Persistent non-restorative sleep

Specialty: General.

• wake up tired
• ineffective sleep
• persistent morning fatigue after sleeping
• poor quality sleep

Why it occurs

• Upper airway resistance syndrome or mild sleep hypopneas (which cause frequent microawakenings without the patient being aware of them)
• Restless legs syndrome or periodic movements of the limbs during sleep (which prevent the entry and consolidation of the delta and REM sleep phases)
• Mood disorders such as major depressive disorder or generalized anxiety (which alter sleep neurochemistry by reducing slow wave sleep)
• Fibromyalgia and chronic widespread pain (constant pain disrupts sleep architecture, generating the intrusion of alpha waves in delta sleep)
• Consumption of alcohol, caffeine, nicotine or stimulant/sedative medications (such as benzodiazepines with a long half-life, which alter the proportion of sleep phases).

Initial workup

Complete nocturnal polysomnography with monitoring of limb movements and continuous pulse oximetry, Epworth sleepiness scale, actigraphy for one week, and determination of serum ferritin levels (crucial in restless legs).

Standard management

• Clonazepam — 0.25 to 0.5 mg orally at night if refractory periodic limb movements or restless legs are confirmed, with dependence caution
• Pramipexole — 0.125 mg orally 2 hours before bed, alternative for restless legs
• Regulatory phytotherapy such as Valeriana officinalis (standardized extract of 300 to 600 mg at night to induce mild muscle relaxation).