Sleep Disorders, Insomnia & Restless Legs Syndrome

AANPCB Adult-Gerontology Primary Care Nurse Practitioner A-GNP

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1 Exam Structure, APRN Foundations & Geriatric Assessment

A-GNP Exam Logistics, Blueprint & Scoring Structure APRN Scope of Practice, Consensus Model & Interprofessional Collaboration Comprehensive Health History & Subjective Assessment Across Adult Lifespan Comprehensive Physical Examination & Clinical Assessment Skills

2 Health Assessment, Diagnostic Reasoning & Clinical Procedures

Diagnostic Reasoning, Test Interpretation & Clinical Decision-Making Screening Guidelines & Evidence-Based Health Promotion (USPSTF) Comprehensive Geriatric Assessment (CGA), Frailty & Function In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

3 Cardiovascular & Peripheral Vascular Disorders

Essential Hypertension & Hypertensive Urgency/Emergency Management Coronary Artery Disease, Acute Coronary Syndromes & Post-MI Care Heart Failure (HFrEF & HFpEF) Diagnosis, Staging & 4-Pillar GDMT Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

4 Respiratory, HEENT & Dermatological Disorders

Asthma Management across the Adult Lifespan (GINA Guidelines) Chronic Obstructive Pulmonary Disease (COPD) Staging & Management (GOLD Guidelines) Community-Acquired Pneumonia & Lower Respiratory Tract Infections Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

5 Endocrine, Metabolic & Renal/Genitourinary Disorders

Type 2 Diabetes Mellitus Management Thyroid Disorders: Hypothyroidism, Hyperthyroidism & Subclinical Disease Chronic Kidney Disease (CKD) Staging & Diabetic/Hypertensive Nephropathy Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

6 Gastrointestinal, Hematologic & Immunologic Disorders

Upper Gastrointestinal Disorders: Dyspepsia, GERD, PUD & H. pylori Lower Gastrointestinal Disorders: IBS, IBD, Diverticulitis & Colorectal Screening Liver, Biliary & Pancreatic Disorders: NAFLD/MASLD, Cirrhosis & Cholecystitis Hematologic & Immunologic Disorders: Anemias, Anticoagulation & Immunizations

7 Neurological, Cognitive & Psychiatric Disorders

Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment Neurological Disorders: Stroke, TIA, Parkinson's Disease & Headache Syndromes Major Depressive Disorder & Anxiety Disorders in Adults & Older Adults Sleep Disorders, Insomnia & Restless Legs Syndrome

8 Geriatric Syndromes, Polypharmacy & Deprescribing

The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use Polypharmacy Management, Pharmacokinetics/Pharmacodynamics in Aging & Deprescribing Protocols Fall Risk Assessment (CDC STEADI), Gait/Balance & Mobility Impairments Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

9 APRN Professional Practice, Ethics, Quality & Healthcare Policy

Musculoskeletal Disorders: Osteoarthritis, Osteoporosis, Gout & Back Pain Dermatological Disorders: Lesions, Skin Cancers, Infections & Rash Evaluation Palliative Care, Advance Care Planning, Pain Management & End-of-Life APRN Professional Practice, Quality Improvement, Ethics & Healthcare Policy

Sleep Disorders, Insomnia & Restless Legs Syndrome

Key Takeaways Explain This Topic AI

DSM-5-TR Insomnia Disorder requires sleep difficulty occurring at least 3 nights per week for at least 3 months causing daytime impairment.

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the universally recommended first-line, gold-standard treatment for chronic insomnia.

Beers Criteria 2023 strictly advises avoiding benzodiazepines and Z-drugs (Zolpidem) in older adults due to severe risks of falls, fractures, delirium, and parasomnias.

STOP-BANG questionnaire screens for Obstructive Sleep Apnea (OSA), requiring definitive diagnosis via Polysomnography (AHI Measurement).

Restless Legs Syndrome (RLS) requires mandatory serum ferritin checking (supplementing iron with Vitamin C if < 50 mcg/L) and Alpha-2-delta ligands (Gabapentin) as first-line pharmacotherapy.

Last updated: July 2026

Sleep Disorders, Insomnia & Restless Legs Syndrome in Clinical Practice

Sleep architecture undergoes substantial changes across the adult lifespan, with older adults experiencing reductions in slow-wave (N3) and REM sleep, increased nocturnal awakenings, and an advanced sleep phase ("early to bed, early to rise"). However, persistent insomnia, excessive daytime sleepiness, nocturnal gasping, or involuntary leg sensations represent pathological conditions rather than normal aging. The advanced practice registered nurse (APRN) must apply evidence-based diagnostic criteria, execute non-pharmacological interventions, adhere to strict sedative prescribing warnings (Beers Criteria 2023), conduct Obstructive Sleep Apnea (OSA) screening, and perform mandatory laboratory workups for Restless Legs Syndrome (RLS).

Insomnia Disorder: Diagnostic Criteria and Evaluation

According to the DSM-5-TR, Insomnia Disorder is defined as a predominant dissatisfaction with sleep quantity or quality associated with one or more sleep disruption patterns:

Difficulty initiating sleep (sleep onset insomnia).

Difficulty maintaining sleep characterized by frequent awakenings (sleep maintenance insomnia).

Early-morning awakening with inability to return to sleep (late insomnia).

Diagnostic Thresholds

To meet criteria for Insomnia Disorder, the sleep disturbance must:

Cause clinically significant distress or impairment in social, occupational, or daytime functioning.

Occur at least 3 nights per week .

Be present for a minimum duration of 3 months .

Occur despite adequate opportunity for sleep.

Assessment Protocol

Clinicians should obtain a 2-week sleep diary logging bedtime, sleep latency, night awakenings, wake time, total sleep time, daytime naps, caffeine/alcohol intake, and medication timing. Secondary causes must be systematically evaluated and optimized, including GERD, nocturnal angina, heart failure, COPD, chronic pain, nocturia secondary to BPH, major depression, and offending medications (e.g., systemic corticosteroids, beta-blockers, SSRIs, decongestants, or late-day diuretics).

Non-Pharmacological Management: CBT-I and Sleep Hygiene

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line, gold-standard treatment for chronic insomnia disorder, demonstrating superior long-term efficacy compared to hypnotic pharmacotherapy.

Core Components of CBT-I

Stimulus Control Therapy: Re-establishes the association between bed and sleep:

Go to bed only when feeling sleepy.

Use the bed and bedroom only for sleep and sexual intimacy (no reading, TV, work, or smartphone use in bed).

If unable to fall asleep or return to sleep within 15 to 20 minutes , get out of bed, move to another dimly lit room, engage in a quiet activity (reading a physical book), and return to bed only when sleepy.

Maintain a fixed wake-up time every morning 7 days a week.

Avoid daytime naps (or limit to < 30 minutes before 3:00 PM).

Sleep Restriction Therapy: Restricts time in bed to equal reported total sleep time (minimum baseline 5 hours), consolidating sleep drive. As sleep efficiency (Total Sleep Time / Time in Bed x 100%) exceeds 85%, time in bed is increased by 15 to 30 minutes.

Cognitive Restructuring: Addresses catastrophic beliefs regarding sleep loss.

Sleep Hygiene Education: Maintain a cool (65–68°F), dark, quiet bedroom; avoid heavy meals within 2–3 hours of bedtime; avoid alcohol near bedtime (causes REM suppression and sleep fragmentation); discontinue caffeine at least 6 hours prior to bedtime; avoid screen exposure 1–2 hours before bed.

Pharmacotherapy and Beers Criteria 2023 Warnings
High-Risk Sedatives in Older Adults

The American Geriatrics Society Beers Criteria 2023 warns against traditional hypnotics in older adults (aged >= 65):

Benzodiazepines (Temazepam, Triazolam, Diazepam, Lorazepam): Associated with double the risk of motor vehicle accidents, falls, hip fractures, cognitive impairment, delirium, dependence, and withdrawal.

Non-Benzodiazepine Receptor Agonists ("Z-drugs": Zolpidem, Eszopiclone, Zaleplon): Carry comparable severe risks of falls, fractures, delirium, and dangerous complex sleep behaviors (sleep-walking, sleep-driving while not fully awake). Avoid in older adults.

Over-the-Counter Antihistamines (Diphenhydramine, Doxylamine): Highly anticholinergic; cause acute confusion, delirium, urinary retention, dry mouth, constipation, blurred vision, and fall risk. Avoid in older adults.

Safer Pharmacological Alternatives (When CBT-I is Insufficient)

Ramelteon (Rozerem): Selective melatonin MT1 and MT2 receptor agonist. Non-controlled, carries no GABA activity or fall risk. Safe in older adults for sleep-onset insomnia.

Low-Dose Doxepin (Silenor 3 mg or 6 mg): At low doses (3–6 mg), doxepin acts purely as a selective histamine H1 receptor antagonist without significant anticholinergic activity. Indicated for sleep maintenance insomnia in older adults.

Dual Orexin Receptor Antagonists (DORAs: Suvorexant, Lemborexant): Block wake-promoting orexin neuropeptides. Effective for onset and maintenance insomnia.

Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea (OSA) involves recurrent collapse of the pharyngeal airway during sleep, causing apneas (airflow cessation >= 10 seconds), hypopneas, nocturnal hypoxemia, sympathetic surges, and sleep fragmentation. Uncontrolled OSA is a risk factor for resistant hypertension, atrial fibrillation, stroke, nocturnal MI, and vascular dementia.

Screening with the STOP-BANG Questionnaire
S noring (loud)
T ired (daytime fatigue/sleepiness)
O bserved apneas/gasping
P ressure (Hypertension)
B MI > 35 kg/m2
A ge > 50 years
N eck Circumference > 16 inches (females) or > 17 inches (males)
G ender male

Interpretation: Scores 0–2 = Low risk; 3–4 = Intermediate risk; 5–8 = High risk for moderate-to-severe OSA.

Diagnosis and Management

Polysomnography (PSG): In-lab or home sleep apnea test (HSAT) is mandatory. Measured by Apnea-Hypopnea Index (AHI): Normal < 5, Mild 5–14, Moderate 15–29, Severe >= 30 events/hour.

Treatment: Continuous Positive Airway Pressure (CPAP) is gold-standard therapy. Monitor adherence (minimum 4 hours/night on 70% of nights), counsel on weight loss, avoid sedatives/alcohol, and consider oral appliances.

Restless Legs Syndrome (RLS) / Willis-Ekbom Disease

RLS is a sensorimotor disorder characterized by an irresistible urge to move the legs, accompanied by uncomfortable paresthesias ("crawling", "pulling"). Symptoms follow the URGE criteria:

U rge to move legs with uncomfortable limb sensations.

R est or inactivity triggers or worsens symptoms.

G etting up or moving (walking, stretching) provides relief.

E vening or night onset or peak worsening.

Mandatory Iron Workup Protocol

Central nervous system iron deficiency in the substantia nigra impairs dopaminergic signaling. Serum Ferritin and TIBC must be checked in all RLS patients.

Iron Threshold: If serum ferritin is < 50 mcg/L (or transferrin saturation < 20%), oral iron supplementation ( Ferrous Sulfate 325 mg with Vitamin C 500 mg ) is first-line therapy . Target ferritin level is > 75 to 100 mcg/L.

Pharmacotherapy Guidelines

First-Line Pharmacotherapy: Alpha-2-Delta Calcium Channel Ligands ( Gabapentin enacarbil 600 mg daily, Gabapentin 300–900 mg before bedtime, or Pregabalin 75–150 mg). Highly effective, non-dopaminergic, and avoids augmentation.

Dopamine Agonists Warning (Pramipexole, Ropinirole): Now second-line due to Augmentation —a progressive paradoxical worsening of RLS where symptoms appear earlier in the day, spread to arms, and become more intense. If augmentation occurs, dopamine agonists must be slowly tapered off.