What is the recommended treatment for insomnia in elderly patients with sleep disturbances?

From the Guidelines

The most effective treatment for insomnia in elderly patients is cognitive behavioral therapy for insomnia (CBT-I), which should be considered as the first-line treatment. This approach is recommended due to its ability to improve global outcomes, including increased remission and treatment response, and reduced insomnia severity index (ISI) and Pittsburgh Sleep Quality Index (PSQI) scores compared to controls 1.

Key Considerations

• CBT-I has been shown to improve sleep outcomes in older adults, including reduced sleep onset latency and wake after sleep onset, and improved sleep efficiency 1.
• If medication is necessary, low-dose, short-acting medications such as melatonin or low-dose trazodone should be used temporarily, with careful consideration of potential side effects and interactions 1.
• Traditional sedative-hypnotics like benzodiazepines should be avoided or used very cautiously due to increased risks of falls, cognitive impairment, and dependence in elderly patients.

Treatment Approach

• Start with non-pharmacological approaches, including sleep hygiene education, CBT-I, regular physical activity, and maintaining consistent sleep schedules.
• If medication is necessary, use low-dose, short-acting medications and follow the principle of "start low, go slow" with regular reassessment every 2-4 weeks to evaluate effectiveness and side effects.
• Identify and treat underlying conditions that may contribute to insomnia, such as depression, anxiety, pain, or sleep apnea.

Rationale

The recommended approach is based on the most recent and highest quality evidence, which prioritizes CBT-I as the first-line treatment for insomnia in elderly patients due to its effectiveness and safety profile 1. This approach also takes into account the potential risks and side effects associated with pharmacological treatments, particularly in older adults 1.

From the FDA Drug Label

Both zolpidem doses were superior to placebo on objective (polysomnographic) measures of sleep latency, sleep duration, and number of awakenings Normal elderly adults (mean age 68) experiencing transient insomnia (n=35) during the first two nights in a sleep laboratory were evaluated in a double-blind, crossover, 2-night trial comparing four doses of zolpidem (5,10,15 and 20 mg) and placebo Zolpidem 10 mg was superior to placebo on a subjective measure of sleep latency for all 4 weeks, and on subjective measures of total sleep time, number of awakenings, and sleep quality for the first treatment week.

The recommended treatment for insomnia in elderly patients with sleep disturbances is zolpidem at a dose of 5-10 mg.

• Key benefits:
  • Improves sleep latency
  • Increases sleep duration
  • Reduces number of awakenings
  • Enhances sleep quality 2

From the Research

Treatment Options for Insomnia in Elderly Patients

The treatment of insomnia in elderly patients can be approached through various methods, including psychological/behavioral therapies, pharmacological treatment, or a combination of both 3.

• Psychological/Behavioral Therapies: These are considered the initial treatment intervention by various specialty societies 3. Cognitive behavioral therapy for insomnia is the gold standard for treatment of insomnia in older adults 4.
• Pharmacological Treatment: This plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies 3.

Pharmacological Options

Several pharmacological options are available for the treatment of insomnia in elderly patients, including:

• Ramelteon: This can treat sleep-onset insomnia and has a minimal adverse effect profile, making it a valuable first-line option 5.
• Suvorexant: This can improve sleep maintenance and has mild adverse effects, including somnolence 5.
• Low-dose doxepin: This can improve sleep maintenance 3, 4.
• Zolpidem: This is a helpful drug for the treatment of insomnia in conjunction with cognitive-behavioral therapy, but its use should be approached with caution due to potential side effects such as falls, hip fractures, and complex behaviors 6.
• Dual orexin receptor antagonists: These have shown some improvement in sleep maintenance and sleep continuity 3, 4.
• Melatonin: This slightly improves sleep onset and sleep duration, but product quality and efficacy may vary 3, 4.

Considerations for Treatment

When selecting a treatment option for insomnia in elderly patients, it is essential to consider the potential risks and benefits of each option.

• Benzodiazepines should not be used routinely due to their potential for adverse effects such as dementia, serious injury, and fractures 5.
• Non-benzodiazepine receptor agonists have improved safety profiles compared to benzodiazepines but can still cause side effects such as dementia, serious injury, and fractures 5.
• Sedating low-dose antidepressants should only be used for insomnia when the patient has comorbid depression 5.
• Antipsychotic agents, pramipexole, and tiagabine have considerable adverse effects and should be used with caution 5.
• Gabapentin may be useful in patients with restless leg syndrome or chronic neuropathic pain and insomnia 5.
• Diphenhydramine should be avoided in the elderly due to its potential for adverse effects 5.
• Valerian and melatonin are unregulated products that have a small impact on sleep latency and can produce residual sedation 5.