Advice on sleep hygiene should aim to increase awareness of behavioural, environmental, and temporal factors that may be detrimental or beneficial to sleep.

Offer advice on:

• Normal sleep and changes in sleep patterns that occur with age
• Exercise
  • Increase daily exercise, but not in the evening (within 4 hours of bedtime)
• Limiting/avoidance of caffeine, nicotine and alcohol
  • Caffeine should be avoided after midday
  • Nicotine, alcohol, and large meals should be avoided within 2 hours of bed time
  • Alcohol intake can negatively impact sleep-maintenance
• Relaxation techniques before bed
  • Consider reading a book and/or having a bath
  • Relaxation exercises and techniques such as mindfulness may be helpful if performed in the early evening
• Optimising the sleep schedule
  • Aim to wake up at the same time each day
  • Reduce daytime napping
  • Try only going to bed when feeling sleepy
• Optimising the sleep environment
  • A comfortable sleep environment should be maintained. This includes ensuring that the area is not too hot/cold, noisy, or too bright.
  • The bedroom should only be used for sleep and intimacy
  • Checking or watching the clock throughout the night should be avoided
  • Watching television in bed can negatively affect sleep
• Bright light should be minimized
• Blue light displays from electronic devices such as mobile phones, tablets, and televisions supress melatonin production. As such the use of these devices should be limited in the 2 hours before bedtime.

Devon Partnership Trust has produced a handy fact sheet

Address any triggers or factors associated with onset of insomnia and ensure comorbidities (such as anxiety and depression) are optimally managed.

Review current medicines for drugs that are associated with insomnia or disturbed sleep. Examples include antidepressants (SSRIs, MAOIs, venlafaxine), some antiepileptics (gabapentin, lamotrigine, levetiracetam, pregabalin etc.), beta blockers, diuretics, laxatives, steroids and stimulants. It may be possible to take these agents earlier in the day to minimise problems at night.

Initial management should include advice on sleep hygiene (see above)

If sleep hygiene measures fail and daytime impairment is severe causing significant distress, consider treatment with a short-term hypnotic as detailed below:

If a hypnotic is prescribed:

• Consider the duration of action, adverse effects, interactions and potential for dependency and abuse.
• Use the lowest effective dose for the shortest period possible.
• Inform the person that further prescriptions for hypnotics will not usually be given, ensure that the reasons for this are understood, and document this in the person’s notes.
• Do not issue further prescriptions without seeing the person again.
• If there has been no response to the first hypnotic, do not prescribe another.
• Warn individuals about the risk of drowsiness the next day and to avoid driving when affected

NICE guidance NG215: ‘Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults’ includes guidance on: supporting people; making decisions about prescribing; starting, reviewing and withdrawing a dependence-forming medicine.

If insomnia is likely to resolve soon (e.g. due to a short-term stressor)

Consider a short course (3-7 days) of either:

Zopiclone

• Adult over 18 years, 7.5mg at bedtime
• Some patient groups (e.g. elderly, renal or hepatic impairment etc.) may require a lower dose i.e. 3.75mg at bedtime
• See section 4.1.1 Hypnotics

Zolpidem

• Adult over 18 years, 10mg at bedtime
• Some patient groups (e.g. elderly, debilitated, hepatic impairment) may require a lower dose i.e. 5mg at bedtime
• See section 4.1.1 Hypnotics

If insomnia is not likely to resolve soon

Where available, offer cognitive behavioural therapy for insomnia (CBTi)

Pharmacological treatment may be considered as an adjunct to CBTi, or when CBTi is not available, or is unsuitable. If pharmacological therapy is utilised review the patient in 2-4 weeks and consider the need for a different approach to management or onward referral.

Recommended options include:

Zopiclone

• Adult over 18 years: 7.5mg at bedtime
• Some patient groups (e.g. elderly, renal or hepatic impairment etc.) may require a lower dose i.e. 3.75mg at bedtime
• Maximum treatment duration 2-4 weeks
• See section 4.1.1 Hypnotics

Zolpidem

• Adult over 18 years: 10mg at bedtime
• Some patient groups (e.g. elderly, debilitated, hepatic impairment) may require a lower dose i.e. 5mg at bedtime
• Maximum treatment duration 2-4 weeks
• See section 4.1.1 Hypnotics

Modified-release melatonin

• Only to be considered in patients who are aged 55 years and above and for whom z-drugs are deemed unsuitable.
• Not routinely recommended for the management of insomnia in adults aged 18 to 55 years.
• 2mg per day taken 1-2 hours before bedtime.
• Initial duration of treatment should be 3 weeks. At that time treatment should be reviewed for effectiveness and may be extended for up to an additional 10 weeks (maximum)
• See section 4.1.1 Hypnotics

Antihistamines (e.g. promethazine), are not routinely recommended to treat insomnia but may offer alternative short-term relief to z-drugs in certain clinical scenarios e.g. history of substance misuse. In such cases treatment duration should be limited to less than 7 days.

Antidepressants (e.g low dose amitriptyline) and antipsychotics are not recommended solely to treat insomnia (although insomnia may improve in response to adequate treatment of a comorbid condition i.e. a depressive, hypomanic, or psychotic episode).

Address any triggers or factors associated with maintenance of insomnia (for example illness or other stressors). Ensure comorbidities (such as anxiety and depression) are optimally managed.

Review current medicines for drugs that are associated with insomnia or disturbed sleep. Examples include antidepressants (SSRIs, MAOIs, venlafaxine), some antiepileptics (gabapentin, lamotrigine, levetiracetam, pregabalin etc.), beta blockers, diuretics, laxatives, steroids and stimulants. It may be possible to take these agents earlier in the day to minimise problems at night.

Offer advice on sleep hygiene (see above)

Where available, offer cognitive behavioural therapy for insomnia (CBTi) as the first line treatment for long-term insomnia.

Pharmacological therapy may be considered for management of long-term insomnia only in the circumstances described in the entries below.

If a hypnotic is prescribed:

• Consider the duration of action, adverse effects, interactions and potential for dependency and abuse.
• Use the lowest effective dose for the shortest period possible
• Inform the person that further prescriptions for hypnotics will not usually be given, ensure that the reasons for this are understood, and document this in the person’s notes.
• Do not issue further prescriptions without seeing the person again.
• If there has been no response to the first hypnotic, do not prescribe another.
• Concomitant use of hypnotics is not recommended.
• Warn individuals about the risk of drowsiness the next day and to avoid driving when affected.

NICE guidance NG215: ‘Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults’ includes guidance on: supporting people; making decisions about prescribing; starting, reviewing and withdrawing a dependence-forming medicine.

Daridorexant

• In line with TA922 (for use in adults with symptoms lasting for 3 nights or more per week for at least 3 months, and whose daytime functioning is considerably affected, only if CBTi has been tried but not worked, or CBTi is not available or is unsuitable)
• Sleep hygiene measures and behavioural changes are essential to maximise the treatment effect of daridorexant
• 50mg 30 minutes before going to bed
  • Some patient groups may require a lower dose (see section 4.1.4 Orexin receptor antagonists)
• The length of treatment should be as short as possible.
• Treatment with daridorexant should be assessed within 3 months of starting and should be stopped in people whose long-term insomnia has not responded adequately. If treatment is continued, assess whether it is still working at regular intervals.
• Treatment can be stopped without down-titration

Zopiclone

• As an adjunct to behavioural and cognitive treatment in people with severe symptoms and/or an acute exacerbation. Short course only (<7 days)
• Adult over 18 years: 7.5mg at bedtime
• Some patient groups (e.g. elderly, renal or hepatic impairment etc.) may require a lower dose i.e. 3.75mg at bedtime
• See section 4.1.1 Hypnotics

Zolpidem

• As an adjunct to behavioural and cognitive treatment in people with severe symptoms and/or an acute exacerbation. Short course only (<7 days)
• Adult over 18 years: 10mg at bedtime
• Some patient groups (e.g. elderly, debilitated, hepatic impairment) may require a lower dose i.e. 5mg at bedtime
• See section 4.1.1 Hypnotics

Modified-release melatonin

• Only to be considered in patients who are aged 55 years and above and for whom z-drugs are considered unsuitable.
• Not routinely recommended for the management of insomnia in adults aged 18 to 55 years.
• 2mg per day taken 1-2 hours before bedtime.
• Initial duration of treatment should be 3 weeks. At that time treatment should be reviewed for effectiveness and may be extended for up to an additional 10 weeks (maximum)
• See section 4.1.1 Hypnotics

Review the patient following treatment and consider the need for a different approach to management or onward referral for consideration of an alternative sleep disorder (for example obstructive sleep apnoea).

Antihistamines (e.g. promethazine), are not routinely recommended to treat insomnia but may offer alternative short-term relief to z-drugs in certain clinical scenarios e.g. history of substance misuse. In such cases treatment duration should be limited to less than 7 days.

Antidepressants (e.g low dose amitriptyline) and antipsychotics are not recommended solely to treat insomnia (although insomnia may improve in response to adequate treatment of a comorbid condition i.e. a depressive, hypomanic, or psychotic episode).