Hello,
Thanks for your query.

I appreciate your efforts for medical consultation in so much distress.

Important aspects of your query are:
•     58 year old male
•     Known case of cardiac illness, glaucoma and epigastric hernia
•     Complaints of: insomnia, body ache and poor functionality.
•     Currently on lorazepam 2mg per day
•     Concern related to medicine use for sleep/addiction

Common causes of insomnia in your case may be:
-Poor sleep hygiene
-Excessive stress
-Anxiety
-Depression
-Substance use if present

In treatment of insomnia, first step is to diagnose cause of sleep problem, followed by treatment for cause.

Mirtazapine and Sensival is used for anxiety and depression. They also have sedative properties, leading to improvement in sleep. Sensival is contraindicated in glaucoma, but Mirtazapine can be used safely.

Lorazepam is an antianxiety and sleep inducing agent. But it is used only used for short term, like 2-4 week. Long term Lorazepam use lead to tolerance (progressive requirement for higher dose for same benefit), dependence and exacerbation of stress-anxiety-depressive symptoms. It can be tapered slowly (like 0.5mg every week) under psychiatrist or physician supervision.

Common symptoms of anxiety and depression are:
anxiety, low mood, decrease talk and interaction with others, nervousness, restlessness, mild irritability, excessive worry regarding own health, tremor, muscle spasm (lead to body-ache), heaviness in body, easy fatigability, headache, sleep disturbance, negative thinking, palpitation and dry mouth. Let me know if you are having some of the above symptoms with duration.

Irrespective of cause, below principles of sleep hygiene which will help you in long term:
•     Fix a bedtime and an awakening time. Do not be one of those people who allows bedtime and awakening time to drift. The body "gets used" to falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.
•     Avoid napping during the day
•     Avoid caffeine 4-6 hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.
•     Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime
•     Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep.
•     Use comfortable bedding.
•     Find a comfortable temperature setting for sleeping and keep the room well ventilated.
•     Block out all distracting noise, and eliminate as much light as possible.
•     Reserve the bed for sleep. Don't use the bed as an office, workroom or recreation room. Let your body "know" that the bed is associated with sleeping.
•     Practice relaxation techniques before bed. Relaxation techniques such as yoga, XXXXXXX breathing and others may help relieve anxiety and reduce muscle tension.
•     Don't take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a "worry period" during the evening or late afternoon to deal with these issues.
•     Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
•     Getting Up in the Middle of the Night :Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.
•     A Word About Television: Many people fall asleep with the television on in their room. Watching television before bedtime is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good idea.

I hope this information has been both informative and helpful for you. In case of any doubt, I will be available for follow ups.

Wish you good health.
Regards,

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Hello again,
Thanks for follow up.

Following steps will help you:
-Follow above steps of sleep hygiene.
-It is better to continue Mirtaz in my opinion, as started by your psychiatrist. It will also help in sleep. It will be better than Nurokind G in my opinion.
-Getting rid from sleeping pills required motivation and slow tapering of medicine. It can be tapered slowly (like 0.5mg every week).
-Sorry, I am in Delhi NCR region. It is limitation for us, that we can not prescribe any thing online because of ethical reasons, but we can guide you to resolve your suffering. As you are in Mumbai, you can find several psychiatrist around you. Even you can visit psychiatry department of multi speciality government hospital in your area like: XXXXXXX GS med College, XXXXXXX Med college and their associated hospital.

Please accept my answer in case there are no further queries and recommend our services to your friends too if you have found it helpful.

Wish you good health.
Regards.

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Hello again,
Thanks for follow up.

Q. Hi Doc,Literature says that Mirtaz is contraindicated for Glaucoma.
A. Yes, special precaution is needed with use of mirtaz in glaucoma cases, but it is not absolutely contraindicated. If your symptoms of glaucoma exacerbate with it, then it is better to avoid. In that case, you have to XXXXXXX psychiatrist again for prescription of new medicine.

Q. You have mentioned getting rid of sleeping pills requires motivation.You mean self motivation.
A. Yes

Q. I have stopped taking Zolpidem and in any case never exceeded 5mg which you will also agree is not a big dose.
A. Yes, you had controlled medicine doses by not increasing amount of medicine. But over a period of time tolerance develop and patient tend to increase dose. So, it is better to taper 10-20% dose of medicine every week, irrespective of zolpidem (5mg) or larpose(2mg).

Please accept my answer in case there are no further queries and recommend our services to your friends too if you have found it helpful.

Wish you good health.
Regards.

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