From the Guidelines
The recommended treatment approach for insomnia in elderly patients should begin with non-pharmacological interventions, specifically cognitive behavioral therapy for insomnia (CBT-I), before considering medications. This approach is supported by the most recent and highest quality study, which found that CBT-I is effective in improving sleep outcomes and reducing symptoms of insomnia in older adults 1. Sleep hygiene education is also an essential component of non-pharmacological interventions, and includes maintaining regular sleep schedules, creating a comfortable sleep environment, limiting caffeine and alcohol, and avoiding daytime napping.
Some key points to consider when treating insomnia in elderly patients include:
- CBT-I is a multisession, multicomponent treatment that focuses on sleep-specific thoughts and behaviors, and has been shown to be effective in improving sleep outcomes and reducing symptoms of insomnia in older adults 1.
- Behavioral components of CBT-I include sleep restriction therapy, stimulus control, relaxation therapy, and sleep hygiene education.
- Cognitive therapy components of CBT-I target maladaptive thoughts and beliefs about sleep.
- If medications are necessary, they should be used at the lowest effective dose for the shortest duration possible, and traditional benzodiazepines should generally be avoided due to increased risk of falls, cognitive impairment, and dependence in older adults.
- Short-term use of medications like low-dose trazodone (25-50mg), mirtazapine (7.5-15mg), or melatonin (1-2mg) may be appropriate, and non-benzodiazepine hypnotics like zolpidem (starting at 5mg) or eszopiclone (1-2mg) should be prescribed cautiously with close monitoring 1.
Overall, a conservative approach to treating insomnia in elderly patients is recommended, prioritizing non-pharmacological interventions and minimizing the use of medications to reduce the risk of adverse events and improve sleep outcomes.
From the Research
Treatment Approaches for Insomnia in the Elderly
- Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended treatment approach for insomnia in the elderly, as it has adequate evidence from clinical trials to support its management 2, 3, 4, 5, 6.
- CBT-I is a brief, sleep-focused, multimodal intervention that includes behavioral and cognitive components, such as sleep restriction, stimulus control, relaxation, cognitive strategies, and sleep hygiene education 2, 3, 4, 5, 6.
- Nonpharmacologic modalities, including behavioral, cognitive, and physiologic interventions, may be used alone or in combination with pharmacologic therapy for effective treatment of insomnia in the elderly 3.
- CBT-I has been found to be an effective alternative to pharmacotherapy, with significant improvements in sleep onset latency, wakefulness after sleep, sleep efficiency, and sleep quality in adults with insomnia, including older adults 4, 5.
Components of CBT-I
- Sleep restriction therapy: involves restricting the amount of time spent in bed to improve sleep quality 6.
- Stimulus control therapy: involves removing stimuli that interfere with sleep, such as electronics and stressors 6.
- Sleep hygiene: involves establishing a consistent sleep schedule, avoiding caffeine and nicotine, and creating a relaxing sleep environment 6.
- Cognitive therapy: involves identifying and challenging negative thoughts and beliefs that contribute to insomnia 6.