hours per night. In severe sleep apnea, when it is necessary to use high numbers of positive air pressure, or with concomitant cardiac and respiratory pathology, the patient may experience discomfort due to difficulty exhaling. For such situations, ByPAP devices (with two-level air pressure) have been developed, in which different inspiratory and expiratory pressures can be set, which ensures better tolerability of therapy.

Despite the high effectiveness of CPAP therapy in relation to OSAS symptoms, reducing the risk of cardiovascular and dyshormonal diseases, and even weight loss, patients are reluctant to take such therapy due to the discomfort of sleeping in a mask connected to a working device. Therefore, when identifying indications for treatment, it is important to explain and clearly demonstrate to the patient how breathing disorders develop during sleep, how it affects the whole body, and talk about the increased risk of acute and chronic cardiovascular diseases in order to increase adherence to treatment.

Treatment of secondary RLS should be aimed at finding and eliminating the underlying disease. Most often, this involves replenishing the iron content in the depot with the help of oral preparations. In idiopathic RLS, treatment begins with dopaminomimetics in low doses with gradual increase (pramipexole, ropinirole) or with gabapentin. With insufficient effectiveness, levodopa is prescribed. A positive effect has an increase in the level of physical activity and walking during the first half of the day. Treatment of SPDC is carried out according to the same scheme as the treatment of RLS.

Treatment of most parasomnias (sleepwalking, sleep-talking, confusional awakenings, nocturnal enuresis) is usually not required, at the age of over 14 years they practically disappear. The elimination of nightmares should be carried out when analyzing the causes of disturbing dreams using psychotherapeutic techniques. With severe, maladaptive nightmares, tranquilizers are prescribed, ranging from herbal preparations to benzodiazepine derivatives.

Treatment of RDPS in the absence of daytime movement disorders is to increase the depth of sleep with sedatives, melatonin, and some antidepressants (amitriptyline).