Sleep Maintenance

Sleep maintenance insomnia means frequent or prolonged night awakenings despite adequate opportunity. Common drivers include alcohol, which fragments the second half of the night as it metabolises, nocturia, pain, untreated sleep apnea, perimenopausal vasomotor symptoms, and conditioned hyperarousal. Cognitive behavioural therapy for insomnia is first-line and outperforms medication at long-term follow-up. Melatonin's trial evidence is mainly for sleep onset and circadian shifting, not maintenance, which is why it disappoints people who wake at 3am.

1) Keep the bedroom cool at 16-19C, since core temperature fall supports sleep continuity. 2) Cut alcohol, the most common and most reversible cause of second-half awakenings. 3) Follow a consistent wake time seven days a week, which stabilises circadian and homeostatic drive. 4) Use CBT-I techniques including stimulus control and sleep restriction, the first-line evidence-based treatment. 5) Stop caffeine 8-10 hours before bed given its long half-life. 6) Reduce evening fluid to limit nocturia, and get prostate symptoms assessed if relevant. 7) Block light fully and use a white noise source if the environment is disruptive. 8) Screen for sleep apnea, restless legs and perimenopause, which are frequently missed causes.

• •Cool bedroom 16-19C
• •Alcohol elimination
• •Fixed wake time
• •CBT-I and sleep restriction
• •Caffeine cutoff 8-10h
• •Evening fluid management
• •Full darkness