Treatment: Behavioral, Pharmacologic, PAP and Other Devices, Surgical
Behavioral therapy
CBT-I is first-line for chronic insomnia: stimulus control, sleep restriction, cognitive restructuring, relaxation training, and sleep hygiene education. Sleep restriction builds homeostatic pressure by limiting time in bed to actual sleep time, then titrating upward; stimulus control strengthens the bed-sleep association. Behavioral approaches also treat pediatric insomnia and circadian disorders (light and melatonin timing).
Pharmacologic therapy
Choose agents by indication and comorbidity. Hypnotics (benzodiazepines, Z-drugs, dual orexin receptor antagonists) treat insomnia short-term; avoid long-term benzodiazepines in older adults. Melatonin is used for circadian phase shifting and in blind patients with non-24-hour rhythm. Wake-promoting agents (modafinil, armodafinil, solriamfetol, pitolisant) and sodium oxybate treat narcolepsy; sodium oxybate also reduces cataplexy. Dopamine agonists (pramipexole, ropinirole), gabapentinoids, and iron repletion treat RLS. Beware drug interactions and respiratory depression with opioids and sedatives.
PAP and devices
CPAP is first-line for moderate-to-severe OSA and symptomatic mild OSA; adherence determines benefit. BiPAP is used for pressure intolerance or hypoventilation; adaptive servo-ventilation is contraindicated in central sleep apnea with Cheyne-Stokes and EF ≤45%. Oral appliances (mandibular advancement) suit mild-to-moderate OSA or CPAP intolerance. Positional therapy helps supine-predominant OSA.
Surgical options
Adenotonsillectomy is first-line for most pediatric OSA with adenotonsillar hypertrophy. Adult surgeries include uvulopalatopharyngoplasty, maxillomandibular advancement, and hypoglossal nerve stimulation for selected CPAP-intolerant patients. Surgery is generally considered after failed or refused medical therapy.
Traps
Match drug to disease; know contraindications (ASV in HFrEF with CSA); do not offer surgery as first-line in adults.