Non-Sedative Hypnotic Treatment Of Insomnia Toolkit

Managing Insomnia- Sleep Education & Sleep Hygiene Whatever the cause of your present problem there are still things you can do that will help you get the most out of your sleep now: Don’t expect too much from your sleep. As you get older it is quite normal for sleep to become shorter, lighter, and more broken. You may also find that your normal sleep routines are more easily disturbed. Rather than changing your sleep, you may need to adjust your expectations and your habits. Do you really need as much sleep as your think? Avoid those things which can prevent or disrupt sleep (even if these things have never been a problem in the past). Learn to take more care of your sleep. For example, try drinking less tea or coffee (especially close to bedtime). If you have to get up in the night to go to the toilet, perhaps it is best to avoid late night drinking altogether. Is your bed comfortable and warm enough, and is your bedroom quiet and dark enough? It is extremely important to keep regular habits. In particular, avoid excessive daytime napping, or long lie-ins in the morning. Try to keep at least fairly active during the day, but allow time to ‘wind down’ in the evening. If you have a medical complaint that seems to interfere with your sleep (for example, pain, breathlessness, snoring, or frequent urination at night), see your primary care doctor and explain the problem.

Managing Insomnia- Stimulus Control and Sleep Restriction Beds and bedrooms are very important ‘signals’ for sleep, and actually make a lot of people feel quite sleepy. For those with insomnia, however, these important signals may be lost. With practice, these signals or ‘cues’ can be strengthened so that your sleep gradually improves. The main aim of this treatment approach is to reduce the amount of time you spend awake in bed each night. Listed below are some rules to follow. Establish a set bedtime for yourself. Try to go to bed at this same time each night and settled down to sleep as soon as possible. If you have not gone to sleep after about 20 minutes, get up and leave the bedroom (if possible) until you feel tired again. If you live in one room and cannot leave, at least leave the bed (for example, sit in a chair instead) until you feel tired. It is important that you do not use your bed for anything except sleep. Avoid activities like reading, smoking, listening to the radio, using the computer, or watching TV in bed. If you can’t sleep, get up. Establish a set wake-up time for yourself, and get up at the set time even if you feel tired or in need of more sleep. Try to keep active during the day and avoid napping. Go to bed at the set time. Before putting these rules into practice, you may find it helpful if you first prepare a room or area in your room where you can sit during sleepless periods, and if there are other people you live with, tell them about your sleep treatment.

Managing Insomnia- Progressive Relaxation Physical and mental relaxation are a normal and natural part of good sleep. As we drift into sleep we experience several changes, both in our physical arousal and in our thinking pattern. With sleep – Breathing slows down Heart rate slows down Muscles relax Patterns of thinking change from problem solving which is usually in words, to thoughts in pictures and images These changes are a normal and natural part of good sleep, just as it is normal for our heart rate and breathing to speed up when we exercise. When we prepare for sleep we begin the process of putting our minds and bodies to bed. You can give the natural process a helping hand, by learning a good, deep relaxation. This will help you to reduce your physical arousal, by slowing down your heart rate and breathing and by reducing muscle tension. By focusing on the relaxation you will also stop your mind from racing, you will keep thoughts which might otherwise get in the way of sleep and you will help the natural shift in your thinking from words to pictures. This will help you to achieve a relaxed state and allow you to drift into sleep. PRACTICE Set aside 25 minutes each day, at a convenient time when you will not be disturbed, to practice your relaxation/meditation. If you need tips on how to do this, ask your provider. The more you practice the deeper your relaxation will become and the more it will help you to achieve a good night’s sleep. Once in bed, settle down prepared to sleep and again go through the relaxation. At the end try to hold in your mind the details of a pleasant image. Hold this as vividly as you can, see the colors and movements and hear the sounds, etc. REMEMBER Beware of excuses which prevent you from practicing every day Don’t fall asleep during your daytime relaxation/meditation practice Don’t expect changes in your sleep immediately, as it takes time. Just focus on enjoying the relaxation.

Managing Insomnia- Cognitive Techniques Let’s consider how we can put our minds to bed and stop thoughts from getting in the way of good sleep. Thoughts which get in the way of sleep might be worrying thoughts, which are often about the day that has gone, or the day to come. Put the day to rest We have to put the day to rest. It is helpful to guess what bedtime thoughts may be ahead of time, by rescheduling them to earlier in the day. Set aside time to pay attention to these thoughts in the daytime—a good way is to write them down, perhaps as a journal of the day. We can write details about the day past or to come, and try to tie up loose ends. Change troublesome or negative thoughts into trouble-free realistic thoughts Negative thoughts can be challenged by more realistic versions of the same thoughts, such as: Negative thought I am never going to sleep tonight. I won’t cope tomorrow. I will get sick if I don’t sleep. Everyone else is asleep. Realistic thought I always fall asleep eventually. I will be tired but I will get through it. Insomnia does not cause illness. I am not alone—1 in 5 adults have sleep trouble. Change negative thoughts to realistic thoughts by challenging your beliefs Catch the thoughts you want to block or challenge. These thoughts are often involuntary, habitual, negative, exaggerated or even defeatist. Ask yourself: 1. Is this thought or fact? 3. What is the evidence to support this thought? 2. Am I jumping to conclusions? 4. What is a more realistic alternative thought? A calm mind at bedtime Once in bed settle down quickly and go through your relaxation technique. Use imagery by holding a pleasant scene in your mind. Attempt to block repetitive, unimportant thoughts—one technique is to repeat the word “THE” every two seconds in your head. Remind yourself that you have already put your thoughts to bed. If any disruptive thoughts enter your mind, remind yourself of the realistic alternative you identified during the day. Then use you imagery or block technique to distract yourself and drift into sleep.

No need to try to sleep There is no need to try to sleep! Sleep is natural and will occur if we remove the things that keep us awake. Don’t expect too much too quickly, it takes time

Sleep Diary One of the best ways you can tell if you are getting enough good quality sleep, and whether you have signs of a sleep disorder is by keeping a sleep diary. Use this sample diary to get started. Name Day of the week Today’s date Time I went to bed last night: Mon Tues Wed Thurs Fri Sat Sun Mon Tues Wed Thurs Fri Sat Sun Complete in the Time I woke up this morning: Morning Number of hours slept last night: Number of awakenings: Total time awake last night: Time to fall asleep last night: How awake did I feel when I got up this morning? 1—Wide awake 2—Awake but a little tired 3-- Sleepy Name Day of the week Today’s date Number of caffeinated drinks (coffee, tea, cola) and time when I had them today: Complete Number of alcoholic drinks (beer, in the wine, liquor) and time when I had Evening them today: Naptimes and length of naps today: Exercise times and length of exercise today: How sleepy did I feel during the day today? 1—Very sleepy 2—Somewhat tired 3—Fairly alert 4—Wide awake

Do’s o DO: Establish a regular bedtime and rise time o DO: Only use bed for sleep (if possible) o DO: Exercise in the morning or early afternoon o DO: Take a hot bath a couple of hours before bedtime o DO: Establish a comfortable sleep environment (e.g., bed, and bedding) o DO: Sleep in a dark, quiet area that is temperature controlled (if possible) o DO: Establish a relaxing pre-sleep routine that you use every night before sleep, such as washing your face, getting into pajamas, reading or listening to soft music before turning the lights out Don’ts DON’T: Take daytime naps DON’T: Watch TV in bed DON’T: Use stimulants such as caffeine and nicotine DON’T: Drink alcohol before bedtime DON’T: Go to bed too hungry or too full DON’T: Eat spicy or acidic foods (e.g., orange juice) before bed DON’T: Try too hard to fall asleep DON’T: “Watch the clock” DON’T: Take prescription and over-thecounter medications that might be stimulating (check with your doctor)

Los Sí y los No de los hábitos del sueño Sí o SÍ: Establezca un horario regular para dormirse y levantarse o SÍ: Use solamente la cama para dormir (si es posible) o SÍ: Haga ejercicio en la mañana o temprano en la tarde o SÍ: Tome un baño caliente un par de horas antes de acostarse o SÍ: Establezca un ambiente cómodo para dormir (por ejemplo, cama y ropa de cama) o SÍ: Duerma en una zona oscura y tranquila donde se controle la temperatura (si es posible) o SÍ: Establezca una rutina relajante que utilice todas las noches antes de dormir, como lavarse la cara, ponerse pijama, leer o escuchar música suave antes de apagar las luces No NO: Tome siestas durante el día NO: Vea la televisión en la cama NO: Utilice estimulantes como la cafeína y la nicotina NO: Beba alcohol antes de acostarse NO: Se acueste con hambre o demasiado lleno NO: Coma alimentos picantes o ácidos (por ejemplo, jugo de naranja) antes de acostarse NO: Haga demasiado esfuerzo para dormirse NO: "Mire el reloj" NO: Tome medicamentos de receta ni de venta libre que puedan ser estimulantes (consulte a su médico)

Привычки сна "Можно и нельзя" Можно o МОЖНО: Установите привычку ложиться и вставать в одно и то же время o МОЖНО: Используйте кровать только для сна (если возможно) o МОЖНО: Занимайтесь спортом по утрам или в середине дня o МОЖНО: Принимайте ванну за пару часов до сна o МОЖНО: Создайте комфортные условия для сна (напр., кровать и постельное белье) o МОЖНО: Спите в темном и тихом помещении с температурным контролем (если возможно) o МОЖНО: Создайте расслабляющую рутину подготовки ко сну, которой вы будете следовать каждый вечер, напр., умывание лица, переодевание в пижаму, чтение или прослушивание тихой музыки перед тем, как выключить свет. Нельзя НЕЛЬЗЯ: Спать днем НЕЛЬЗЯ: Смотреть телевизор в кровати НЕЛЬЗЯ: Пользоваться стимуляторами, напр. кофе и никотин НЕЛЬЗЯ: Пить спиртное перед сном НЕЛЬЗЯ: Ложиться в кровать слишком голодным или переевшим НЕЛЬЗЯ: Есть острую или кислую пищу (напр., апельсиновый сок) перед сном НЕЛЬЗЯ: Очень стараться уснуть НЕЛЬЗЯ: “Следить за временем” НЕЛЬЗЯ: Принимать прописанные врачом или продающиеся без рецепта лекарства с возможным возбуждающим эффектом (проконсультируйтесь с вашим врачом)

要 o o o o o 要: 定時睡覺和起床 要: (如果可能) 睡床只作睡覺之用 要: 在早上或下午做些運動 要: 在睡前兩個小時以熱水淋浴 要: 有舒適的睡眠環境 (如，睡床和床上用品) o 要: (如果可能) 在燈暗及安靜的恆溫環 境下睡覺 o 要: 養成每晚睡前放鬆的習慣，如洗臉、 � 音樂 不要 不要: 白天小睡 不要: 在床上看電視 不要: 服用帶刺激性的物品，如咖啡因 和尼古丁 不要: 睡前飲酒 不要: 睡前太餓或太飽 不要: 睡前吃辛辣或酸性的食品 (如 橙汁) 不要: 強迫自己入睡 不要: “看時鐘” 不要: 服用可能有刺激性的處方藥和非 處方藥 (請諮詢你的醫生)

Những cái Nên làm o Nên: Thiết lập giờ giấc đều đặn cho việc đi ngủ và thức dậy o Nên: Chỉ sử dụng giường cho việc ngủ mà thôi (nếu có thể) o Nên: Tập thể dục vào buổi sáng hoặc đầu giờ trưa o Nên: Tắm nước nóng một vài tiếng trước giờ đi ngủ o Nên: Thiết lập một không gian ngủ thoải mái (ví dụ: giường, chăn nệm) o Nên: Ngủ ở một nơi tối, yên tĩnh, nhiệt độ có thể kiểm soát (nếu có thể) o Nên: Thiết lập một thói quen thư giãn trước khi đi ngủ như rửa mặt, mặc quần áo ngủ. đọc sách hoặc nghe nhạc nhẹ trước khi tắt đèn. Những cái Không nên làm Không nên: Ngủ ban ngày Không nên: Nằm xem TV trên giường Không nên: Dùng những chất kích thích như caffeine và nicotine (Coca cola, thuốc lá) Không nên: Uống rượu trước khi đi ngủ Không nên: Đi ngủ khi bụng quá đói hoặc quá no Không nên: Ăn thức ăn cay hoặc nhiều chất axít (ví dụ: nước cam) trước khi đi ngủ Không nên: Cố gắng quá mức để ngủ Không nên: “Nhìn đồng hồ” Không nên: Uống thuốc theo toa hoặc bán trên quầy có những chất kích thích (hỏi bác sĩ của bạn)

Mga Dapat Gawin o GAWIN: Magkaroon ng regular na oras ng pagtulog at paggising o GAWIN: Gumamit lamang ng kama sa pagtulog (kung maaari) o GAWIN: Mag-ehersisyo sa umaga o bandang maaga sa hapon o GAWIN: Maligo ng ilang oras gamit ang mainit na tubig bago matulog o GAWIN: Magkaroon ng maginhawang kapaligiran sa pagtulog (hal., kama, at unan/kumot) o GAWIN: Matulog sa madilim, tahimik na lugar na kontrolado ang temperatura (kung maaari) o GAWIN: Magkaroon ng isang nagpapaginhawang gawain na inyong gagawin sa bawat gabi bago matulog, gaya ng paghihilamos ng inyong mukha, pagsusuot ng padyama, pagbabasa o pakikinig ng malamlam na musika bago patayin ang ilaw Mga Hindi Dapat Gawin HUWAG: Umidlip sa araw HUWAG: Manood ng TV sa kama HUWAG: Gumamit ng mga pampasigla gaya ng kapin at nikotina HUWAG: Uminom ng alak bago matulog HUWAG: Matulog nang sobrang gutom o sobrang busog HUWAG: Kumain ng mga pagkaing maanghang o maasim (hal., orange juice) bago matulog HUWAG: Sikaping mabuti na makatulog HUWAG: “Bantayan ang relo” HUWAG: Gumamit ng mga nireseta at nabibili sa kaunter na mga gamot na maaaring magpasigla (tanungin ang inyong doktor)

REFERRAL FORM Thank you for choosing to refer your patient to us. To start the referral process, please fax this form to the UCSF service to which you are referring your patient. Fax numbers can be found online at www.ucsfhealth.org/prd/ Include brief pertinent medical records, including test results that support the consultation If you require additional assistance, please call (800) 444-2559 and ask for either the UCSF practice or the Physician Liaison Service. Date: From: No. of pages: Title: To UCSF practice: Phone: Fax: Fax: PAT I E N T I N F O R M AT I O N Name of patient: DOB: Interpreter needed: Yes No Home phone: Language: Work or cell phone: If child, name of parent: Address: City: Zip: Insurance: Include patient’s insurance card (both sides) and HMO authorization if required C O N S U LTAT I O N R E Q U E S T I N F O R M AT I O N Diagnosis/ICD-9: Name of UCSF MD (if known): Specialty: Reason for consultation: By providing the information requested and signing below, you agree that we may initiate treatment following consultation or perform medically necessary diagnostics, in association with this consultation. We look forward to collaborating with you on your patient’s treatment plan. R E F E R R I N G P H Y S I C I A N I N F O R M AT I O N Referring MD: Specialty: Phone: Fax: PCP name: Phone: Signature: NOTICE OF CONFIDENTIALITY: This is a confidential fax and is intended solely for the person indicated above. If you are not the intended person, you are hereby notified of the confidential nature of this fax and that you are not entitled to read, copy or otherwise disseminate any of the information contained herein.

hypnotic taper is recommended. However the guideline does not include specifics regarding these parameters (BHS Safer Sedative-Hypnotic Prescribing Guidelines). REFERENCES AND FURTHER READING: 1. Billoti S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer's disease: case-control study. BMJ. 2014;349:g5205 doi: 10.1136/bmj .