In our outpatient practice, we treat all sleep disorders. Patients often come to us with snoring, sleepiness, trouble sleeping, or acting out dreams. Patients may come to us with diagnoses of sleep apnea, narcolepsy, idiopathic hypersomnia, insomnia, restless leg syndrome, REM behavioral disorder, or anything else sleep-related.
For some time, we were accepting patients with memory disorders. We are no longer taking new patients with memory disorders. We are not accepting office patients for headache, back pain, sciatica, Alzheimer's disease, Parkinson's disease, loss of consciousness, seizure, or stroke. That said, if we are investigating sleep and find evidence of any of the above, we may initiate an evaluation and refer appropriately.
We previously participated in trials of new Alzheimer's medications. While I continue to believe that such studies are valuable, for business reasons, we are no longer involved in these trials.
I (Dr. Abaluck) only see new neurology patients in an ER and hospital setting. I take regular call at Paoli Hospital and handle neurological emergencies including stroke and seizure.
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Half-life is the single most important quality of any hypnotic. Longer half life increases risk of hangover but addresses sleep maintenance insomnia. For sleep maintenance insomnia, I do not provide patients the option of taking middle of the night medications, because from a behavioral perspective, such medications reward awakening.
|Presentation||Drug||Onset (Min)||Half Life (Hrs)|
|Sleep onset insomnia||Zaleplon (Sonata)||5-20||1|
|Sleep onset insomnia||Triazolam||10-20||1.5 - 5|
|Sleep onset insomnia||Zaleplon (Ambien)||10-20||1.5 - 2.4|
|Sleep Maintenance Insomnia||Eszopiclone (Lunesta)||10-30||5 - 6|
|Sleep Maintenance Insomnia||Lorazepam||15-40||10 - 15|
|Sleep Maintenance Insomnia||Temazepam||45-60||8 - 20|
|Sleep Maintenance Insomnia||Belsomra||30-60||12|
|Sleep Maintenance Insomnia & Anxiety||Clonazepam||20-60||20 - 60|
Let’s assume your patient has insomnia and elects medication management. Here is how the presence of comorbidities influences my management. Note that Clonazepam has a half life of 2 days, so I never use it for insomnia unless I am also treating a daytime symptom, like anxiety.
If our patient has none of these comorbidities, and I elect medication instead of or in addition to behavioral therapy, I always start with a benzodiazepene, benzodiazepene receptor agonist (BZRA- Sonata, Ambien, or Lunesta), or Belsomra. From among these medicines I select based upon medication half-life.
|Restless Leg Syndrome||Gabapentin, Horizant, Lyrica|
|Night Owl Tendencies||Melatonin or Ramelteon|
|Parasomnias||Ativan or Clonazepam|