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Occasional difficulty falling asleep or staying asleep is common. To diagnose insomnia, the International Classification of Sleep Disorders—2nd edition (ICSD2), requires that the individual must have a sleep complaint (ie, difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or sleep that is nonrestorative or of poor quality), the sleep complaint must occur despite adequate opportunity and circumstances for sleep, and there must be daytime impairment related to the nighttime sleeping difficulty (eg, fatigue or malaise, mood disturbance or irritability, daytime sleepiness). Insomnia can be classified based on symptom duration, but definitions based on duration vary. Generally, insomnia must be present for at least a month to be considered a chronic insomnia.
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A detailed history is essential in determining the causes of insomnia. Key factors include recent stressors, and symptoms of depression, anxiety, or other psychiatric disorders.
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Instruments that can be helpful in the evaluation of insomnia include sleep questionnaires, sleep logs, symptom checklists, psychological screening tests, and interviews of bed partners. Examples of self-administered questionnaires are the Insomnia Severity Index (specific to insomnia) and the Pittsburgh Sleep Quality Index (a general questionnaire of sleep problems). Polysomnography and/or wrist actigraphy (which estimates sleep and wakefulness based on wrist movements) are not indicated for the routine evaluation of insomnia unless suggested by signs and symptoms of comorbid sleep disorders. Laboratory tests should be similarly guided based on signs or symptoms of comorbid conditions that appear associated with the insomnia.
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Differential Diagnosis
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In older adults, psychological problems, symptoms related to underlying medical illnesses, and the effects of medications are common causes of insomnia. Often, multiple factors may contribute to insomnia in the older patient.
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Many medical conditions can interfere with sleep, including chronic pain, dyspnea, gastroesophageal reflux disease, and nocturia. Medications reportedly account for 10% to 15% of cases of insomnia. Table 50–1 lists common offending agents. Many other agents can disrupt sleep, including caffeine and nicotine. Caffeine is an ingredient in many nonprescription medications and foods, and many people are unaware that they are ingesting caffeine-containing products. Nighttime alcohol use, while causing initial drowsiness, can interfere with sleep architecture later in the night and worsen sleep. Withdrawal from sedative–hypnotic agents can also lead to worsening insomnia.
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Most published guidelines recommend psychological and behavioral treatments as first-line therapy for the management of chronic insomnia. Cognitive–behavioral therapy for insomnia generally combines several treatments, including stimulus control, sleep restriction and cognitive therapy. Stimulus control promotes behaviors such as establishing regular morning rising and bedtimes, using the bedroom only for sleep and sexual activity, going to bed only when sleepy and getting out of bed if unable to fall asleep, and avoiding or limiting naps. Sleep restriction therapy seeks to improve sleep efficiency by causing modest sleep deprivation (by limiting time in bed) and then gradually increasing time in bed as sleep efficiency improves. Cognitive therapy focuses on correcting inaccurate ideas and thoughts about sleep. Cognitive–behavioral therapy for insomnia is generally provided by a psychologist with expertise in behavioral sleep medicine, but simpler approaches have been developed and tested for use by other personnel, such as nurses.
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Sleep hygiene is often a component of more comprehensive behavioral interventions for insomnia. Sleep hygiene addresses lifestyle and environmental factors (Table 50–2). However, simple sleep hygiene alone is rarely effective in the patient with a longstanding, severe chronic insomnia. Other behavioral interventions may include meditation and relaxation techniques to guide patients in recognizing and relieving tension and anxiety.
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Prescription medications—
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Pharmacologic agents (Table 50–3) can be considered if behavioral interventions are not fully successful, or the patient has an acute problem with insomnia and the benefits appear to outweigh the risks of these medications. Thoughtful selection of agents to minimize adverse side effects and drug interactions is reached by evaluating symptom types (eg, problem with sleep onset vs. awakening during the night), agent characteristics, comorbid conditions, and cost. In older adults, the starting dose should be the lowest available. Patient dosage self-adjustment should be discouraged.
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Benzodiazepines and related drugs are commonly prescribed for sleep. Long-acting benzodiazepines (eg, flurazepam) should not be used in older patients because of the risk of daytime carryover (sedation), falls, and fractures. Short- and intermediate-acting benzodiazepines can be used in older people; however, caution is warranted because of the risk of tolerance to the hypnotic effects of the medication and the potential for rebound insomnia on withdrawal. These agents also result in an increased risk of falls, and their half-life can be longer in older people.
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Nonbenzodiazepine hypnotics may have fewer side effects, and less daytime carryover, compared with benzodiazepines. Although structurally different from benzodiazepines, these agents also act at the gamma-aminobutyric acid (GABA) benzodiazepine receptor, but perhaps with greater specificity for sedative effects. In the United States, currently available nonbenzodiazepine agents include zolpidem, zaleplon, and eszopiclone (see Table 50–3). Caution is also warranted in the use of these newer sleeping medications for the management of chronic insomnia in older adults.
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The melatonin receptor agonist ramelteon is approved for sleep-onset insomnia. It is not a scheduled agent. With a half-life of 2.6 hours, it has been shown to reduce sleep latency and to increase total sleep time without rebound or withdrawal effects.
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There is some evidence for using a low-dose sedating antidepressant at night (with a more stimulating antidepressant during the day) for depressed patients who also report insomnia. Most published guidelines discourage use of a sedating antidepressant for insomnia unless the patient has failed other agents, or has an indication for an antidepressant. Low-dose doxepin is the only antidepressant that has been FDA approved for insomnia. However, like other sedating tricyclic antidepressants (eg, amitriptyline), it is not recommended for use in older patients because of its strong anticholinergic side effects.
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Nonprescription medications—
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Nonprescription sleeping aids often contain a sedating antihistamine (eg, diphenhydramine) alone or in combination with an analgesic. Diphenhydramine and similar compounds are not recommended for older people because of potent anticholinergic effects and the development of tolerance to sedating effects over time. A bedtime dose of an analgesic agent alone (eg, acetaminophen) may be safe and helpful if pain disrupts sleep. The herbal product valerian does not have sufficient evidence to support routine use. However, there is some evidence for use of prolonged-release melatonin.