Evie Summers
Sleep disorders are a significant concern for the elderly, with chronic insomnia affecting 57% of the elderly in the United States, impairing their quality of life, functionality, and health. While sleep issues are common in older adults, it is important to distinguish between insomnia and advanced or delayed sleep phase syndrome, which involves napping during the day or at unconventional times. Treatment for insomnia in the elderly typically involves psychological/behavioural therapies, pharmacological treatment, or a combination of both. Non-pharmacological approaches, such as sleep hygiene, stimulus control, relaxation techniques, and behavioural therapies like cognitive-behavioural therapy, are often recommended as first-line treatments. When it comes to medication, controlled-release melatonin and doxepin are typically suggested as initial options for older adults. If these are ineffective, Z-drugs like zolpidem, eszopiclone, and zaleplon can be considered. Benzodiazepines, despite their common use, are not recommended due to their high abuse potential and the availability of safer alternatives.
| Characteristics | Values |
|---|---|
| Treatment for insomnia in elderly patients | Pharmacological Management, Psychological/Behavioral Therapies, or a combination of both |
| Treatment guidelines | Nonpharmacologic approaches such as sleep hygiene and behavioral methods |
| Drugs for insomnia | Orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines |
| FDA-approved drugs for insomnia | Suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon |
| Non-FDA-approved hypnotic agents | Melatonin, diphenhydramine, tryptophan, and valerian |
| Sedative hypnotics | Antidepressants, melatonin agonists, orexin receptor antagonists |
| Behavioral therapy techniques | Cognitive-behavioral therapy, stimulus control, progressive muscle relaxation, paradoxical intention |
| Sleep disorders in the elderly | Underdiagnosed, retirement, health problems, death of spouse/family members, changes in circadian rhythm |
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What You'll Learn
Behavioural therapy techniques
CBT-I generally takes 6 to 10 sessions delivered weekly or bi-weekly. Sessions involve psychoeducation, stimulus control, sleep restriction, sleep hygiene, relaxation training, and cognitive therapy techniques. Psychoeducation involves providing information about the connection between thoughts, feelings, behaviours, and sleep. Stimulus control interventions strengthen the association between bed and sleep, with instructions such as only going to bed when sleepy, getting out of bed if not asleep after 15-20 minutes, and using the bed only for sleep and sex. Sleep restriction treatment (SRT) aims to limit the total time spent in bed to match sleep ability and opportunity, using data from sleep diaries. Sleep hygiene interventions include no alcohol or caffeine before bed, no clock-watching, no daytime naps, consistent bed and wake-up times, and a sleep-conducive environment. Relaxation training can include progressive muscle relaxation, guided imagery, breathing exercises, and meditation. Cognitive therapy techniques involve questioning automatic thoughts or beliefs when they arise.
Other behavioural interventions that can help improve sleep include getting enough sunlight during the day, which helps regulate melatonin, and improving your sleep environment by making your room comfortable, dark, and quiet.
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Pharmacological treatment
Sleep disorders are a significant source of concern in the geriatric population. Several factors may contribute to sleep disturbances in older adults, including retirement, health problems, the death of a spouse or family member, and changes in circadian rhythm. Sleep complaints are common among the elderly, and it is important for physicians to differentiate between insomnia and other conditions such as advanced or delayed sleep phase syndrome.
If the first-line agents are ineffective, 'Z-drugs' such as zolpidem, eszopiclone, and zaleplon can be considered. These nonbenzodiazepine hypnotics are effective for improving sleep onset due to their shorter half-lives. Eszopiclone has a half-life of 6 hours, and higher doses are more suitable for sleep maintenance, while lower doses can aid in falling asleep. Zolpidem is also available in an extended-release form that can be used for both sleep onset and maintenance. However, it is important to note that zolpidem and zaleplon are not effective for sleep maintenance.
For those who struggle with staying asleep, low-dose doxepin and suvorexant, an orexin receptor antagonist, can be beneficial. While suvorexant is relatively effective, it is no more effective than the Z-drugs and is much more expensive. Benzodiazepines, while commonly used to treat insomnia, are not recommended due to their high abuse potential and adverse effects, especially with long-term use. Trazodone, a sedating antidepressant, is sometimes used off-label for insomnia, but it carries significant risks, and its efficacy is not supported by scientific evidence in patients without associated depression.
Other non-FDA-approved hypnotic agents that are commonly used include diphenhydramine, tryptophan, and valerian. However, limited data is available regarding their benefits and harms. It is important to note that drug-drug interactions are a concern in elderly patients who often take multiple medications, and this should be considered when prescribing sleep aids.
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Sleep hygiene rules
Sleep is an essential part of our lives, and it is no different for the elderly. Sleep disorders and insomnia are common issues for older adults, and these can significantly impact their quality of life. To improve sleep, it is recommended that non-pharmacological approaches be tried first. These include sleep hygiene rules and behavioural methods.
- Maintain a consistent sleep schedule: Go to bed and wake up at the same time every day, even on weekends or days off. This helps to regulate your body's internal clock and improve the quality of your sleep.
- Create a relaxing bedtime routine: Engage in calming activities before bed, such as reading, listening to soothing music, or practising relaxation techniques like deep breathing or meditation. Avoid stimulating activities and screen time close to bedtime, as these can interfere with your sleep schedule.
- Make your bedroom sleep-friendly: Ensure your bedroom is cool, dark, quiet, and free from distractions. Consider using blackout curtains, earplugs, or a white noise machine to create a comfortable sleep environment. Also, ensure your mattress, pillows, and bedding are comfortable and supportive.
- Limit daytime naps: While napping can be beneficial, try to limit naps to no more than 30 minutes and avoid napping too close to bedtime. Napping too frequently or for too long can disrupt your nighttime sleep.
- Exercise regularly: Engage in regular physical activity during the day, preferably in natural light. However, avoid strenuous exercise close to bedtime, as it may make it harder to fall asleep.
- Avoid stimulants and heavy meals close to bedtime: Caffeine, nicotine, and alcohol can disrupt sleep. Avoid consuming these substances close to bedtime, and limit heavy or spicy meals that may cause discomfort or indigestion, making it harder to fall asleep.
These sleep hygiene rules can help improve sleep quality and duration. However, if sleep issues persist, it is important to consult a healthcare professional, as there are various pharmacological treatments available for insomnia in the elderly. These include melatonin, doxepin, zolpidem, eszopiclone, and zaleplon.
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Orexin receptor antagonists
Sleep is essential for human well-being, but older persons (over 65 years old) often experience a reduction in the quality and quantity of sleep. This age group is more at risk of disorders accompanied or exacerbated by poor sleep, including Alzheimer's disease (AD) or related dementias.
Orexin/hypocretin neuropeptides are produced by hypothalamic neurons and play a critical role in regulating arousal, wakefulness, and various physiological functions. They bind to two G-protein coupled receptors, orexin 1 and orexin 2. Dysregulation of the orexin system occurs with aging and AD, making orexin receptor antagonists (ORAs) advantageous for these populations.
ORAs are approved for the treatment of insomnia in adults and have been shown to be efficacious hypnotics in older persons and dementia patients. They are generally well tolerated and are likely to be most effective when administered early in sleep/wake dysregulation to reestablish good sleep/wake behaviours.
Several phase II studies of dual orexin receptor antagonists (DORAs), including almorexant, lemborexant, and filorexant, have shown some improvement in sleep maintenance and sleep continuity. Other DORAs such as suvorexant, daridorexant, and seltorexant have also demonstrated efficacy in treating chronic insomnia across diverse clinical populations, including those with AD.
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Benzodiazepines
While benzodiazepines can be effective in treating insomnia in the elderly, there are some concerns about their use. One concern is the risk of falls, as higher dosage levels may increase this risk. Additionally, there is limited data on the efficacy of benzodiazepines in the elderly population. Only one large-scale study has been conducted, which found that temazepam significantly decreased subjective sleep latency compared to a placebo.
It is important to note that non-pharmacologic approaches to insomnia treatment are generally recommended as the first line of treatment. These include sleep hygiene and behavioral methods such as cognitive-behavioral therapy, stimulus control, progressive muscle relaxation, and paradoxical intention. These approaches can be used alone or in combination with pharmacotherapy and may aid in the long-term management of insomnia.
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Frequently asked questions
Behavioural therapy techniques such as cognitive-behavioural therapy, stimulus control, progressive muscle relaxation, and paradoxical intention are recommended as first-line therapies for insomnia. Sleep hygiene rules should also be followed.
Controlled-release melatonin and doxepin are recommended as first-line agents. If these are ineffective, the so-called Z-drugs (zolpidem, eszopiclone, and zaleplon) can be used. Benzodiazepines are not recommended due to their high abuse potential, but they can be used to treat insomnia in some cases.
Several factors may contribute to sleep disturbances in the elderly, including retirement, health problems, death of a spouse or family member, and changes in circadian rhythm.
Benzodiazepines can cause memory impairment, loss of coordination, and daytime somnolence. They may also disrupt the quality of sleep by distorting sleep architecture and reducing deep sleep time.
Yes, light therapy has been used to manage sleep disturbances in patients with dementia.
