Managing Adult Insomnia Confidently

Monika E. Reynolds, MSN, FNP-C, and Pamela H. Cone, PhD, CNS

ABSTRACT
Insomnia is a significant health problem often ineffectively managed in primary care.
Patients should be briefly screened for sleep issues at every visit. Insomnia management
focuses on patient education in nonpharmacologic treatments including sleep hygiene,
sleep restriction, stimulus control, relaxation techniques, mindfulness practices, and
cognitive therapies. Hypnotics should be used appropriately and sparingly. No single
treatment is fully effective; each patient will require a unique blend of treatments for
maximal effectiveness. Nurse practitioners should work closely with patients to find
the best mix of modalities for them.

Keywords: cognitive behavioral therapy for insomnia, insomnia, nonpharmacologic

management, primary care, sleep hygiene
Ó 2018 Elsevier Inc. All rights reserved.

S leep is an essential function for human life. At

least 30% of adults sleep less than 6 hours each
night, which is significantly less than the rec-
ommended 7 to 9 hours.1 Regular lack of adequate
treatments, proper hypnotic use, and monitoring for
treatment success.

PATHOPHYSIOLOGY OF SLEEP AND INSOMNIA

sleep, or insomnia, can be debilitating and is
associated with a host of chronic diseases, including
cardiovascular disease, cancer, obesity, diabetes,
hypertension, chronic pain, depression, and anxiety.2
Insomnia can also lead to impaired daytime
functioning, decreased work productivity, trouble
concentrating, increased accidents, and fatigue, as
well as emotional distress, volatile mood, and
irritability.2,3 With such prevalence and widespread
consequences, inadequate sleep has been identified as
a growing health concern.
Nurse practitioners (NPs) in primary care are
likely to see numerous patients each week who
report problems sleeping. As such, it is essential to be
mindful of proper diagnosis and management strate-
gies for insomnia. Current recommendations focus
on nonpharmacologic management strategies for
insomnia because these are highly effective and can
be used in unique combinations for each patient.3
However, providers are often unaware of the details
of these strategies and feel unprepared to teach them
in the office.4 This article provides thorough
instruction in insomnia diagnosis and management,
focusing on patient education in nonpharmacologic
Sleep provides the opportunity for necessary bio-
logical tasks of rest and restoration and supports
neurologic functioning; without sleep, physical and
neurologic abilities diminish greatly.2 In normal sleep
function, the hypothalamus guides sleep and
wakefulness through circadian rhythms, causing
regular fluctuations in physical arousal and sleepiness
in a 24-hour period. Circadian rhythms can be
influenced by environment; cool temperature and
darkness promote sleepiness at night, whereas shift
work and stress hormones disrupt these rhythm cues.3
The pathophysiology of insomnia is based in
physical hyperarousal.2,3 Hyperarousal can have
numerous causes, such as acute stress, anxiety,
excessive worry, or inability to enter a restful state.
Much like the fight-or-flight response, the
sympathetic nervous system is activated in
hyperarousal, which releases norepinephrine into the
blood. This increases heart rate and blood pressure
and activates the hypothalamic-pituitary-adrenal axis,
increasing blood cortisol and glucose levels.2,3 Under
stress, hyperarousal provides more available energy
and enables the body to move quicker and stronger
than in normal situations. However, hyperarousal is

www.npjournal.org The Journal for Nurse Practitioners - JNP 1

counterproductive to rest and sleep, resulting
in insomnia.
SCREENING AND CLINICAL PRESENTATION
Screening
Primary care providers should briefly screen for sleep
issues at every patient encounter during the general
health questionnaire because most adults will expe-
rience sleeping problems at some point in their
lives.3,4 Screening can be accomplished by asking the
following simple question: “How are you
sleeping?”4(p68) Frequent screening provides the
opportunity for earlier identification of sleep
disturbance and timely diagnosis and treatment
of insomnia.
Clinical Presentation
Patients with insomnia do not typically present with
the chief complaint of sleep issues. Rather, it is during
patient interview that sleep problems are identified.
Insomnia presents with problems initiating or main-
taining sleep with associated daytime dysfunction.3
Issues with sleep initiation include not being able to
fall asleep at bedtime or lying awake for several hours
in bed unable to sleep.2 Patients may also complain of
problems maintaining sleep, such as waking up
several times during the night or waking up early and
not being able to go back to sleep.4 Finally, patients
often report daytime symptoms, such as excessive
fatigue, irritability, difficulty focusing at work or on a
specific task, or not feeling refreshed after waking
from a night of sleep.3,4 Any of these complaints
should be investigated for a cause and could be a
symptom of insomnia.5
DIAGNOSTIC EVALUATION
Patient Interview
When evaluating for insomnia, it is essential to take a
thorough sleep history, focusing on the frequency
and timing of sleep issues, bedtime routine, and
nighttime environment.2 NPs must also take a
detailed medical, psychiatric, and substance use
history, including all current medications, herbal or
alternative therapies, tobacco, illicit drugs, and
alcohol use, to rule out other organic causes of sleep
disturbance.2,3 During this process, providers should
2 The Journal for Nurse Practitioners - JNP
be vigilant for behavioral or medical sources of sleep
disturbance because addressing this source will
improve sleep.
Several conditions and medications are associated
with sleep disturbance; these include obstructive sleep
apnea, nocturia, restless legs syndrome, congestive
heart failure, asthma, gastroesophageal reflux disease,
chronic pain, anxiety, and depression, as well as the
use of corticosteroids, antidepressants, anticonvul-
sants, bronchodilators, antihistamines, thyroid sup-
plementation, oral contraceptives, nicotine, and
alcohol.2,3 In diagnostic evaluation, it is essential that
providers consider all organic causes of insomnia
symptoms and provide a thorough evaluation for any
conditions they suspect could be contributing to
sleep disturbance.2,3 Disturbance in sleep caused by
another condition or behavior is not true clinical
insomnia. It is helpful to remember that problems
falling asleep are often issues of poor sleep hygiene or
medication or substance use, whereas early
awakenings typically have psychological origins, such
as depression or clinical anxiety. It is also important to
work with the patient to identify current sources of
stress because high stress levels can cause sleep issues
because of nighttime hyperarousal (Table 1).2,3
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders
(Fifth Edition) provides a clear list of criteria for
insomnia diagnosis that is easily accessible for NPs.
Diagnostic criteria are as follows:
1. Patient reports dissatisfaction with current sleep
quality or quantity, including issues of initiating
or maintaining sleep
2. Sleep issues cause significant daytime dysfunc-
tion or distress, either in professional life or
relationships, and disrupt behaviors or
emotional state
3. Sleep issues occur at least 3 times a week for at
least 3 months
4. Sleep issues occur despite adequate available
opportunity for sleep
5. There is no other identifiable organic cause of
sleep issues5
When making a diagnosis of insomnia, it is
essential to rule out other medical, behavioral, or
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Table 1. Common Organic Causes of Insomnia2,3,6 behavioral problem areas on which to focus. After
Medical Conditions Medications and Substances
reviewing the sleep diary and ruling out other
Asthma Corticosteroids
organic causes of sleep disturbance, a diagnosis of
insomnia can be properly made.6
Obstructive sleep apnea Antidepressants (SSRIs)
Nocturia Bronchodilators MANAGEMENT
Congestive heart failure CNS stimulants The most common request from patients with
Paroxysmal nocturnal Anticonvulsants insomnia is for prescription hypnotics. However, the
dyspnea recommended first-line therapy for insomnia is
Gastroesophageal reflux Diuretics nonpharmacologic management.6 Treatment
disease strategies are based on behavioral and psychological
Chronic pain Beta-blockers interventions in the form of sleep hygiene education
COPD Anticholinergics
and the components of cognitive behavioral therapy
for insomnia (CBT-I), including sleep restriction,
Restless leg syndrome Antihistamines
stimulus control, relaxation techniques, mindfulness,
Pregnancy Thyroid hormone
and cognitive strategies for sleep promotion.
replacement
When considering nonpharmacologic treatments,
Thyroid disease Oral contraceptives
it is important to remember that no single strategy is
Coronary artery disease Appetite suppressants recommended to be used alone. The American
Liver cirrhosis with high Nicotine Academy of Sleep Medicine supports each individual
ammonia treatment as partially effective and recommends that
Anxiety Alcohol treatments be used together in a multicomponent
Depression Caffeine strategy for maximal effectiveness.6 No single
CNS ¼ central nervous system; COPD ¼ chronic obstructive pulmonary disease;
treatment will be successful with every patient, and
SSRIs ¼ selective serotonin reuptake inhibitors. different strategies may be more or less helpful for
different patients.2,3 It is important to work with
psychological causes of insomnia symptoms as dis- each patient individually, based on their sleep
cussed previously. diary, reported symptoms, and success of therapies,
to determine over time the best
Evaluation combination for the patient’s unique symptoms
The most commonly used insomnia questionnaires and situation.
are the Epworth Sleepiness Scale, which measures the
severity of sleepiness experienced by the patient, and Nonpharmacologic Management
the Pittsburgh Sleep Quality Index, which provides a Sleep Hygiene Education. Sleep hygiene educa-
measurement of sleep quality.3 It is important to use a tion is the most frequently recommended non-
questionnaire during evaluation to provide objective pharmacologic management strategy for insomnia.3,7
data and establish insomnia severity at the time of The goal of sleep hygiene is to help patients to be
diagnosis. Questionnaires should also be used to more aware of evening and bedtime practices and
monitor treatment success during follow-up visits. how these can affect sleep.6 The National Sleep
To ensure proper diagnosis, NPs should also have Foundation, supported by a myriad of sleep research,
patients complete a 2-week sleep diary.3,4 The diary recommends a number of behaviors that promote
should include bedtime and morning wake time, quality sleep.7 The most popular sleep hygiene
total time spent in bed, time spent asleep, timing and principles include a regular bedtime; daytime
duration of nighttime awakenings, sleep exercise; a quiet sleep environment; keeping the
environment, bedtime routine, sleep medication use, bedroom dark and cool; and avoiding alcohol,
and daytime symptoms.3 A comprehensive sleep caffeine, nicotine, daytime naps, and stressful or
diary can also assist with treatment by highlighting cognitively stimulating activities before bedtime, such

www.npjournal.org The Journal for Nurse Practitioners - JNP 3

as television or smartphone use.3,7 Caffeine directly
causes sleep disturbance when consumed within 6
hours of bedtime.8 Bedtime smartphone use is
associated with sleep problems, including worse sleep
quality, difficulty falling asleep, and increased daytime
fatigue, and, thus, should be avoided before bed.9
NPs should feel confident in teaching sleep hygiene
to their patients, as well as identifying when violating
these behaviors are contributing factors to insomnia
symptoms during sleep diary review (Table 2).
CBT-I. CBT-I is a highly effective treatment
strategy for insomnia. However, it is infrequently
used in primary care because providers report inad-
equate office time or training in conducting general
cognitive behavioral therapy or specifics for insomnia
management.10,11 Patients are often not referred to a
psychologist’s office for CBT-I unless their insomnia
is severe, which leaves most patients suffering from
insomnia without the helpful strategies of CBT-I.
The specific components of CBT-I are simple, easy
to teach to patients, and highly effective, even when
administered by nonpsychiatric professionals.10 Each
of these strategies are thoroughly discussed, with the
goal that NPs will feel confident in using these
nonpharmacologic management strategies to treat
insomnia in primary care.
Sleep restriction. One of the most effective com-
ponents of CBT-I is sleep restriction.2,6 The goal of
sleep restriction is to limit the amount of time spent
Table 2. Sleep Hygiene Education3,7
Guidelines
Regular sleep routine and bedtime
Keep bedroom cool, dark, and comfortable
Use earplugs, white noise machines, or eyeshades as
desired
Limit daytime naps
Exercise during the day, but not 3 hours before bed
Avoid alcohol before bed
Avoid stimulants before bed, such as caffeine and
nicotine
Avoid stressful or cognitively stimulating activities
before bed
Avoid rich, heavy food before bed
4 The Journal for Nurse Practitioners - JNP
in bed to the time spent sleeping.11 Contrary to
popular belief, staying in bed longer does not result in
higher-quality sleep. Decreasing the overall time
spent in bed produces mild sleep deprivation in
patients by allowing for less sleep opportunity (or
time spent in bed trying to sleep, but, in insomnia,
often spent lying awake in bed).10 Mild sleep
deprivation in a scheduled manner resets and
stimulates the body’s endogenous sleep drive, thus
improving sleep.11
As a provider, sleep restriction is conducted by
writing a “sleep prescription.”11(pe509) Upon
review of the patient’s 2-week sleep diary,
providers calculate an average time spent sleeping
and an average time spent awake in bed. The sleep
prescription is written by adding the average time
spent sleeping plus 50% of the average awake time
in bed.11 It is important to note that sleep
prescription time cannot be less than 5 hours per
night to ensure sleep deprivation is not severe.11
Over time, as the patient begins to sleep more, the
sleep prescription increases. It is recommended that
if the patient sleeps for at least 80% of the sleep
prescription time for a week, the sleep prescription
is increased by 20 minutes for the next week. If
80% of the sleep prescription is not met, the sleep
prescription is kept the same, and patients are
encouraged to continue with sleep restriction
training.11 Although it can take time, sleep
restriction is a central behavioral component of
CBT-I and is highly effective in increasing sleep
time and quality (Table 3).3,6,10
Stimulus control. Stimulus control is a mainstay
behavioral component of CBT-I and applies the
principles of classical conditioning to promote
sleep.6,10 The goal of stimulus control is to strengthen
associations between sleep-promoting stimuli
(bedtime and the bed) with sleep and to weaken
associations of negative thoughts or problem
behaviors with sleep.2 Poor sleep practices, such as
watching television in bed, going to bed when not
tired, and spending too much awake time in bed,
have decreased the mind’s association of sleep with
sleep stimuli, and, as a result, the bed is no longer a
cue for sleep.2,10 Stimulus control is designed to
repair this cognitive association.
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Table 3. Sleep Restriction Prescription11
Sleep diary data Sleep time ¼ average of time spent
asleep
Rest time ¼ average of total time
spent in bed
Bedtime ¼ time sleep starts
Formula Sleep time þ 1/2 (rest time) ¼ sleep
prescription
Example 3 þ 1/2 (7) ¼ 3 þ 3.5 ¼ 6.5
Bedtime: 11:30 PM
Wake time: 6:00 AM
There are 2 parts of stimulus control to teach to
patients: promoting sleep behaviors and avoiding
negative behaviors. The promotion of sleep be-
haviors in bed is typically the more challenging
aspect. To foster associations with sleep, patients
should go to bed only when sleepy and set a
scheduled rise time in the morning, regardless of
how much sleep was achieved during the night.2 If
lying in bed unable to sleep, patients should leave
the bed, go to another room in the house for
approximately 10 to 15 minutes, and return to bed
only when feeling sleepy again.2,3 These behaviors
strengthen the mind’s association between feelings
of sleepiness and sleeping in bed, thus creating a
cognitive cue. Patients should also avoid behaviors
that create a negative association with sleepiness in
bed, such as watching television, reading
stimulating books, working on the computer,
having long phone conversations, or spending
hours awake in bed, including avoiding daytime
naps.2 According to stimulus control theory, the
bed should be used only for sleep and sexual
activity, and any other activity should be done
elsewhere in the home.2 In these ways, the mind
relearns to associate sleep with the bed, thus
promoting sleep and treating insomnia.
Relaxation techniques. Relaxation techniques are
used as a component of CBT-I to decrease
sympathetic stimulation and reduce physical arousal
at bedtime.12 Two of the most frequently used
strategies for relaxation are diaphragmatic breathing
and progressive muscle relaxation. Both are effective
in promoting sleep and relaxation at bedtime.12
Diaphragmatic breathing is done by taking long, deep
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breaths from the abdomen while lying supine.
Patients should place both hands on the abdomen
and focus on gradual abdominal rise and fall with
each deep breath. Diaphragmatic breathing increases
parasympathetic nervous stimulation via the vagus
nerve, thus decreasing vascular tone and heart rate to
produce skeletal muscle relaxation.2 In progressive
muscle relaxation, patients systematically tense and
release muscle groups throughout the body. Muscle
groups are activated and held for 5 to 10 seconds and
then completely released. This causes deeper muscle
relaxation than there is at rest.12 Relaxation
techniques treat insomnia by decreasing physical
arousal and promoting biological calmness. Because
they do not directly address sleep issues, they are
recommended as adjunctive therapy and are best
combined with other strategies for insomnia
management.3,6
Mindfulness practices. Mindfulness strategies are
designed to reconnect the mind with the body in an
effort to facilitate calmness and awareness. The most
commonly used strategy is mindful meditation.
Meditation is the practice of sitting calmly and
creating a prolonged moment of peace and quiet.13
During meditation, patients can also spend time
focusing on gratitude, sources of joy, or acts of
forgiveness.2 There are dozens of available
mindfulness practices, and patients should be
encouraged to spend some time exploring which
ones they prefer. Mindfulness strategies treat
insomnia by decreasing arousal, reducing stress and
anxiety, decreasing blood pressure, promoting
physical peace, and supporting mind and body
relaxation to promote sleep.13
Cognitive therapy. Cognitive therapies focus on
identifying dysfunctional beliefs about sleep and
altering them so they do not interfere with sleep.2,10
Common unrealistic sleep expectations include that
sleep must be 8 hours without waking to be good,
falling asleep should happen within 10 minutes of
bedtime, and tiredness upon initial awakening means
sleep was not restful.2,13 These negative thoughts
about sleep increase anxiety and worry, which
increases arousal and worsens insomnia symptoms.2,6
Correcting these erroneous beliefs can break this
cycle to improve sleep.
The Journal for Nurse Practitioners - JNP 5
 Cognitive therapies are typical psychological
treatments that providers most often associate with
CBT-I. These therapies can take more office time
because problematic thought patterns can be difficult
to identify. If unable to provide cognitive therapy,
patients should be referred to appropriate psychiatric
services or sleep centers.2,6 NPs can also consider the
use of Web-based cognitive therapy programs, which
are increasingly popular. However, cognitive therapy
is not considered a necessity in current
recommendations for treating insomnia.6 Thus, if
time or provider training limits providing cognitive
therapy in the office, using a combination of the
aforementioned 4 strategies is considered
comprehensive, even without the cognitive
component. This is termed multicomponent therapy and
is the current recommendation for the
nonpharmacologic management of insomnia.6(p1417)
Pharmacologic Management
Although nonpharmacologic management strategies
are recommended as the primary treatment for
insomnia, there are cases in which patients benefit
greatly from short-term use of sleep-assisting medi-
cations or hypnotics. Patients often report trying
over-the-counter sleep aids without success before
seeking medical care; common choices include
melatonin, Benadryl, and Tylenol PM (McNeil
Consumer Healthcare, Fort Washington, Pennsyl-
vania).3 These medications are not recommended to
treat insomnia because of anticholinergic side effects
such as constipation, blurry vision, urinary retention,
sedation, and confusion.3 The exception is
melatonin, a hormone supplement that can support a
healthy circadian rhythm. However, melatonin is
considered a dietary supplement, and, thus, it can be
difficult to regulate the strength and formulation
without pharmaceutical oversight.
Several hypnotics are available for treating
insomnia. Nonbenzodiazepine receptor agonists are
the primary recommendation for insomnia; these
include zolpidem, zaleplon, and eszopiclone.3,14
These medications are effective in increasing sleep
onset and duration without the negative side effects
of benzodiazepines. Benzodiazepines, such as
quazepam, estazolam, and temazepam, have
frequently been used to treat insomnia in the past.
6 The Journal for Nurse Practitioners - JNP
However, they can be sedating and addictive and, if
used, should only be used for a short duration with
quick, scheduled weaning.14 Selective melatonin
receptor agonists are newer hypnotic agents, such as
ramelteon and tasimelteon.3,4 These medications are
most effective in treating insomnia associated with
circadian rhythm issues and shift work because these
help to regulate melatonin production to stabilize the
sleep-wake cycle.14 Finally, sedating antidepressants,
such as trazodone, mirtazapine, and doxepin, are
often used to treat insomnia that presents with
concurrent mild depressive symptoms (see
Supplementary Table 4, available online at http://
www.npjournal.org).3,10
The goals of pharmacologic management are the
same as nonpharmacologic management—to improve
sleep and daytime functioning.3 Although the use of
medications is effective, it must be managed closely to
prevent inappropriate use and habit formation and
should not last for longer than 3 to 6 months.14
Hypnotics should be also used sparingly in older
adults.14 Hepatic and renal clearance rates are reduced
in elderly patients, which can lead to higher drug levels
in the body. Thus, sedating medications can have more
powerful and lasting effects and should be limited in
older adults when possible.
FOLLOW-UP, REFERRAL, AND CONTINUING
EDUCATION
Insomnia can be persistent and should be followed
closely. Upon diagnosis after sleep diary review, NPs
should begin patient education in nonpharmacologic
management strategies discussed in the previous sec-
tions.2,3,6 It is recommended that nonpharmacologic
treatments are given 4 to 6 weeks to improve
insomnia symptoms before starting hypnotic
medications.14 Nonpharmacologic strategies may not
quickly eradicate all insomnia symptoms, but patients
should report improving sleep quantity and quality. It
is also important to ensure patients are implementing
strategies correctly and regularly to be effective. If
nonpharmacologic management does not improve
insomnia symptoms at subsequent follow-up visits,
patients may be started on hypnotics.3 Dosage should
be started low and increased slowly to avoid sedation,
side effects, and misuse and discontinued in a
scheduled manner.3 Regardless of strategies, patients
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should return for follow-up every 4 to 8 weeks based
on the severity of symptoms.3
Nonpharmacologic interventions for insomnia
are considered general healthy sleep practices and can
be used indefinitely.3,15 However, hypnotic use
should be limited as much as possible. Once sleep has
improved, hypnotic dosage and frequency should be
decreased slowly to wean patients appropriately.3
Common practice is to first decrease dosage amount
and then decrease frequency. It is important to
inform patients that transient rebound insomnia is
common during hypnotic discontinuation.3 The
return of insomnia symptoms should only last a few
days, and once physiological dependence decreases,
sleep efficacy should return. Rarely, patients may
require long-term medication for insomnia. In these
cases, patients should be followed every 6 months to
ensure proper medication use and symptom control.3
Finally, if insomnia persists for more than 6
months or if symptoms do not improve with treat-
ment, patients should be referred to sleep specialists,
sleep disorder clinics, or psychiatric professionals
trained in CBT-I.2,6 Courses are available for
providers to become certified in general cognitive
behavioral therapy or CBT-I, both in person and
online, through Beck Institute, PESI Behavioral
Health Continuing Education, and many local
universities and colleges.
CONCLUSION
Sleep problems are widely prevalent today, and
NPs should be vigilant in screening for and
appropriately diagnosing insomnia. Best manage-
ment practice focuses on nonpharmacologic treat-
ments, and strategies should be used in
combination for optimal results. NPs should feel
confident in their abilities to teach strategies to
patients and seek specialty certification if desired.
Hypnotics should be used sparingly and for a short
duration in patients with severe symptoms. Non-
pharmacologic multicomponent therapy is the best
way to facilitate long-term improvement in
insomnia symptoms, and comprehensive
www.npjournal.org
management is essential to improve sleep and
quality of life in patients with insomnia.
SUPPLEMENTARY DATA
Supplementary tables associated with this article can
be found in the online version at https://doi.org/10.
1016/j.nurpra.2018.08.019.
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Monika E. Reynolds, MSN, FNP, FNP-C, is a Nurse
Practitioner in Ontario, CA and Adjunct Faculty at the School of
Nursing, Azusa Pacific University in Azusa, CA, and Kaiser
Permanente Baldwin Park Medical Center in Baldwin Park,
CA. She is available at monika.e.reynolds@gmail.com.
Pamela H. Cone, PhD, CNS, is Professor at the School of
Nursing, Azusa Pacific University. In compliance with national
ethical guidelines, the authors report no relationships with business
or industry that would pose a conflict of interest.
1555-4155/18/$ see front matter
© 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.nurpra.2018.08.019
The Journal for Nurse Practitioners - JNP 7
Supplementary Table 4. Hypnotic Medication
Prescriptions3,8
Medication Dose
Nonbenzodiazepine
receptor agonists

Zolpidem 5-10 mg PO qhs

Zaleplon 5-10 mg PO qhs
Eszopiclone 1-3 mg PO qhs
Benzodiazepines
Estazolam 1-2 mg PO qhs
Temazepam 7.5-30 mg PO qhs

Selective melatonin
receptor agonists
Ramelteon 8 mg PO qhs
Tasimelteon 20 mg PO qhs
Antidepressants

Trazodone 25-50 mg PO qhs

Mirtazapine 15-45 mg PO qhs
Doxepin 10-50 mg PO qhs
qhs ¼ every night at bedtime; PO ¼ by mouth.

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