What are the recommended treatments for insomnia in the elderly?

From the Guidelines

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia in elderly patients, as it has been shown to improve sleep outcomes and reduce symptoms of insomnia. This approach involves sleep restriction, stimulus control, relaxation techniques, and sleep hygiene education, and can be delivered through various methods, including in-person individual therapy, group therapy, telephone-based modules, and self-help books 1.

When medications are necessary, short-term use of low-dose options is preferred. Appropriate medications include low-dose trazodone (25-50mg), mirtazapine (7.5-15mg), or melatonin (1-3mg) 1. If these are ineffective, short-term use of non-benzodiazepine hypnotics like zolpidem (5mg) or eszopiclone (1-2mg) may be considered. Traditional benzodiazepines should generally be avoided due to increased fall risk, cognitive impairment, and dependence potential.

Some key points to consider when treating insomnia in elderly patients include:

• Medication duration should be limited to 2-4 weeks when possible, with gradual tapering to prevent rebound insomnia 1.
• Elderly patients are more sensitive to medication side effects due to altered metabolism and drug clearance, making lower starting doses and careful monitoring essential.
• Addressing underlying conditions like depression, anxiety, pain, or sleep apnea is also crucial for effective insomnia management.
• Sleep hygiene practices, such as maintaining regular sleep schedules, creating a comfortable sleep environment, avoiding caffeine and alcohol before bedtime, limiting daytime napping, and reducing screen time before sleep, can also help improve sleep outcomes 1.

Overall, a comprehensive approach that incorporates non-pharmacological and pharmacological treatments, as well as addressing underlying conditions and promoting sleep hygiene practices, is essential for effective management of insomnia in elderly patients.

From the FDA Drug Label

The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Two of these trials were in elderly patients (n=523) Overall, at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg), eszopiclone significantly decreased sleep latency and improved measures of sleep maintenance Elderly subjects (ages 65 to 86) with chronic insomnia were evaluated in two double-blind, parallel-group trials of 2 weeks duration One study (n=231) compared the effects of eszopiclone with placebo on subjective outcome measures, and the other (n=292) on objective and subjective outcome measures. The first study compared 1 mg and 2 mg of eszopiclone with placebo, while the second study compared 2 mg of eszopiclone with placebo. All doses were superior to placebo on measures of sleep latency. In both studies, 2 mg of eszopiclone was superior to placebo on measures of sleep maintenance.

The recommended treatments for insomnia in the elderly include eszopiclone at a dose of 1 to 2 mg.

• Key benefits of eszopiclone for elderly patients with insomnia include:
  • Reduced sleep latency
  • Improved sleep maintenance
• Important considerations for the use of eszopiclone in elderly patients include:
  • Next-day residual effects, such as psychomotor and memory impairment
  • Potential for rebound insomnia and withdrawal-emergent anxiety and insomnia 2

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 All zolpidem doses were superior to placebo on the two primary PSG parameters (sleep latency and efficiency) and all four subjective outcome measures (sleep duration, sleep latency, number of awakenings, and sleep quality).

Zolpidem is also effective for the treatment of insomnia in the elderly, with recommended doses of 5 mg.

• Key benefits of zolpidem for elderly patients with insomnia include:
  • Improved sleep latency and efficiency
  • Increased sleep duration and quality
• Important considerations for the use of zolpidem in elderly patients include:
  • Next-day residual effects, such as decreased performance on the Digit Symbol Substitution Test (DSST)
  • Potential for anterograde amnesia and impaired sleep on the first post-treatment night at doses above the recommended elderly dose of 5 mg 3

From the Research

Recommended Treatments for Insomnia in the Elderly

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

• Psychological/Behavioral Therapies: These are often viewed as the initial treatment intervention by various specialty societies 4. Cognitive Behavioral Therapy (CBT) has been shown to be effective in both short- and long-term management of insomnia in older adults, resulting in improved sleep efficiency and increased time spent in slow-wave sleep compared to pharmacological treatments like zopiclone 5.
• Pharmacological Treatment: This plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies 4. FDA-approved drugs for insomnia include suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon. The choice of a hypnotic agent in the elderly is symptom-based, with ramelteon or short-acting Z-drugs treating sleep-onset insomnia, and suvorexant or low-dose doxepin improving sleep maintenance 4.
• Non-Pharmacological Interventions: These have been found to be effective in treating insomnia in the elderly. A systematic review and network meta-analysis found that interventions such as acupressure, auricular acupuncture, mindfulness-based stress reduction program, and tart cherry juice were better than their control interventions in improving sleep quality 6. Another study found that non-pharmacological treatments like acupuncture, behavioral therapy, and cognitive behavioral therapy (CBT) showed significant superiority in effectiveness compared to wait-list 7.

Considerations for Treatment

When considering treatment for insomnia in the elderly, it's essential to evaluate the patient's symptoms, contributing factors, and effects on daytime function 8. Non-pharmacological strategies are a mainstay of treatment for chronic insomnia, but hypnotics have a role in treating transient insomnia and chronic insomnia that does not improve with non-pharmacological treatment or treatment of associated primary conditions 8. The choice of treatment should be based on the individual patient's needs and symptoms, with consideration of the potential benefits and harms of each treatment option 4, 6.