Insomnia is defined as the inability to fall asleep, the inability to stay asleep, or waking up earlier than desired. In order to have a clinical diagnosis of insomnia the patient must have an adequate sleep opportunity and adequate sleep environment. The sleep disturbance must also have an impact on their quality of life such as fatigue, impaired cognitive performance, mood disturbance, daytime sleepiness, behavioral problems, reduced motivation, proneness for errors, or concerns about sleep. Insomnia is categorized as chronic if it persists more than 3 months and short term if it has lasted fewer than 3 months. The most recent International Classification of Sleep Disorders no longer emphasizes previously distinguished insomnia subtypes or insomnia due to mental or medical disorders. This is because it is increasingly recognized that even when insomnia is related to another condition, treatment of the comorbid condition often does not cure the insomnia. Furthermore, individual patients often have an overlap across insomnia subtypes.
Insomnia is a highly prevalent sleep disorder, affecting up to 10% of young adults; however it increases to about 30% in those greater than 65 years. Transient insomnia may affect up to 30% to 40% of the population. The prevalence of insomnia is much higher in older adults, which is likely due to age-related reductions in sleep efficiency and the accrual of comorbidities that are associated with insomnia. A recent meta-analysis of epidemiologic studies shows that the relative risk of insomnia in women compared with men increases with age.
Comorbid psychiatric conditions increase the likelihood of developing chronic insomnia. Depression is perhaps the most common and strongly associated mental illness with insomnia. Anxiety is also a risk factor for developing insomnia; as is being a caregiver for an ill family member, with up to 40% of caregivers reporting taking sleep aids for insomnia.
A wide variety of medical problems are associated with insomnia. Epidemiologic evidence shows a greater prevalence of insomnia in hypertension, heart disease, arthritis, lung disease, gastrointestinal reflux, stroke, and neurodegenerative disorders, to only name a few. Symptoms of medical illnesses that can disrupt sleep include pain, paresthesias, cough, dyspnea, reflux, and nocturia.
Many medications can impair sleep or change sleep architecture. If stimulating medications (eg, caffeine, sympathomimetics, bronchodilators, activating psychiatric medications) are taken too near to bedtime, sleep can be disturbed (Table 49-3).
TABLE 49-3EFFECT OF COMMON DRUGS TAKEN BY OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 49-3 EFFECT OF COMMON DRUGS TAKEN BY OLDER ADULTS
|SEDATING ||ALERTING |
Calcium channel blockers
Late-life insomnia is often a long-lasting problem. One study showed that a third of older patients had persistent severe insomnia symptoms at 4-year follow-up. Among women older than 85 years, more than 80% reported sleeping difficulties, with many using over-the-counter (OTC) sleeping medications. Several epidemiologic studies have linked sleep disturbances with worse health-related quality of life, nursing home placement, and even death.
The causes of insomnia are often multifaceted. One popular theoretical model for insomnia posits that there are predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are a vulnerability to insomnia and may include anxiety, depression, or hyperarousal. Precipitating factors are triggers for insomnia such as loss of a spouse, retirement, moving to a new home, or any other sort of stressor. Perpetuating factors are maladaptive habits or beliefs that the patient has acquired to deal with the insomnia such as spending long periods in bed or taking naps.
As noted earlier, insomnia in older adults is often comorbid with medical or psychiatric illnesses. The symptoms such as pain, dyspnea, or nocturia may be so significant that these become the primary driving factors behind the sleep disturbance.
Patients with insomnia may present to their primary care provider with specific complaints about either not being able to fall asleep or stay asleep. However, many patients do not talk to their doctors about their sleep complaints. Instead, the presence of insomnia may be revealed by eliciting self-medication with OTC or alternative sedatives.
A careful sleep history and evaluation should be conducted in patients with insomnia in order to assess whether there are comorbid sleep disorders, such as SDB, underlying the sleep disturbance.
PSG and other sleep studies are not necessary in the evaluation of insomnia; however, they should be obtained if a comorbid sleep condition is suspected. Sleep diaries with daily entries over 1 to 2 weeks can be very helpful in determining the severity of the insomnia as well as identifying possible perpetuating factors such as irregular bedtimes or late-night caffeine (Table 49-4). This may help the patient gain more insight into their sleep problem. Wrist actigraphy in conjunction with a sleep diary can be used to obtain a more objective measure of the patient’s overall sleep-wake pattern. This device is particularly helpful when accuracy of the sleep diary is questionable or when sleep-wake misperception is suspected.
TABLE 49-4SAMPLE SLEEP DIARY |Favorite Table|Download (.pdf) TABLE 49-4 SAMPLE SLEEP DIARY
|NAME:_____________________________ || || || || ||DATE: __________TO________ |
| ||MONDAY ||TUESDAY ||WEDNESDAY ||THURSDAY ||FRIDAY ||SATURDAY ||SUNDAY |
| 1. Bedtime || || || || || || || |
| 2. Time taken to fall asleep (after lights off) || || || || || || || |
| 3. Number of nighttime awakenings || || || || || || || |
| 4. Wake-up time || || || || || || || |
| 5. Time out of bed (morning) || || || || || || || |
| 6. Total sleep time (night only) || || || || || || || |
| 7. Total wake time (night only) || || || || || || || |
| 8. Nap time (if any) || || || || || || || |
| 9. Medication (time/dosage) || || || || || || || |
|10. Alcohol (time/dosage) || || || || || || || |
|11. How was your sleep last night?a || || || || || || || |
|12. How tired were you in the morning?b || || || || || || || |
Behavioral and nonpharmacologic interventions appear to have better long-term efficacy with fewer side effects than pharmacologic interventions. Therefore, behavioral interventions are preferred for the treatment of insomnia, particularly in older patients. However, access to highly skilled professionals trained in such interventions may be limited in some health care systems.
Most pharmacotherapy for insomnia is designed and approved for the treatment of transient sleep disturbances. Pharmacotherapy can be considered when insomnia is triggered by an acute event or when chronic insomnia persists despite behavioral insomnia treatment. Sedative-hypnotics have been associated with adverse side effects in older adults, such as falls, cognitive slowing, and fractures. Therefore, if a sedative-hypnotic is used in older individuals, the smallest dose of an agent with the least risk of adverse events should be chosen for the shortest duration necessary. In general, short-acting drugs should be used for patients who have trouble falling asleep while intermediate-acting drugs should be used when patients have trouble staying asleep (Table 49-5).
TABLE 49-5PRESCRIPTION MEDICATIONS COMMONLY USED FOR INSOMNIA IN OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 49-5 PRESCRIPTION MEDICATIONS COMMONLY USED FOR INSOMNIA IN OLDER ADULTS
|CLASS, MEDICATION ||STARTING DOSE (MG) ||USUAL DOSE (MG) ||HALF-LIFE (H) ||COMMENTS |
|Intermediate-acting benzodiazepine |
|Temazepam ||7.5 ||7.5–30 ||8.8 ||Psychomotor impairment, increased risk of falls |
|Short-acting nonbenzodiazepines |
|Eszopiclone ||1 ||1–2 ||6 ||Reportedly effective for long-term use in selected individuals; may be associated with unpleasant taste, headache; avoid administration with high-fat meal |
|Zaleplon ||5 ||5–10 ||1 (reportedly unchanged in older adults) ||Reportedly little daytime carryover, tolerance, or rebound insomnia |
|Zolpidem ||5 ||5 ||1.5–4.5 (3 in older adults, 10 in hepatic cirrhosis) ||Reportedly little daytime carryover, tolerance, or rebound insomnia |
|Melatonin receptor agonist |
|Ramelteon ||8 ||8 ||1.5 (2.6 in older adults) ||Dizziness, myalgia, headache, other adverse events reported; no significant rebound insomnia or withdrawal with discontinuation |
|Sedating antidepressants |
|Doxepin ||3 ||3–6 ||15.3 (doxepin); 31 (metabolite) ||Somnolence/sedation, nausea, and upper respiratory tract infection reported; antagonizes central H1 receptors (antihistamine); active metabolite; should not be taken within 3 h of a meal |
|Mirtazapine ||7.5 ||7.5–45 ||31–39 in older adults; 13–34 in younger adults; mean = 21 ||Increased appetite, weight gain, headache, dizziness, daytime carryover; used for insomnia with depression |
|Trazodone ||25–50 ||25–150 ||Reportedly 6 ± 2; prolonged in older adults and obese individuals ||Moderate orthostatic effects; administration after food minimizes sedation and postural hypotension; used for insomnia with depression |
Benzodiazepines have had a long history of being used for insomnia. These drugs bind nonselectively to the γ-aminobutyric acid benzodiazepine (GABA-A) receptor subunits. The overall effects of these drugs are to induce anxiolysis, sedation, and amnesia. Temazepam, lorazepam, and estazolam are intermediate-acting agents that are most commonly used for insomnia, while triazolam is a shorter-acting agent that is sometimes used for insomnia. Due to next-day effects, the longer-acting agents, flurazepam and quazepam, should not be used in older adults. Benzodiazepines do decrease the time to fall asleep by about 10 minutes on average and the number of awakenings, thereby increasing the total sleep time by 30 to 60 minutes during the nighttime. The side effects associated with this class of medications include confusion, falls, rebound insomnia, tolerance, and withdrawal symptoms on discontinuation. These agents are all Beer criteria–listed medications as potentially inappropriate for use in geriatric patients.
Nonbenzodiazepine-benzodiazepine receptor agonists (NBRAs [ie, nonbenzodiazepines such as eszopiclone, zolpidem, and zaleplon]) are structurally unrelated to benzodiazepines but bind selectively to the GABA-A receptors. They generally produce sedation and amnestic effects without the anxiolytic properties. These agents likely have similar efficacy to benzodiazepines but with a somewhat better side effect profile, in part due to their relatively short duration of action. In healthy older adults without comorbidities, NBRAs are relatively well tolerated. Zolpidem and zaleplon should only be taken immediately before bed because of their rapid onset of action. Eszopiclone has a longer duration of action than the other NRBAs, and is better for sleep maintenance but may cause drowsiness in the morning. There is also an extended-release form of zolpidem that can be used for sleep maintenance insomnia. Guidelines only recommend these medications for use in short-term insomnia. Concerns remain regarding the risks of falls, confusion, and fracture in older adults, particularly in those with frailty. The emergence of complex sleep-related behaviors such as sleep driving and sleep eating has been seen with zolpidem, which may be class side effect with these agents.
Melatonin receptor agonists (eg, ramelteon) are approved for insomnia. Rather than activating GABA receptors, ramelteon is selective for the MT1/MT2 melatonin receptors. Ramelteon has been shown to reduce total sleep latency and increase sleep time in older adults, with fewer side effects. Somnolence, dizziness, headache, and fatigue can be side effects of this agent. The major downside of ramelteon is that its lack of amnestic properties makes it somewhat less effective for subjective improvement in sleep.
Other agents are available for treatment of insomnia. The tricyclic antidepressant doxepin has recently been developed for insomnia in a low-dose formulation (3–6 mg). For comparison, the usual antidepressant dose of doxepin is 100 to 300 mg per day. At these low dosages doxepin selectively antagonizes H1 receptors, which is believed to have sleep-promoting effects. The duration of action for doxepin makes it more attractive for problems with sleep maintenance rather than sleep onset. The use of low doses of other sedating antidepressants such as trazodone and mirtazapine at bedtime is common. However, there is limited evidence to support this practice. In fact, a study in the use of trazodone for nondepressed patients showed that there was short-term benefit, which dissipated after 2 weeks. Thus, the benefits may be very small compared to the potential for side effects. However, if there is comorbid depression it should be treated, and sedating antidepressants may be a good choice as primary or adjunctive therapy.
Although sedating antipsychotics are sometimes used to treat insomnia, there is scant evidence demonstrating their efficacy, and these medications can have significant adverse events, including increased mortality particularly in older adults with dementia. Guidelines suggest that sedating antipsychotics should not routinely be used in the management of insomnia in older adults without coexisting serious psychiatric conditions that warrant use of these agents.
Almost half of all older adults report the use of nonprescription OTC sleeping agents. Common nonprescription agents include sedating antihistamines, acetaminophen, alcohol, melatonin, and herbal products. The sedating antihistamines (eg, diphenhydramine) are the most common ingredients in these OTC drugs marketed for sleep. Diphenhydramine is sedating through its potent anticholinergic effect, and tolerance to its sedating effect develops rapidly. The long half-life of diphenhydramine may result in next-day sedation. Patients may also experience dry mouth, urinary retention, delirium, decreased cognition, constipation, and increased ocular pressure. For these reasons, diphenhydramine should not be used as a primary treatment for insomnia in older patients. Many patients may use alcohol to self-medicate for insomnia; however, it can interfere with sleep in the later evening and worsen sleep difficulties.
Other supplements are available OTC, such as melatonin and valerian. One drawback of these supplements is the lack of standardization and oversight of traditional pharmaceuticals. There is evidence that melatonin improves time to fall asleep and sleep efficiency in older adults. However, the results of studies have been mixed. Valerian is a herbal product marketed for insomnia due to its mild sedative properties. Some valerian preparations contain multiple botanicals, which may increase the chance of side effects. A recent systematic review on the efficacy for valerian for insomnia was inconclusive. Kava, another herbal product marketed for insomnia, has a significant risk of adverse events, including hepatotoxicity, and is not recommended.
Behavioral and other nonpharmacologic interventions
Behavioral treatment of insomnia is the safest, and perhaps, the most effective therapy for insomnia in older adults. This modality of therapy has also proven effective in patients with comorbid conditions. Effective behavioral interventions for insomnia go beyond sleep hygiene, which is not generally effective when used alone for chronic insomnia. Several randomized trials and systematic reviews provide strong evidence for cognitive behavioral therapy for insomnia (CBT-I). CBT-I usually combines sleep hygiene, stimulus control, sleep restriction, and cognitive therapy, each of which will be discussed in greater detail below. CBT-I has reliably been shown to produce improved sleep efficiency, decreased nighttime wakefulness, and greater satisfaction with sleep. In at least two randomized trials with older adults comparing CBT-I with a prescription sedative-hypnotic agent, participants reported better improvement in sleep and more satisfaction with the CBT-I therapy. One feature that permeates studies comparing CBT-I to pharmacologic therapy is that the improvements with CBT-I are more sustained. One of the major downsides to CBT-I is the limited access to practitioners who are trained in this specific therapy, but efforts are underway in some health care systems to increase access. Also, CBT-I requires significant buy-in from the patient. New delivery models that involve the use of the internet, nonspecialist providers, and telehealth-based CBT-I have yielded promising preliminary results.
Sleep hygiene is education on a list of general guidelines to maintain a healthy sleep-wake routine. When a sleep history is performed behaviors that contribute to disruptive sleep should be ascertained. Examples of these behaviors include sleeping with the television on, or excessive caffeine consumption. The patient should be educated on some of their behaviors that constitute poor sleep hygiene (Table 49-6).
TABLE 49-6SLEEP HYGIENE RULES FOR OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 49-6 SLEEP HYGIENE RULES FOR OLDER ADULTS
Check effect of medication on sleep and wakefulness.
Avoid caffeine, alcohol, and cigarettes after lunch.
Limit liquids in the evening.
Keep a regular bedtime-waketime schedule.
Avoid naps or limit to 1 nap a day, no longer than 30 min.
Spend time outdoors (without sunglasses), particularly in the late afternoon or early evening.
Exercise—but limit exercise immediately before bedtime.
Stimulus-control therapy is designed to break the negative associations patients have with their sleep environment, which have come about from maladaptive behaviors. Patients are instructed to not have any other in-bed activities aside from sleep or sex, and to only go to bed when tired enough to fall asleep. They should unwind prior to going to bed and should not watch an alarm clock. If the patient cannot fall asleep within approximately 20 minutes they should get out of bed and do a relaxing activity and only return to bed when able to fall asleep. For a regular pattern to develop the patient needs to avoid napping and should get out of bed the same time each day. Daytime sleepiness may increase early in this therapy (Table 49-7).
TABLE 49-7INSTRUCTIONS FOR STIMULUS-CONTROL THERAPY FOR OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 49-7 INSTRUCTIONS FOR STIMULUS-CONTROL THERAPY FOR OLDER ADULTS
Patient should only go to bed when tired or sleepy.
If unable to fall asleep within 20 min, patient should get out of bed (and bedroom if possible). While out of bed, do something quiet and relaxing.
Patient should only return to bed when sleepy.
If unable to fall asleep within 20 min, patient should again get out of bed.
Behavior is repeated until patient can fall asleep within a few minutes.
Patient should get up at the same time each morning (even if only a few hours of sleep).
Naps should be avoided.
Sleep-restriction therapy was developed from the observation that many patients with insomnia spend a large amount of time in bed unsuccessfully attempting to sleep. This unsuccessful attempt at sleep causes anxiety and frustration which then can lead to the negative associations around the sleep environment. Sleep-restriction therapy is guided by the patient’s sleep diary. The amount of time the patient actually sleeps is calculated and the patient is only allowed to spend that amount of time plus around 15 minutes in bed each night for the following week. Since the amount of sleep will be less this will lead to some sleep deprivation, which then may allow the patient to subsequently fall asleep more quickly and have more consolidated sleep. Once the patient is spending at least 85% of their time asleep the time in bed is increased gradually until the patient is getting adequate sleep (Table 49-8).
TABLE 49-8INSTRUCTIONS FOR SLEEP RESTRICTION THERAPY FOR OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 49-8 INSTRUCTIONS FOR SLEEP RESTRICTION THERAPY FOR OLDER ADULTS
Calculate the average amount of time in bed per night reported by patient.
Patient is only allowed to stay in bed for this amount of time plus 15 min.
Patient must get up at the same time each day.
Daytime napping should be strictly avoided.
When sleep efficiency has reached 80% to 85%, patient can go to bed 15 min earlier.
This procedure should be repeated until patient can sleep for 8 h (or period needed for a good night’s sleep).
Cognitive therapy in CBT-I addresses the maladaptive thoughts or dysfunctional beliefs patients have about their sleep. This is essential to be addressed to ensure adherence to the behavioral aspects of the therapy. Other components of CBT-I may include various relaxation techniques and scheduled worry time. Image rehearsal therapy may be helpful with patients who have trouble sleeping from nightmares related to PTSD.
There are several small studies that have found a beneficial effect of bright light, either from natural sunlight or light boxes, on the sleep of older adults. The reported effects of light on insomnia are more variable than those reported for circadian rhythm disorders. Evening light exposure may be useful for those who go to sleep and wake up too early (ie, advanced sleep phase), while morning exposure may be useful in patients who stay up and sleep in late (ie, delayed sleep phase).
There is less evidence to support other behavioral interventions, but individual patients may find them useful. For example, bathing before sleep can enhance sleep quality in some older individuals, which is likely related to changes in body temperature. A moderate exercise program can improve sleep in healthy sedentary older adults. However, strenuous exercise should not be done close to bedtime because this may interfere with sleep. Some studies have shown a beneficial effect of Tai Chi on symptoms of insomnia.