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It is always advisable to provide patients with information on good sleep hygiene practices (see Table 5-1). Although behavioral techniques such as stimulus control, progressive muscle relaxation, biofeedback, and sleep-restriction seem to complement pharmacotherapy, cognitive-behavioral therapy (CBT) alone may have better long-term outcome, compared to the combination of CBT and medications. In contrast, added CBT seems to facilitate the tapering of hypnotics.

When a hypnotic agent is prescribed, patients should be advised to take the medication on an empty stomach and with ample fluids (e.g., a full glass of water) to promote rapid onset of effect. For patients prone to nocturia, fluid intake should be limited during the hours before bedtime.

The clinician should always caution patients regarding possible side effects:

• potential impairments in memory, coordination, or driving skills

• unsteadiness if they are awakened after having taken a sleep aid

• tapering of medication before discontinuation; this will be required if medication is used for more than a few nights

• avoiding the use of alcohol when taking a hypnotic, as the effects are additive

• the propensity for medication abuse by patients with drug or alcohol problems

Universally accepted guidelines for dosing and duration of use for hypnotics are not established. Both dose and duration must be individualized with the goal of finding the lowest dose and the shortest duration. Short-term treatment (i.e., from one or two nights to one or two weeks) is reasonable for most patients.

Some patients with chronic insomnia may benefit from longer-term use, provided that there is careful monitoring by the prescribing physician. No criteria are presently available to identify this subpopulation. It seems reasonable to consider several short-term trials, with gradual tapering at the end of each period and a drug-free interval between each period, to establish the patient's need for and the appropriateness and value of continued therapy. Drug-free time intervals between initial treatment periods should range from one to three weeks, depending on the half-life of the agent and its active metabolites and the rapidity of the taper schedule. Re-evaluation of such a patient's continued need for hypnotic medication at 3- to 6-month intervals is also reasonable.

As the elderly are particularly susceptible to falls or confusion from hypnotic medication, use of the lowest available dosage strength is advisable. The elderly should also avoid the use of longer half-life agents or those with active metabolites with long half-lives because such medications tend to accumulate due to pharmacodynamic differences in drug metabolism in the elderly.

For individuals who prefer behavioral and nonpharmaco-logical approaches to their insomnia, hypnotic use two or three times per week may be beneficial.

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