Bedtime Battles, Part 3
- Avoid caffeine late at night. Although many people without ADHD report that coffee actually helps them to sleep, there is usually a fine line between the right amount and too much caffeine. Caffeine is a potent diuretic, and while it may help some fall asleep, it causes awakening two or three hours later to void the bladder.
If the patient spends hours a night with thoughts bouncing and his body tossing, this is probably a manifestation of ADHD. The best treatment is a does of stimulant-class medication 45 minutes before bedtime. This course of action, however, is a hard sell to patients who suffer from insomnia. Consequently, once they have determined their optimal dose of medication, I ask them to take a nap an hour after they have taken the second dose.
Generally, they find that the medication's "paradoxical effect" of calming restlessness is sufficient to allow them to fall asleep. Most adults are so sleep-deprived that a nap is usually successful. Once people see for themselves, in a "no-risk" situation, that the medications can help them shut off their brains and bodies and fall asleep, they are more willing to try medications at bedtime. About two-thirds of my adult patients take a full dose of their ADHD medication every night to fall asleep.
What if the reverse clinical history is present? One-fourth of people with ADHD either don't have a sleep disturbance or have ordinary difficulty falling asleep. Stimulant-class medications at bedtime are not helpful to them. Dr. Brown recommends Benedryl, 25 to 50 mg, about one hour before bed. Benedryl is an antihistamine sold without prescription and is not habit-forming. The downside is that it is long-acting, and can cause sleepiness for up to 60 hours in some individuals. About 10 percent of those with ADHD experience severe paradoxical agitation with Benedryl and never try it again.
The next step up the treatment ladder is prescription medications. Most clinicians avoid sleeping pills because they are potentially habit-forming. People quickly develop tolerance to them and require ever-increasing doses. So, the next drugs of choice tend to be non-habit-forming, with significant sedation as a side effect. They are:
- Melatonin. This naturally occurring peptide released by the brain in response to the setting of the sun has some function in setting the circadian clock. It is available without prescription at most pharmacies and health food stores. Typically the dosage sizes sold are too large. Almost all of the published research on Melatonin is on doses of 1 mg or less, but the doses available on the shelves are either 3 or 6 mg. Nothing is gained by using doses greater than one milligram. Melatonin may not be effective the first night, so several nights' use may be necessary for effectiveness.
- Periactin. The prescription antihistamine, cyproheptadine (Periactin), works like Benedryl but has the added advantages of suppressing dreams and reversing stimulant-induced appetite suppression. For those with no appetite loss, weight gain may limit Periactin's usefulness.
- Clonidine. Some practitioners recommend in a 0.05 to 0.1 mg dose one hour before bedtime. This medication is used for high blood pressure, and it is the drug of choice for the hyperactivity component of ADHD. It exerts significant sedative effects for about four hours.
- Antidepressant medications, such as trazadone (Desyrel), 50 to 100 mg, or mirtazapine (Remeron), 15 mg, used by some clinicians for their sedative side effects. Due to a complex mechanism of action, lower doses of mirtazapine are more sedative than higher ones. More is not better. Like Benedryl, these medications tend to produce sedation into the next day, and may make getting up the next morning harder than it was.
Problems waking up
Problems in waking and feeling fully alert can be approached in two ways. The simpler is a two-alarm system. The patient sets a first dose of stimulant-class medication and a glass of water by the bedside. An alarm is set to go off one hour before the person actually plans to rise. When the alarm rings, the patient rouses himself enough to take the medication and goes back to sleep. When a second alarm goes off, an hour later, the medication is approaching peak blood level, giving the individual a fighting chance to get out of bed and start his day.
A second approach is more high-tech, based on evidence that difficulty waking in the morning is a circadian rhythm problem. Anecdotal evidence suggests that the use of sunset/sunrise-simulating lights can set the internal clocks of people with Delayed Sleep Phase Syndrome. As an added benefit, many people report that they sharpen their sense of time and time management once their internal clock is set properly. The lights, however, are experimental and expensive (about $400).
Disturbances of sleep in people with ADHD are common, but are almost completely ignored by our current diagnostic system and in ADHD research. These patterns become progressively worse with age. Recognition of sleep disturbance in ADHD has been hampered by the misattribution of the initial insomnia to the effects of stimulant-class medications. We now recognize that sleep difficulties are associated with ADHD itself, and that stimulant-class medications are often the best treatment of sleep problems rather than the cause of them.