Question 1

A 48-year-old woman presents with a 6-month history of difficulty falling asleep and maintaining sleep, occurring 5 nights per week. She lies in bed for 9 hours but estimates she sleeps about 5 hours. She has tried melatonin supplements and diphenhydramine without benefit. She is requesting a prescription for zolpidem because her friend takes it and "it works great." What is the most appropriate first-line treatment recommendation?

Accepted Answer

CBT-I is the recommended first-line treatment for chronic insomnia disorder by every major guideline (ACP, AASM, ESRS). It is more effective than medications long-term, produces durable improvement that persists after treatment ends, and has no side effects or dependence risk. Pharmacotherapy is second-line, appropriate when CBT-I is unavailable, insufficient, or as a bridge while CBT-I is initiated. A sleep study may be warranted if there are symptoms suggesting another sleep disorder (snoring, witnessed apneas, restless legs), but the presentation described is classic psychophysiological insomnia.

Question 2

A 62-year-old obese man with hypertension presents complaining of "insomnia." He reports waking multiple times during the night, feeling unrefreshed every morning, and experiencing morning headaches. He is fatigued all day and has fallen asleep during meetings at work. His wife, who sleeps in a separate room, reports that he snores "like a freight train" and that she has witnessed him stop breathing during sleep. He is requesting a sleep medication. What is the most appropriate next step?

Accepted Answer

This is not insomnia disorder. The presentation, loud snoring, witnessed apneas, morning headaches, excessive daytime somnolence, obesity, and hypertension, is classic for obstructive sleep apnea. The STOP-BANG score is high (Snoring, Tiredness, Observed apneas, Pressure/hypertension, BMI likely >35, Age >50). Polysomnography is the diagnostic study. Prescribing any sedative-hypnotic in this context is dangerous because these medications suppress respiratory drive and worsen apneic episodes. Treatment of OSA is CPAP, not sedation.

Question 3

A 78-year-old woman with mild cognitive impairment presents with sleep maintenance insomnia. She wakes at 2-3 AM and cannot return to sleep. Her daughter reports she has been taking diphenhydramine (Benadryl) nightly for the past year and seems "more confused" recently. You want to discontinue the diphenhydramine and start an appropriate alternative. Which of the following is the most appropriate pharmacological choice?

Accepted Answer

In an elderly patient with cognitive impairment, diphenhydramine is a clear problem: anticholinergic burden worsens cognition and is listed on the Beers Criteria. Lorazepam (benzodiazepine) increases fall risk, causes cognitive impairment, and is on the Beers Criteria for elderly patients. Quetiapine carries metabolic risk, fall risk, and tardive dyskinesia risk disproportionate to the indication. Zolpidem 10mg is above the recommended dose for women and elderly patients and carries risk of complex sleep behaviors and falls. Low-dose doxepin (3-6mg, FDA-approved for sleep maintenance insomnia, studied in elderly populations) or suvorexant (orexin antagonist with favorable cognitive and fall-risk profile in elderly patients) are the most appropriate choices. CBT-I should also be offered concurrently.

Insomnia Disorder

Red Flags & Key Clinical Considerations

Obstructive Sleep Apnea Symptoms

REM Sleep Behavior Disorder

New-Onset Insomnia in Elderly Patients

Related Medications

Practice With Related Cases

References & Further Reading