What are the recommended treatments for a 68-year-old patient with insomnia?

From the Guidelines

For a 68-year-old patient with insomnia, I recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, which includes sleep hygiene education, stimulus control, sleep restriction, relaxation techniques, and cognitive therapy. This approach is supported by the American Academy of Sleep Medicine clinical practice guideline, which suggests that CBT-I is the treatment of choice for chronic insomnia disorder in adults 1.

Key Components of CBT-I

• Sleep restriction therapy
• Stimulus control
• Cognitive therapy
• Relaxation techniques

If non-pharmacological approaches are insufficient, short-term medication may be considered. However, it's essential to weigh the benefits and harms of pharmacological treatment, especially in older adults. The 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines advise against the use of benzodiazepines, antihistamines, and antipsychotics for the treatment of chronic insomnia disorder due to their adverse effect profiles 1.

Pharmacological Treatment Options

• Low-dose options: doxepin (3-6mg) at bedtime
• Short-term use of zolpidem (5mg), eszopiclone (1-2mg), or temazepam (7.5-15mg) may be appropriate, but limited to 2-4 weeks due to increased fall risk and cognitive impairment concerns in older adults

Melatonin (1-2mg) taken 1-2 hours before bedtime may help regulate sleep cycles with minimal side effects. Patients should establish a consistent sleep schedule, avoid caffeine after noon, limit alcohol, exercise regularly but not close to bedtime, and create a comfortable sleep environment. Underlying conditions like sleep apnea, depression, or pain should be addressed, as they commonly contribute to insomnia in older adults. Regular follow-up is essential to monitor effectiveness and adjust treatment as needed.

Lifestyle Modifications

• Establish a consistent sleep schedule
• Avoid caffeine after noon
• Limit alcohol
• Exercise regularly but not close to bedtime
• Create a comfortable sleep environment

It's crucial to consider the patient's preferences, values, and comorbid medical and psychiatric conditions when selecting a treatment approach. The American College of Physicians clinical practice guideline recommends using a shared decision-making approach to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1.

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 In a double-blind, parallel-group trial of 6 weeks’ duration comparing eszopiclone 2 mg and 3 mg with placebo, both 2 mg and 3 mg were superior to placebo on LPS at 4 weeks. Elderly subjects (ages 65 to 86) with chronic insomnia were evaluated in two double-blind, parallel-group trials of 2 weeks duration, all doses were superior to placebo on measures of sleep latency.

For a 68-year-old patient with insomnia, the recommended treatments include:

• Eszopiclone (PO): at a dose of 1 to 2 mg for elderly patients, which has been shown to decrease sleep latency and improve sleep maintenance in clinical trials 2.
• Zolpidem (PO): at a dose of 5 mg for elderly patients, which has been shown to be effective in reducing sleep latency and improving sleep quality in clinical trials 3.
• Ramelteon (PO): at a dose of 4 mg or 8 mg, which has been shown to reduce sleep latency in clinical trials, although the 8 mg dose may be more effective 4.

Key considerations:

• The choice of medication should be based on the patient's individual needs and medical history.
• The lowest effective dose should be used to minimize the risk of adverse effects.
• Patients should be monitored for adverse effects, such as next-day residual effects, rebound insomnia, and memory impairment.

From the Research

Recommended Treatments for Insomnia in a 68-year-old Patient

• Nonpharmacologic therapy is recommended as the first line of treatment, including addressing sleep hygiene issues and exercise 5
• Cognitive behavioral therapy for insomnia (CBT-i) is considered the most effective nonpharmacological treatment for chronic insomnia, with benefits including no side effects and long-term improvements in sleep quality 6
• Exercise is also recommended as it improves sleep as effectively as benzodiazepines in some studies and has other health benefits 5

Pharmacologic Options

• Hypnotics, such as benzodiazepines, should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances 5
• Newer-generation nonbenzodiazepines, such as zolpidem, zaleplon, eszopidone, and ramelteon, have a better safety profile and are recommended for long-term treatment of chronic insomnia 5
• Low-dose doxepin, melatonin, and dual orexin receptor antagonists are also considered pharmacologic options for older adults 7

Considerations for Older Adults

• Age-related alterations in sleep physiology should be taken into account when treating insomnia in older adults 7
• Clinicians should consider patient-specific criteria, such as medical history and other drug use, when recommending treatment 8
• The use of certain medications, such as narcoleptics, melatonin, antihistamines, and long half-life benzodiazepines, is not recommended in older adults 9