Discover how integrative chiropractic care for insomnia can help improve your sleep quality and overall wellness.

Abstract: An Evidence-Based, Integrative Framework for Overcoming Insomnia

In this educational post, I share a comprehensive, first-person exploration of modern, evidence-based insomnia care grounded in a collaborative, multidisciplinary practice. As Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, I present current research findings and practical strategies that combine integrative chiropractic, functional medicine, rehabilitative therapies, and clinical psychopharmacology. Central to our approach is our team-based model at Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, where Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine) (NPI #1164426749, Texas MD License #J2933) serves as our Medical Director and Collaborative Physician, providing essential medical oversight to ensure safety, precision, and continuity of care.

We will navigate the intricate neurophysiology of sleep, including the roles of the circadian rhythm, sleep-wake homeostasis, and key neurochemicals like adenosine, melatonin, histamine, and orexin. I will break down the essential stages of Non-REM and REM sleep, highlighting their critical functions in memory consolidation, emotional regulation, and the brain’s waste clearance via the glymphatic system. The discussion will underscore the significant risks associated with untreated insomnia, from psychiatric disorders to neurodegenerative diseases.

I will then transition into a holistic and individualized assessment framework, followed by a detailed comparison of evidence-based treatments. This includes an in-depth analysis of Cognitive Behavioral Therapy for Insomnia (CBTi) as the first-line approach and a thorough review of various hypnotic medications, explaining their mechanisms of action, benefits, and drawbacks. Finally, I will integrate these concepts into the context of our multidisciplinary practice, demonstrating how integrative chiropractic care, functional medicine, and medical oversight work synergistically to restore natural sleep patterns and promote long-term well-being. I also detail how we manage insomnia across diverse patient profiles, including those with addiction histories and older adults with cognitive impairments, using noncontrolled hypnotics like doxepin and ramelteon, dual orexin receptor antagonists, targeted sleep hygiene interventions, and referrals for sleep medicine when appropriate.

Introduction: My Approach to Insomnia Within an Evidence-Based, Integrative Framework

Hello and welcome. I am Dr. Alex Jimenez, and on behalf of our entire team at Injury Medical Clinic PA, I am delighted to share this educational journey into a topic that affects millions of people yet often goes unaddressed: insomnia. As a Doctor of Chiropractic (DC) with extensive certifications in Functional Medicine (CFMP, IFMCP), Advanced Technology Neurology (ATN), and Cellular Communication Science Technology (CCST), and as an Advanced Practice Registered Nurse and Board-Certified Family Nurse Practitioner (APRN, FNP-BC), my career has been dedicated to understanding the intricate web of connections between the body’s systems. My passion lies in unraveling the root causes of chronic conditions to restore health and vitality. When patients come to me for help with insomnia, I recognize that sleep disturbance is rarely a single-variable problem. It is frequently a complex convergence of physiological dysregulation, lifestyle factors, pain, psychological stress, medication effects, and—often overlooked—autonomic imbalance.

At our clinic in El Paso, Texas, we pride ourselves on a unique, integrative model of care. This approach is built on a strong collaborative foundation, most notably with our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a Board-Certified Internist with an incredible four decades of experience. Her expertise in internal medicine provides the essential medical oversight that allows us to offer a truly comprehensive, multidisciplinary scope of services. This multidisciplinary setup is common and essential in integrative or injury care clinics, where an MD provides medical direction alongside a chiropractor to ensure alignment on safety and therapeutic goals.

Together, Dr. Cardenas and I lead a dedicated team that blends integrative chiropractic care, medical management, functional medicine, personal injury rehabilitation, and advanced therapeutic modalities. This synergy ensures that our patients receive a holistic, personalized treatment plan that addresses not just their symptoms but the underlying physiological imbalances driving their health concerns. Our multidisciplinary model integrates:

• Chiropractic care for mechanical, nociceptive, and autonomic contributors to insomnia
• Internal medicine oversight for diagnostics, cardiometabolic risk management, and medication safety
• Functional medicine to identify and address root-cause physiology (inflammation, nutrient status, hormones, gut-brain axis)
• Rehabilitation and movement medicine to improve sleep through physical function and pain modulation
• Behavioral medicine and CBT-I to optimize sleep behaviors and cognitive patterns
• Sleep medicine referrals when sleep apnea, restless legs, or refractory insomnia is suspected

Today, we will explore the profound impact of sleep on our mental and physical well-being. We will not merely be discussing sleep aids; instead, we will be diving deep into the latest scientific findings from leading researchers in sleep medicine. I will be presenting their groundbreaking work through the lens of modern, evidence-based research, explaining the complex neurophysiology of sleep and the devastating consequences of its absence. We will dissect the mechanisms of action, advantages, and drawbacks of various treatment approaches, both pharmacological and non-pharmacological.

Crucially, I will connect these concepts back to our integrative care model. You will learn how chiropractic adjustments, functional medicine protocols, and targeted lifestyle interventions can fundamentally influence the body’s sleep-wake cycles. We will explore how correcting structural misalignments in the spine can enhance nervous system function, how addressing nutritional deficiencies and hormonal imbalances can rebalance sleep biochemistry, and how our collaborative approach with Dr. Cardenas ensures that every aspect of your health is considered in your journey toward restful, restorative sleep. This post is designed to be an in-depth, easy-to-understand guide, taking you from the basics of sleep science to the forefront of clinical practice. Let’s begin.

The Pervasive and Chronic Nature of Insomnia

As a clinician, I see the downstream effects of poor sleep every single day in my practice. Insomnia, the persistent difficulty with sleep initiation, duration, consolidation, or quality, is a remarkably common condition. Yet, it remains one of the most under-recognized and undertreated health issues in modern society. The statistics are truly staggering. Research from leading institutions has consistently shown that anywhere from 20% to 50% of all patients visiting their primary care provider have chronic insomnia (Bollu & Kaur, 2019). This isn’t a fleeting issue for them; it’s a long-term battle that degrades their quality of life.

Unfortunately, this problem is escalating. Over the past few decades, the prevalence of insomnia has been on a concerning upward trend, a phenomenon many experts, including myself, link directly to our modern lifestyle. We live in a world saturated with artificial light and digital screens. Our days are filled with relentless stimulation from smartphones, tablets, computers, and televisions, all of which emit a significant amount of blue light. As we will explore in detail, this constant exposure profoundly disrupts the body’s natural sleep-promoting mechanisms, effectively suppressing our ability to fall and stay asleep.

What is particularly troubling from a clinical standpoint is the communication gap. Despite how widespread this issue is, a shockingly small number of patients actually bring it up with their healthcare providers. Studies reveal that only about a quarter to a half of patients ever disclose their struggles with insomnia to their primary care physician (PCP). Compounding this, a significant number of providers may not be proactively screening for it. In one survey, nearly three out of four patients reported that their PCP did not ask about their sleep during their most recent visit (Grandner, 2022). This represents a massive missed opportunity for intervention.

It is also vital to understand that insomnia is not a monolithic condition. It manifests differently from person to person, influenced by a unique combination of genetic, environmental, and psychological factors. Similarly, the amount of sleep an individual needs is not a one-size-fits-all prescription. It varies considerably, most notably with age.

Understanding Individual Sleep Needs Across the Lifespan

The recommendation for sleep duration changes as we mature and our brains and bodies develop. When I work with families, I emphasize the importance of age-appropriate sleep targets:

• School-Aged Children and Adolescents: For this group, we typically recommend a goal of nine to ten hours of sleep per night. This is a critical period of cognitive development, and adequate sleep is non-negotiable for learning, memory, and emotional regulation.
• Adults: For most adults, the sweet spot for restful, restorative sleep lies somewhere between seven and nine hours. This range allows for the completion of multiple full sleep cycles, which are essential for physiological repair and mental health.

Falling short of these targets, especially chronically, sets the stage for a cascade of health problems. Recognizing who is most vulnerable is the first step in effective prevention and treatment.

Identifying the Key Risk Factors for Insomnia

Through decades of research, the scientific community has identified several key demographics and conditions that place individuals at a higher risk for developing insomnia. In our integrative practice, we maintain a high index of suspicion for these factors during our initial patient assessments.

• Older Age: This is perhaps one of the most significant risk factors. As we age, our sleep architecture naturally changes. We tend to experience less deep sleep and more frequent awakenings. This physiological shift, combined with a higher prevalence of chronic medical conditions and medication use, makes older adults particularly susceptible to insomnia.
• Female Gender: Studies consistently show that women are more likely to experience insomnia than men (Sateia & Buysse, 2010). This vulnerability is especially pronounced during periods of hormonal fluctuation, such as the peri- and postmenopausal stages, when changes in estrogen and progesterone can severely disrupt sleep.
• Veterans and Active-Duty Military Personnel: This population carries a heavy burden of risk. The unique stressors of military service, including combat exposure, irregular schedules, and a higher incidence of traumatic brain injuries (TBI) and post-traumatic stress disorder (PTSD), contribute to a significantly elevated rate of chronic insomnia.
• Lower Socioeconomic Status and Homelessness: The instability, stress, and unsafe environments associated with poverty and homelessness create formidable barriers to restful sleep. These individuals often lack a quiet, secure place to rest and are grappling with constant worry, making sleep a luxury they can’t afford.
• Poor Overall Health and Multiple Comorbidities: The presence of chronic diseases—such as chronic pain, cardiovascular disease, diabetes, or respiratory conditions—is strongly linked to insomnia. Pain, breathing difficulties, or the need to urinate frequently can fragment sleep. From a functional medicine perspective, the underlying inflammation associated with these conditions also disrupts sleep-regulating neurotransmitters.
• Mental Illness: The relationship between mental health and sleep is bidirectional and deeply intertwined. Conditions like anxiety, depression, Attention-Deficit/Hyperactivity Disorder (ADHD), and bipolar disorder almost universally involve sleep disturbances. Insomnia is not just a symptom; it can also trigger or worsen these conditions, creating a vicious cycle.
• History of Traumatic Brain Injury (TBI): A TBI, particularly multiple TBIs, can cause lasting damage to the brain regions and neurochemical pathways that regulate sleep. We see this frequently in our personal injury patients, where post-concussive syndrome often includes severe, persistent insomnia.
• Alcohol Use Disorder: Many people mistakenly believe that alcohol is a sleep aid. While it can induce initial drowsiness, alcohol severely disrupts sleep architecture later in the night, particularly suppressing REM sleep. Chronic heavy alcohol use can cause long-lasting and sometimes permanent damage to the brain’s sleep-regulating systems, even long after a person has achieved sobriety.

Understanding these risk factors allows us, as clinicians, to be more proactive in our screening and to tailor our interventions to the specific needs of each patient.

The Intricate Neurophysiology of Sleep: The Brain’s Master Clock and Chemical Balancers

The process of falling asleep and waking up feels simple, but it is orchestrated by an incredibly complex and still somewhat mysterious interplay of brain structures, hormones, and neurotransmitters. Unraveling this neurophysiology is key to understanding both the causes of insomnia and the mechanisms of our treatments. Two fundamental processes govern our sleep: the circadian rhythm and sleep-wake homeostasis. I teach patients—and our team—to view insomnia through the lens of these biological drivers that we can measure and modify.

The Circadian Rhythm: Our 24-Hour Internal Clock

Most of us are familiar with the concept of the circadian rhythm, the brain’s innate 24-hour internal clock that governs cycles of sleepiness and alertness. This is known as Process C. Governed by the suprachiasmatic nucleus (SCN) in the hypothalamus, circadian timing aligns with light-dark exposure, melatonin secretion, and peripheral clocks in our organs (Buijs & Kalsbeek, 2001; Czeisler et al., 1999). The command center for this rhythm is a tiny, yet powerful, cluster of neurons located in the hypothalamus called the suprachiasmatic nuclei (SCN). Think of the SCN as the master clock or the sleep pacemaker of our brain (Moore, 2013).

The SCN is exquisitely sensitive to light. When light, particularly blue light, enters our eyes, specialized cells in the retina send signals directly to the SCN. In response to light, the SCN orchestrates a cascade of hormonal and neuronal signals throughout the body to promote wakefulness. As light fades in the evening, the SCN signals the pineal gland to begin producing melatonin, the “hormone of darkness,” which promotes sleepiness. This is a beautifully evolved system designed to synchronize our internal biology with the external 24-hour day-night cycle.

In my practice, particularly from a functional medicine and chiropractic standpoint, I emphasize how modern life sabotages this system. The constant exposure to bright artificial lights and screens late at night sends a confusing signal to the SCN, essentially telling our brain it’s still daytime. This suppresses melatonin production and delays the onset of sleep, directly contributing to difficulty falling asleep. Chiropractic adjustments can help optimize the nervous system, which relays these crucial signals between the eyes, the SCN, and the rest of the body. A well-functioning nervous system is better equipped to maintain a robust and resilient circadian rhythm.

Sleep-Wake Homeostasis: The Drive to Sleep

The second critical process is sleep-wake homeostasis, or Process S, which can be thought of as a biological balancing act between our need for sleep and our drive for wakefulness. The principle is simple: the longer you are awake, the greater your body’s pressure, or drive, to sleep becomes. This mounting pressure is known as the homeostatic sleep drive.

Several key neurochemicals are involved in this homeostatic process, but one of the most important is adenosine. Adenosine is a byproduct of cellular energy consumption in the brain. As our neurons fire throughout the day, using up energy, adenosine levels steadily accumulate in the brain and promote sleep pressure; adequate sleep clears adenosine (Porkka-Heiskanen et al., 2000). Adenosine acts as an inhibitory neurotransmitter, meaning it slows down neuronal activity. Specifically, it inhibits wakefulness-promoting neurons in key arousal centers of the brain (Basheer, Strecker, & McCarley, 2004). At the same time, it helps stimulate sleep-promoting neurons and promotes the relaxation of blood vessels, which increases blood flow and helps prepare the brain for sleep.

This is where caffeine comes into the picture. Caffeine is a potent adenosine receptor antagonist. It works by binding to the same receptors that adenosine would normally bind to, effectively blocking adenosinadenosine’sromoting signal. This is why caffeine makes us feel alert and awake—it’s not providing energy, but rather masking the brain’s fatigue.

Another crucial player is melatonin, the hormone we mentioned earlier. Produced by the pineal gland under the direction of the SCN, melatonin doesn’t put you to sleep in the way a sedative does. Instead, it acts as a “gate-opener” for sleep, signaling to the body that it’s nighttime and time to wind down. Melatonin shapes circadian phase and sleep onset; prescription melatonin-receptor agonists like ramelteon target MT1/MT2 receptors and are useful in sleep-onset insomnia with minimal abuse potential (Zammit et al., 2007).

Furthermore, our brain’s reserves are intimately linked to our sleep drive. During wakefulness, our brain cells, particularly supportive cells called astrocytes, deplete their stores of glycogen, which is a primary source of cellular energy. Sleep is the critical period when these glycogen stores are replenished. Without adequate sleep, the brain essentially runs on an energy deficit, which impairs cognitive function, mood, and overall cellular health.

The Wakefulness-Promoting Neurotransmitters

Just as there are chemicals that promote sleep, there are also powerful neurotransmitters that drive wakefulness and arousal. Among the most important are histamine and orexin (also known as hypocretin).

• Histamine, which many people associate with allergic reactions, plays a crucial role in the brain as a powerful wakefulness-promoting agent. Neurons that produce histamine are located in the hypothalamus and project widely throughout the brain, stimulating alertness and arousal. This is why older, first-generation antihistamines (like diphenhydramine, the active ingredient in Benadryl) cause significant drowsiness—they cross the blood-brain barrier and block these histamine receptors in the brain.
• Orexin is another key neuropeptide produced in the hypothalamus. It is considered a master regulator of the wakeful state, strongly exciting and stabilizing the activity of other wakefulness-promoting systems (Sakurai, 2007). Orexin peptides (hypocretin-1, -2) stabilize wakefulness; dysregulated orexin contributes to hyperarousal. The loss of orexin-producing neurons is the underlying cause of narcolepsy, a condition characterized by overwhelming daytime sleepiness and a sudden loss of muscle tone.

The mechanisms of action of several modern hypnotic medications, which we will discuss later, are designed to specifically target these wakefulness-promoting systems, either by blocking histamine or by antagonizing orexin receptors. For example, Dual Orexin Receptor Antagonists (DORAs) modulate this system to promote sleep without deep sedation (Herring et al., 2016; Saper et al., 2010).

The disruptive effect of blue light from our digital devices cannot be overstated. It directly interferes with both the circadian rhythm (by suppressing melatonin) and sleep-wake homeostasis. By keeping our brains in a state of hyper-arousal late at night, blue light disrupts the delicate balance of these neurochemicals, making the transition to sleep incredibly difficult. This is why a core component of my patient education focuses on “sleep hygiene,” particularly minimizing screen time in the hours leading up to bedtime.

Navigating the Stages of Sleep: A Journey Through the Night

Our sleep is not a static state of unconsciousness. Instead, it is a dynamic and highly structured journey that follows a predictable pattern of distinct stages. We cycle through these stages multiple times throughout the night, with each cycle serving unique and vital functions for our brain and body. A full sleep cycle typically lasts around 90 minutes, and most people experience four to six of these cycles in a healthy night of sleep.

The stages are broadly categorized into two types: Non-REM (NREM) sleep and REM (Rapid Eye Movement) sleep.

The Non-REM Sleep Stages: Building and Repairing

The first three stages of sleep are characterized as Non-REM sleep. This is the period of quiet rest, where the body focuses on physical restoration and repair.

• Stage 1 (N1): The Lightest Stage of Sleep

• • This is the transitional phase between wakefulness and sleep. It’s the lightest stage of sleep, where the body hasn’t yet relaxed. During this stage, brain waves begin to slow down from their daytime patterns, and people are often very easily awakened. You might experience muscle twitches or the sensation of falling. This stage is very brief, typically lasting for less than ten minutes.

• Stage 2 (N2): The Gateway to Deeper Sleep

• • As we drift into Stage 2, our body and brain activity continue to slow down. We see a notable increase in parasympathetic nervous system activity—the “rest and digest” system. Our muscles relax further, our body temperature drops, and both our heart rate and respiratory rate slow down. The brain activity is characterized by unique waveforms called sleep spindles and K-complexes, which are thought to help protect sleep by suppressing responses to external stimuli. This stage is significantly longer, lasting for about 30 to 60 minutes per cycle. We spend the majority of our total sleep time in Stage 2.

• Stage 3 (N3): Deep, Restorative Sleep

• • This is the deepest and most restorative phase of sleep, often referred to as “slow-wave sleep” because it is dominated by very slow, high-amplitude delta brain waves. During this stage, our heart rate, respiratory rate, and brain activity reach their lowest points of the night. People in Stage 3 are very difficult to awaken, and if they are, they often feel groggy and disoriented. This is the critical period for physical recovery. It’s when the body releases growth hormone, which facilitates tissue repair and muscle growth. It’s also the brain’s clearance system, the glymphatic system, that is most active. This crucial stage typically lasts for 20 to 40 minutes per cycle and is more prominent in the first half of the night.

Stage 4 (REM Sleep): The Mind’s WMind’sp

Following the NREM stages, we transition into the fourth stage, known as Rapid Eye Movement (REM) sleep. This stage is paradoxically a period of intense brain activity, yet profound physical paralysis.

• The Dreaming Stage: This is the stage where the majority of our vivid, narrative-based dreaming occurs.
• Physiological Arousal: Surprisingly, during REM sleep, we see a significant increase in heart rate and respiratory rate, sometimes to levels similar to when we’re awake. The brain’s electrical activity also becomes highly active, resembling the patterns seen during wakefulness. This is why REM is sometimes called “paradoxical sleep.”
• Muscle Atonia: While the mind is racing, the body is effectively paralyzed. A state of general atonia, or a temporary loss of muscle tone, prevents us from acting out our dreams. This is a protective mechanism. In certain sleep disorders, like REM Sleep Behavior Disorder, this paralysis fails, and individuals can physically enact their dreams, which can be dangerous.
• Essential for Brain Health: REM sleep is absolutely critical for our cognitive and emotional well-being. Two key processes occur during this phase:

1. 1. Memory Consolidation: This is our brain’s way of taking newly acquired information and experiences from the day and converting them into stable, long-term memories (Rasch & Born, 2013). REM sleep appears to be particularly important for consolidating procedural memories (learning a new skill) and spatial memories.
   2. Emotional Processing: REM sleep is essential for our ability to recognize, understand, and respond to our own emotions and the emotions of others. It helps us process the emotional content of our experiences, effectively “resetting” our emotional circuits. By engaging various neural networks, REM sleep helps to strip the emotional charge from stressful memories, allowing us to learn from them without being perpetually traumatized. Inadequate REM sleep is strongly linked to mood dysregulation and increased emotional reactivity.

This stage lasts anywhere from 10 to 60 minutes, and the duration of REM periods tends to increase with each successive sleep cycle throughout the night. This means that most of our REM sleep occurs in the early morning hours. This is why waking up too early can disproportionately rob us of this crucial stage of sleep.

The Brain on Sleep: Neuroplasticity and Waste Clearance

Recent breakthroughs in neuroscience have illuminated just how vital sleep is for maintaining the brain’s health and function. Two concepts, in particular, have revolutionized our understanding: neuroplasticity and the glymphatic system.

Sleep’s Sleep’s Neuroplasticity and Synaptogenesis

Neuroplasticity is the brain’s ability to reorganize itself by forming new neural connections throughout life. It allows neurons (nerve cells) to adjust their activities and connections in response to new information, sensory stimulation, development, or damage. Sleep is a prime time for these processes to occur.

During sleep, the brain is not simply “off.” It is actively working to allow neurons to rest, regenerate, and repair themselves from the metabolic stress of daytime activity. More than that, sleep promotes the creation of new synaptic connections, a process known as synaptogenesis. These new connections are the physical basis of learning and memory. When we learn something new, sleep helps to strengthen the relevant neural pathways, making that knowledge more permanent. Conversely, it also helps to prune away irrelevant or weak connections, which is an important process for maintaining an efficient and uncluttered neural network (Tononi & Cirelli, 2014).

From an integrative perspective, we can support this process through various modalities. Chiropractic adjustments, for instance, reduce physical stress on the nervous system by correcting spinal misalignments. This reduction in “neural noise” can create a more favorable internal environment for these restorative neuroplastic processes to occur during sleep. Functional medicine interventions, such as providing the brain with essential nutrients like omega-3 fatty acids, B vitamins, and antioxidants, supply the raw materials needed for neuronal repair and the formation of new synapses.

The Glymphatic System: The Brain’s Brain’s Cleanup Crew

One of the most exciting discoveries in modern neuroscience is the glymphatic system. This is a recently identified macroscopic waste-clearance system that uses a unique network of glial cells and perivascular pathways (the spaces surrounding blood vessels) to flush metabolic waste products out of the brain (Jessen et al., 2015).

Think of it as the brain’s lymphatic system. As our brain cells work hard, they produce metabolic byproducts. If these waste products were allowed to accumulate, they would become toxic to neurons. The glymphatic system is the mechanism by which the brain cleans house.

Crucially, research has shown that this system is predominantly active during sleep, particularly during deep, slow-wave sleep (Stage N3). During this stage, the space between brain cells actually expands, allowing cerebrospinal fluid to flow more freely through the brain tissue, collecting waste products and flushing them out.

This has profound implications for neurodegenerative diseases. Many of these devastating conditions are characterized by the excessive accumulation of specific toxic proteins in the brain. The glymphatic system is responsible for clearing these very proteins:

• Beta-amyloid plaques: The hallmark of Alzheimer’s disease.
• Tau: Alzheimer’s is also implicated in Alzheimer’s and other “tau ” diseases
• Alpha-synuclein proteins: The key protein aggregates found in Parkinson’s disease and dementia.

This research provides a powerful mechanistic link between chronic poor sleep and an increased risk for developing these neurodegenerative disorders later in life. When we consistently fail to get enough deep sleep, we are essentially impeding our brain’s ability to perform its nightly cleanup. Over years and decades, this can lead to a dangerous buildup of toxic proteins, setting the stage for cognitive decline.

This is why, at our clinic, we view the treatment of insomnia not just as a quality-of-life issue, but as a critical strategy for long-term brain health and disease prevention. Every intervention we employ—from chiropractic care to enhance nervous system function to nutritional support for brain health to behavioral strategies for improving sleep quality—aims to restore the body’s natural ability to achieve deep sleep and activate this vital glymphatic clearance system.

The Far-Reaching Consequences of Untreated Insomnia

The impact of chronic insomnia extends far beyond simply feeling tired the next day. It is a systemic issue that increases the risk and exacerbates the symptoms of a wide range of physical and psychiatric conditions. The ripple effects of sleep deprivation can touch every aspect of a patient’s life. Clinicians frequently encounter patients who report feeling “tired,” “sluggish,” or fatigued. While these are common complaints, they often signal a deeper, more significant underlying issue: chronic insomnia. It is critical to understand that insomnia is not merely a lifestyle inconvenience; it is a clinical condition with debilitating effects that ripple through every aspect of a person’s life.

Cognitive person’sr Function Decline

From a functional perspective, the most immediate and noticeable consequences of sleep deprivation are on our patients’ cognitive and motor function. When the brain doesn’t get the restorative needs it needs, its capacity to function optimally plummets. This is not just a subjective feeling of being “off”; it is a measurable decline in neurological performance.

• Impaired Social and Occupational Function: Research has consistently shown that individuals who have insomnia have a higher risk of missing classes at school or days at work (Sivertsen et al., 2009). The fatigue and cognitive fog make it difficult to meet daily responsibilities. Furthermore, this struggle can lead to social withdrawal. Rates of loneliness and social isolation are significantly increased in the sleep-deprived population, as the energy required for social engagement is not there. This creates a vicious cycle, as isolation itself can worsen mood and, in turn, sleep.
• Deterioration of Cognitive Performance: The impact on cognitive function is profound and multifaceted. We observe significant declines in several key areas:

• • Alertness: The ability to remain attentive and responsive to the environment is severely compromised.
  • Learning and Memory: Sleep is crucial for memory consolidation. With insomnia, patients experience marked difficulties with learning new information and recalling it later, particularly affecting short-term and working memory.
  • Processing Speed: The speed at which the brain can process information slows down considerably.
  • Executive Function: This high-level cognitive suite responsible for planning, decision-making, and self-regulation declines, making it difficult to organize the day and make sound judgments (Killgore, 2010).

• Impaired Motor Function: Sleep deprivation leads to slowed reaction times and reduced coordination. This translates into a very real and dangerous increase in the risk for work-related injuries and motor vehicle accidents (Garbarino et al., 2021). The danger is comparable to that of driving under the influence of alcohol.

The Intricate Link Between Sleep, Immunity, and Inflammation

More recently, research has illuminated the complex, bidirectional relationship between sleep and the immune system. We now understand that poor sleep quality is not just a consequence of being sick; it is a direct cause of immune dysfunction.

• Neuroinflammation and Immune Compromise: Poor sleep has been associated with central neuroinflammation. At the same time, it compromises the peripheral immune system.

• • Increased Inflammatory Markers: Sleep-deprived individuals have elevated levels of pro-inflammatory cytokines (like IL-6, TNF-?) and C-reactive protein (CRP) (Irwin, 2015). This chronic, low-grade inflammation is a known driver of many chronic diseases.
  • Leukocyte Dysfunction: We see a decrease in leukocyte counts and functional capacity (white blood cells).
  • Reduced Vaccine Efficacy: Sleep deprivation can lead to reduced antibody titers from vaccinations, meaning the body may not mount a robust protective response (Lange et al., 2003).

Metabolic, Hormonal, and Systemic Dysregulation

The damage from insomnia extends deep into our body’s fundamental regulatorybody’sms.

• Metabolic and Hormonal Imbalance:

• • Impaired Glucose and Lipid Metabolism: Sleep deprivation induces a state of insulin resistance, increasing the risk of developing type 2 diabetes. It also alters lipid metabolism, contributing to high cholesterol.
  • Maladaptive Hormonal Signaling: Levels of ghrelin (the “hunger hormone”) increase, while levels of leptin (the “satiety hormone”) decrease, driving cravings for high-calorie foods and contributing to weight gain and obesity.

• Gut Microbiome Disruption: Sleep loss dysregulates the gut microbiome, altering the balance of beneficial bacteria and leading to increased gut permeability (“leaky gut”) and systemic inflammation (Smith et al., 2019).
• Impaired Energy and Tissue Recovery: Sleep is when the body stores energy and performs crucial tissue repairs. Insomnia impairs these processes, leading to a state of chronic cellular stress.

Increased Morbidity and Mortality: The Long-Term Consequences

The cumulative effect of this systemic dysfunction is a dramatic increase in the risk for serious chronic diseases and, ultimately, premature death. We see a bidirectional relationship with numerous common comorbidities; not only does insomnia increase the risk of these conditions, but these conditions also worsen insomnia.

• Cardiovascular and Cerebrovascular Disease: Chronic insomnia is a significant independent risk factor for hypertension, heart attacks, and strokes (Javaheri & Redline, 2017).
• Kidney Disease: The link between poor sleep and chronic kidney disease is becoming increasingly clear.
• Sleep Issues: Several studies have linked chronic sleep disruption to an increased risk for numerous types of sleep issues.
• Diabetes: As mentioned, the impairment of glucose metabolism directly increases the risk of developing type 2 diabetes.
• Dementia and Alzheimer’s Disease: This is Alzheimer’smost concerning link. High-quality studies have shown that patients with insomnia have an over fifty percent increased risk for Alzheimer’s disease compared to those without insomnia (Bubu et al., 2020). Even more alarmingly, older adults with insomnia have a two-fold increased risk for mortality compared to their well-rested peers (Dew et al., 2003).

The Strong Link to Psychiatric Disorders and Mental Health

The relationship between sleep and mental health is profoundly bidirectional. Poor sleep can be a trigger for mental illness, and mental illness almost always disrupts sleep.

• Mood Disorders: Untreated insomnia is a major risk factor for both the onset and relapse of major depressive disorder and bipolar disorder.
• Anxiety Disorders: There is a powerful link between insomnia and all types of anxiety disorders, including panic disorder and post-traumatic stress disorder (PTSD).
• Substance Use Disorders: Many individuals with insomnia turn to substances like alcohol to self-medicate, which often worsens the underlying sleep disturbance over time.
• Psychotic Symptoms: Severe sleep deprivation can, in some cases, increase the risk for experiencing psychotic symptoms, such as hallucinations or paranoid delusions.
• Suicidality: This is one of the most critical connections. There is a strong and well-documented relationship between sleep deprivation and suicidal ideation, behaviors, and even completed suicides (Woznica, 2022). Insomnia can increase feelings of hopelessness and impair impulse control. For this reason, any patient reporting significant insomnia must be carefully and directly screened for suicidal thoughts. At our clinic, this is a non-negotiable part of our assessment protocol.

Given these severe and life-altering consequences, it is imperative that we, as healthcare providers, recognize and treat insomnia with the seriousness it deserves. Restoring sleep is not just about feeling better; it’s about restoring function and protecting long-term health.

A Systematic Approach to Assessing Insomnia

With the understanding of how profoundly insomnia impacts health, it becomes clear why assessing our patients’ sleep quality should be a routine part of every clinical encounter. It is recommended that we consider sleep as a vital sign, just as pain was added in recent years. This assessment can be efficiently initiated during the initial nursing or Medical Assistant (MA) triage process.

Initial Screening and Comprehensive Evaluation

1. Use a Validated Screening Tool: To standardize this assessment, I recommend instruments like the Insomnia Severity Index (ISI). This brief, 7-item questionnaire is easy for patients to complete and provides a reliable score of insomnia severity. A positive screening (typically a score of 8 or higher) should trigger a more thorough evaluation.
2. Conduct a Thorough History: For patients with a positive screening, a comprehensive history is the next step. A helpful mnemonic to guide this conversation is OLD CARTS:

• • Onset: When did the sleep problems begin? What was happening in your life at that time?
  • Location: Not applicable, but you can ask about the sleep environment.
  • Duration: How long do the episodes of poor sleep last? How many nights a week?
  • Characteristics: What is the sleep problem like? Difficulty falling asleep (sleep-onset insomnia)? Waking up in the middle of the night (sleep-maintenance insomnia)? Waking up too early (late insomnia)?
  • Aggravating/Alleviating Factors: What makes it worse (e.g., stress, caffeine)? What makes it better?
  • Radiation: Not applicable.
  • Timing: Is there a pattern to when it occurs?
  • Severity: On a scale of 1-10, how severe is the problem? How much does it impact your daily life?

• Assess the Sleep Routine and Daytime Functioning:

• • Sleep Diary: While many patients bring in data from their smartwatches, the research on the accuracy of these consumer-grade devices is not yet robust enough for clinical decision-making. The gold standard remains a sleep diary, tracked by hand or with a validated app. It should log bedtimes, wake times, time to fall asleep, awakenings, and a rating of sleep quality. This provides a much more accurate picture of sleep patterns and efficiency.
  • Impaired Daytime Functioning: A crucial part of the diagnosis is the presence of daytime impairment. You must ask: “How are your sleep problems affecting you during the day?” Look for reports of fatigue, cognitive difficulties, mood disturbances, and impaired performance.

Evaluating Comorbidities and When to Refer

It is vital to review the patient’s list of chronic conditions, as many common issues can interfere with sleep. Addressing these underlying problems is often a key step in improving sleep quality.

Condition	How It Can Interfere with Sleep
Chronic Pain	Discomfort makes it difficult to fall asleep and stay asleep.
Nocturia (frequent urination)	Waking up multiple times to use the restroom.
Gastroesophageal Reflux (GERD)	Heartburn and discomfort are worse when lying down.
Restless Legs Syndrome (RLS)	An irresistible urge to move the legs, especially at night.
Mental Health Conditions	Anxiety and depression are strongly linked to insomnia.
Respiratory Conditions (Asthma, COPD)	Difficulty breathing, coughing, and wheezing can disrupt sleep.
Endocrine Disorders (e.g., Thyroid)	Hormonal imbalances can interfere with sleep-wake cycles.
While most cases of primary insomnia can be managed in our setting, it is crucial to recognize when a referral to a sleep medicine specialist is warranted. The two most common situations are:

1. Suspected Sleep Apnea: This is a serious condition where breathing repeatedly stops and starts during sleep. If a patient endorses several of the following symptoms, a referral is strongly indicated:

• • Chronic, unrefreshing sleep
  • Nocturia
  • Loud, recurrent snoring
  • Gasping or choking sounds during sleep
  • Witnessed apneic episodes
  • Morning dry mouth or headaches
  • Significant daytime sleepiness and fatigue

• Treatment-Resistant Insomnia: If you have tried one or more evidence-based treatment approaches without success, it is time to refer. A sleep specialist can conduct more advanced diagnostics, such as an overnight sleep study (polysomnography), to uncover more complex underlying issues.

A Multimodal and Individualized Treatment Strategy for Chronic Insomnia

Fortunately, we now have many effective treatment options for our patients with chronic insomnia. The key to success is to formulate a multimodal and individualized strategy. Research has consistently found that individual treatment options, when used in isolation, often have only a modest effect size (Morin et al., 2006). By approaching the problem from multiple angles, we can create a synergistic effect that leads to lasting improvement.

This is where our integrative model at Injury Medical Clinic shines. Under the medical direction of Dr. Cardenas, we combine evidence-based conventional treatments with chiropractic care, functional medicine principles, and lifestyle interventions to create a truly holistic plan.

Mind-Body Techniques and Relaxation

A central feature of insomnia is a hyperaroused state of mind. The patient lies in bed, their thoughts racing, unable to “switch off.” Therefore, teaching them effective relaxation techniques to calm the mind and body at night is a foundational step.

• Meditation: Mindfulness meditation teaches individuals to observe their thoughts without judgment, helping to break the cycle of anxious thinking about sleep.
• Guided Imagery: This technique involves focusing on pleasant and calming images, which can distract from worry and induce a relaxed state.
• Progressive Muscle Relaxation (PMR): This involves systematically tensing and then relaxing different muscle groups, helping to release physical tension.

Many of these skills can be learned with a therapist, but numerous excellent smartphone apps can guide patients through these exercises.

The Role of Integrative Chiropractic Care

In our clinic, chiropractic care is a cornerstone of the integrative approach to insomnia. The nervous system is the master controller of the body, governing everything from our stress response to our sleep-wake cycles.

• Modulating the Autonomic Nervous System (ANS): The ANS has two main branches: the sympathetic (“fight-or-flight”) and the parasympathetic (“rest-and-digest”). Many patients with insomnia are stuck in a state of sympathetic dominance. Chiropractic adjustments have been shown to help shift the balance towards the parasympathetic nervous system (Welch & Boone, 2008). This down-regulation of the stress response is crucial for creating a physiological state conducive to sleep. By addressing vertebral subluxations—misalignments that can interfere with nerve function—we can help restore proper neurological signaling and shift autonomic balance through mechanoreception and proprioceptive inputs (Pickar, 2002).
• Reducing Musculoskeletal Tension and Pain: Chronic pain is a major disruptor of sleep. Pain disrupts sleep architecture, increases microarousals, and amplifies daytime fatigue; poor sleep further increases pain sensitivity—a bidirectional cycle (Haack et al., 2012). Chiropractic care is exceptionally effective at addressing the musculoskeletal sources of pain, such as neck pain, back pain, and headaches. By reducing pain and physical tension, we remove a significant barrier to restful sleep.
• Improving Overall Well-being: Patients often report improved overall well-being and relaxation following an adjustment. This results from restoring proper biomechanics and neurological function, making it easier to wind down at the end of the day.

The care I provide is always within the context of the patient’s overall health plan, overseen by our medical director, Dr. Cardenas. This ensures that the chiropractic interventions are appropriate and integrated seamlessly with any other medical treatments.

Cognitive Behavioral Therapy for Insomnia (CBTi): The First-Line Treatment

When we look at the evidence, one treatment stands out above all others for chronic insomnia: Cognitive Behavioral Therapy for Insomnia, or CBTi. It is now considered the first-line treatment option by major medical organizations, recommended even before medication (Qaseem et al., 2016).

CBTi is a structured, evidence-based psychotherapy that is highly effective for improving sleep quality. One of its greatest strengths is that its benefits are long-lasting, even after the patient stops seeing the clinician. While CBTi is typically provided by licensed therapists, it is essential for all of us as clinicians to understand its basic tenets.

The Cognitive Component: Reshaping Thoughts and Beliefs About Sleep

A primary goal of CBTi is to reduce sleep-related worry. Many patients with insomnia develop a dysfunctional relationship with sleep. They get into bed and “try” very hard to fall asleep, which paradoxically creates anxiety that keeps them awake. The goal of the cognitive portion of CBTi is to shift the patient’s mindset away from forcing sleep and towards allowing sleep to happen naturally. This is achieved by identifying, challenging, and replacing cognitive distortions, such as:

• Catastrophizing: “If I don’t get 8 hours of sleep tonight, I will fail my presentation tomorrow.”
• Overgeneralization: “I had one bad night, so I’ll never sleep well again.”
• Unrealistic Expectations: “I must fall asleep within 10 minutes of my head hitting the pillow.”

The therapist helps the patient challenge these thoughts with more realistic alternatives, reducing the anxiety and pressure surrounding bedtime.

The Behavioral Component: Modifying Habits and Environment

The behavioral component of CBTi focuses on eliminating ineffective sleep-related behaviors.

1. Sleep Hygiene Education: This is the foundation, involving counseling on behaviors and environmental factors that promote good sleep.
2. Relaxation Techniques: As previously discussed, teaching techniques like meditation and PMR helps the patient wind down.
3. Sleep Restriction and Improving Sleep Efficiency: This is one of the most powerful but counterintuitive components. Sleep efficiency is a crucial metric, calculated as: Sleep Efficiency = (Total Time Asleep / Total Time in Bed) x 100. For many patients with insomnia, this efficiency is very low. The goal of sleep restriction is to break this cycle. The therapist will initially advise the patient to reduce their time in bed to match the actual amount of time they are currently sleeping.

• • Initial Phase: For a patient getting 5.5 hours of sleep in 8 hours, the therapist might advise them to stay in bed for only 6 hours per night. This consolidates sleep and builds a strong sleep drive.
  • Gradual IncBedse: As the patient’s sleep efficiency improves to 85%-90%, the therapist will advise them to increase their time in bed in 15-minute increments gradually. This process is extremely effective in improving sleep quality.

AccessiBedCBTi: Overcoming Barriers

One of the biggest challenges with CBTi is access. However, there are now many digital CBTi options available.

• Smartphone Apps: Apps like the VA’s “CBT-i Coach” provide a secure, free program. Subscription-based apps like Headspace or Calm also have extensive modules on managing insomnia.
• Telemedicine: Many therapists now offer CBTi through telemedicine, greatly expanding access.

While digital options lack one-on-one guidance, they can still be incredibly effective for motivated patients (Trauer et al., 2015).

Balancing Body and Metabolism- Video

Sleep Hygiene: The Foundational Behaviors for Optimal Sleep

Regardless of the specific treatment plan, educating patients on sleep hygiene is essential. These are the behavioral and environmental recommendations designed to optimize sleep by aligning our biology with our behavior.

Creating a Sleep-Sanctuary Environment

The bedroom environment plays a powerful role in signaling to the brain that it is time for sleep.

• Create a Calm, Quiet, and Comfortable Bedroom:

• • Temperature: A cool room (around 60-67°F or 15-19°C) is more conducive to sleep.
  • Light: The room should be as dark as possible. Blackout curtains and eye masks are very helpful.
  • Sound: The room should be quiet. A white noise machine or earplugs can be effective.

Regulating the Circadian Rhythm

Consistency is key to regulating the body’s internal clock.

• Adhere to a Consistent Sleep Schedule: Advise patients to go to bed and wake up at roughly the same time every day, even on weekends and holidays.
• Minimize Napping: Bedtime or late-afternoon naps can disrupt the circadian rhythm. If a patient must nap, it is recommended to keep it under an hour and to do it earlier in the day.

Managing Substances and Stimuli

What we consume and do in the hours before bed has a direct impact on our ability to sleep.

• Avoid Stimulants in the Evening:

• • Caffeine: Avoid caffeine for at least 6-8 hours before bedtime.
  • Nicotine: This is also a stimulant and can disrupt sleep.

• Avoid Alcohol Before Bedtime: While alcohol may initially make someone feel sleepy, it significantly disrupts sleep architecture later in the night.
• Exercise Timing: Vigorous exercise should not be done too late in the day. Encourage exercise earlier in the day or gentle activities like stretching in the evening.
• Reduce Screen Time: This is one of the most important recommendations. The blue light from screens suppresses the release of melatonin. It is strongly recommended that patients put away all screens in the one to two hours leading up to bedtime.

Strengthening the Bed-Sleep Connection

A core principle is to re-establish the brain’s association between the bed and sleep.

• Use the Bed Only for Sleep and Sex: Avoid working, eating, or watching TV in bed.
• CovBedBedside Clocks: ClocBedatching is a major source of anxiety. Advise them to turn the clock face the wall or remove it.
• The 15-20 Minute Rule: If a patient has been unable to sleep for more than 15 to 20 minutes, they should get out of bed. They should go to another room and do something with low energy and low light, like reading a book (not on a screen). They should not get back into bed until they feel tired. This helps break the frustrating cycle of lying awake in bed.

Pharmacological Interventions: A Guide to Hypnotic Medications

While lifestyle changes and CBTi are the cornerstones of treatment, there are situations where pharmacotherapy (hypnotics) is appropriate. The decision to start a medication should always involve a thorough conversation with the patient, weighing the risks and benefits. It’s also important to note that many of these medications have a strong placebo effect, highlighting the powerful role of patient expectation.

Essential Counseling Points Before Starting a Hypnotic

Before a patient starts any sleep medication, there are several critical topics to review:

1. Use the Lowest Effective Dose, As Needed: The mantra is “start low, go slow.”
2. Discuss”Common Risks:

• • Falls and Injuries: Hypnotics can cause next-day drowsiness and impaired coordination.
  • Confusion and Cognitive Impairment: Some medications can cause “brain fog.”
  • Complex Sleep Be”aviors: Th”s includes sleepwalking, sleep driving, and sleep eating, where the person has no memory of the event.
  • Tolerance and Dependency: With some medications, the body can develop a tolerance or dependency.

• Warn Against Mixing with Other Sedating Substances: It is extremely dangerous to combine hypnotics with alcohol, cannabis, muscle relaxants, or opioids.
• Advise Against Over-the-Counter (OTC) Antihistamine Sleep Aids: Long-term use of OTC sleep aids containing diphenhydramine (e.g., Benadryl) has been associated with an increased risk for developing mild cognitive impairment and dementia due to their anticholinergic properties (Gray et al., 2015). I do not recommend these for chronic insomnia.

Mechanisms of Action: How Sleep Medications Work

To make informed decisions, it’s helpful to understand how different hypnotics work.

• Antidepressants: These primarily work by blocking histamine H1 receptors, a primary wakeful neurotransmitter.
• Benzodiazepines: These enhance the signaling of GABA (gamma-aminobutyric acid), the brain’s main inhibitory neurotransmitter. They are positive allosteric modulators (PAMs) that bind to numerous subtypes of the GABA-A receptor, essentially “turning up the volume” on the brain’s natural calming signal (Brains, 2007).
• “Z-Drugs” (Non-benzodiazepine Receptor Agonists): Like benzodiazepines, these enhance GABA signaling but are more selective. Most (zolpidem, zaleplon) target the alpha-1 subtype of the GABA-A receptor, which is thought to be most directly involved in sedation.
• Dual Orexin Receptor Antagonists (DORAs): This is the newest class. They work by blocking both orexin-1 and orexin-2 receptors. Orexin is a key wakeful chemical, so by blocking its system, these drugs help to “turn off” the brain’s wake-up signal.
• Melatonin agonists: These mimic the action of melatonin by activating melatonin MT1 and MT2 receptors in the SCN.

A Detailed Look at the Medication Classes

Antidepressants

• FDA-Approved: Doxepin (Silenor)

• • Dose: FDA-approved at a very low dose range of 3-6 mg for insomnia.
  • Mechanism: At these ultra-low doses, its primary action is as a potent antihistamine, blocking the H1 receptor.
  • Advantages: It has a very low risk for dependency and tolerance and is not a controlled substance. It is particularly effective for sleep maintenance and is generally very well tolerated.
  • Drawbacks: The most common side effect is next-morning drowsiness.

• Off-Label Use: Many providers use other antidepressants like trazodone, mirtazapine, and amitriptyline as sleep aids. While I have seen success with these options, it is crucial to understand that this is off-label use, as research guidelines do not currently support their use for insomnia due to a lack of sufficient evidence.

Benzodiazepines

• Examples: Temazepam (Restoril), Triazolam (Halcion), Lorazepam (Ativan).
• Characteristics: These are affordable and effective but come with significant risks and should only be used for short-term (2-4 weeks).
• Risks and Limitations:

• • High risk for tolerance and dependency.
  • Risk for abuse and diversion.
  • Significant risk of respiratory depression, confusion, and falls, especially in older adults. Their use in older people is strongly discouraged.

Benzodiazepine Receptor Agonists (“Z-Drugs”)

• Examples: Eszopiclone (Lunesta), Zaleplon (Sonata), Zolpidem (Ambien).
• Advantages: Generally affordable with a lower risk for tolerance and dependency than benzodiazepines. Their variety allows for individualized treatment:

• • For Middle-of-the-Night Awakenings: Zaleplon and sublingual zolpidem have a rapid onset and short half-life.
  • For Sleep Onset and Maintenance: Eszopiclone and zolpidem CR work well for helping patients fall and stay asleep.

• Drawbacks: This class has the highest risk for complex sleep behaviors (sleepwalking, sleep driving). It is critical to counsel patients on this risk.

Dual Orexin Receptor Antagonists (DORAs)

• Examples: Suvorexant (Belsomra), Lemborexant (Dayvigo), Daridorexant (Quviviq).
• Characteristics: This is the newest class. Taking them with food can delay their onset.
• Advantages:

• • Lower Risk Profile: Appear much less risky than benzodiazepines and Z-drugs.
  • Long-Term Use: Strong research supports their safety for long-term, chronic use.
  • Effective for Sleep Maintenance: Particularly effective at helping patients sleep through the night.
  • Safety in Specific Populations: Appear to be safe and effective for patients with dementia and Alzheimer’s disease (Herring Alzheimer’s).

• Drawbacks: The major drawback is the considerable cost. Insurance often requires prior authorization.

Melatonin and Melatonin Agonists

• Melatonin Supplements:

• • Review: Many patients are willing to try supplements first.
  • Dosing and Administration: I recommend a dosage between 1 and 3 mg, administered one to two hours before bedtime.
  • Risks: Supplements are not regulated by the FDA, so there may be risks of inconsistent dosing or contamination. I recommend a trusted brand with third-party testing.

• Prescription Melatonin Agonist: Ramelteon (Rozerem)

• • Dose: Comes in one dose, 8 mg.
  • Mechanism: It agonizes both the MT1 and MT2 melatonin receptors.

• Best Use Cases: Both the supplement and ramelteon are best for sleep onset issues or circadian rhythm disruptions.
• Advantages: They have a very low-risk profile, with no risk for dependency or tolerance. Many studies recommend these options for minors.

Other Supplements and Alternative Options

Patients may ask about options like magnesium, valerian root, or lavender extract. Unfortunately, these are not recommended for chronic insomnia due to a lack of consistent and robust scientific evidence.

Case Translation and Clinical Reasoning: Applying These Principles

The following cases illustrate how we translate evidence into practice at Injury Medical Clinic, integrating medical oversight, chiropractic care, behavioral strategies, and functional medicine insights.

Case 1: A 57-Year-Old Male with Insomnia and Addiction History

I met MC, a 57-year-old man with depression, anxiety, hypertension, obesity, and a past alcohol use disorder (sober > 15 years). He reports difficulty initiating and maintaining sleep. OTC melatonin has not helped, and he avoids controlled substances due to his addiction history.

Clinical Considerations & Treatment Plan:

• Risk Stratification: His obesity and age increase his risk for obstructive sleep apnea (OSA). A referral for a home sleep apnea test (HSAT) is considered.
• Behavioral Foundations: We start with strict sleep hygiene and a referral for CBT-I.
• Pharmacologic Options (Noncontrolled): Given his addiction history, we avoid Z-drugs and benzodiazepines.

• • Ramelteon is an excellent choice for his sleep onset difficulty due to its low abuse potential.
  • Low-dose doxepin (3–6 mg) is a good option for his sleep maintenance issue.

• Integrative Chiropractic Care: We address cervical instability to reduce pain signals and sympathetic arousal. We also train diaphragmatic breathing to enhance vagal tone.
• Internal Medicine Oversight (Dr. Cardenas): Dr. Cardenas evaluates his cardiovascular risks, manages his hypertension, and coordinates the OSA screening.
• Rationale: MC’s addiction history guidesMC’saway from traditional sedatives. Ramelteon and low-dose doxepin align with his needs and safety profile. The integrative approach addresses physiological drivers like pain and autonomic imbalance, while medical oversight ensures overall safety.

Case 2: A 70-Year-Old Female with Chronic Insomnia and MCI

CP is a 70-year-old woman with chronic insomnia, mild cognitive impairment (MCI), depression, eczema, and osteoporosis. Her zolpidem 5 mg is no longer effective. She awakens 3–4 hours after falling asleep. Fall risk and cognitive safety are paramount.

Clinical Considerations & Treatment Plan:

• Sedative-Hypnotic Safety: Z-drugs carry risks of cognitive impairment and falls in older adults. Tapering off zolpidem is a primary goal.
• Medication Strategy:

• • Switching to a Dual Orexin Receptor Antagonist (DORA) like lemborexant or daridorexant is a safer choice due to their better profile in older adults with MCI and effectiveness for sleep maintenance (Rosenberg et al., 2019).
  • Low-dose doxepin is another safe alternative for sleep maintenance.

• Behavioral Interventions: We emphasize strict sleep hygiene, particularly ceasing prolonged daytime napping and avoiding screens in bed.
• Dermatologic Comfort: Her eczema worsens sleep. Optimizing her topical therapy to reduce nocturnal itch is a key part of her sleep plan.
• Integrative Chiropractic Care: We use gentle, age-appropriate techniques for autonomic downregulation and comfort. Postural and balance training is integrated to reduce her fall risk.
• Internal Medicine Oversight (Dr. Cardenas): Dr. Cardenas reviews her polypharmacy to minimize fall risk and ensures her plan is compatible with her MCI and osteoporosis.
• Rationale: CP’s profile mandates safer cCPs. DORAs target orexin signaling to sustain sleep with lower risk. Strong behavioral interventions and addressing her eczema—a direct sleep disruptor—are crucial. The collaborative approach ensures her complex medical needs are managed safely.

Clinical Observations from My Practice

Over years of clinical work at Injury Medical Clinic and through my professional collaborations, I’ve observed that:

• Patients with musculoskeletal pain and high sympathetic tone often experience profound sleep improvements after targeted chiropractic care and breathing retraining.
• Older adults benefit from DORAs for maintenance insomnia with fewer next-day effects compared to Z-drugs, especially when combined with rigorously applied sleep hygiene.
• Functional medicine approaches—especially weight reduction in obese patients—shift sleep quality and reduce OSA risk significantly.
• CBT-I remains our most enduring tool, and when we add movement medicine and autonomic modulation, adherence improves and outcomes stabilize.

These insights reflect patterns I’ve discussed across my clinical platforms and collaborations (Jimenez, n.d.; Jimenez, n.d.-b).

Conclusion: Integrative, Evidence-Based Insomnia Care That Respects Complexity

Insomnia is multifactorial and demands a coordinated, mechanism-based, and patient-centered approach. In our El Paso clinic, with the medical leadership of Dr. Maria Guadalupe Cardenas, MD, and the integrative chiropractic and functional medicine strategies I provide, we deliver care that blends pharmacologic precision, behavioral rigor, and physiologic restoration. Safety, collaboration, and shared decision-making anchor our process. By combining modern options like DORAs and CBT-I with foundational autonomic modulation and pain reduction, we give our patients the best chance to reclaim the restorative sleep that is so essential for their health and vitality.

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