From the Guidelines
Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment for insomnia in elderly patients. This approach involves a combination of treatments, including sleep hygiene education, stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, and has been shown to be effective in improving sleep outcomes and reducing symptoms of insomnia in older adults 1.
Key Components of CBT-I
- Sleep hygiene education: maintaining consistent sleep-wake times, avoiding caffeine and alcohol before bedtime, creating a comfortable sleep environment, and limiting daytime napping
- Stimulus control: associating the bed with sleep and removing distractions
- Sleep restriction: limiting time spent in bed to improve sleep efficiency
- Relaxation techniques: such as deep breathing, progressive muscle relaxation, and mindfulness meditation
- Cognitive restructuring: identifying and challenging negative thoughts and beliefs about sleep
Pharmacological Options
If medications are necessary, short-term use of low-dose medications is preferred. Options include:
- Melatonin (1-2mg taken 1-2 hours before bedtime)
- Trazodone (25-50mg at bedtime)
- Mirtazapine (7.5-15mg at bedtime) Benzodiazepines and Z-drugs (zolpidem, eszopiclone) should be avoided when possible due to increased risks of falls, cognitive impairment, and dependence in older adults 1.
Addressing Underlying Conditions
Underlying conditions like sleep apnea, restless leg syndrome, depression, or pain should be addressed, as they commonly contribute to insomnia in this population. Regular physical activity during the day and light exposure in the morning can also help regulate the sleep-wake cycle in older adults 1.
High-Value Care
CBT-I is an effective therapy for chronic insomnia disorder and can be performed and prescribed in the primary care setting, making it a high-value care option for elderly patients with insomnia 1.
From the FDA Drug Label
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 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. 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
The recommended treatment for insomnia in the elderly is zolpidem at a dose of 5 mg. This dose has been shown to be effective in improving sleep latency, sleep duration, and sleep quality in elderly patients with transient insomnia 2.
- Key benefits of zolpidem for insomnia in the elderly include:
- Improved sleep latency
- Improved sleep duration
- Improved sleep quality
- Important considerations when using zolpidem in the elderly include:
- Recommended dose is 5 mg
- Higher doses may be associated with increased risk of adverse effects, such as anterograde amnesia 2
From the Research
Treatment Options for Insomnia in the Elderly
The treatment of insomnia in the elderly can be approached through various methods, including nonpharmacological and pharmacological interventions.
Nonpharmacological Interventions: These are often recommended as the first line of treatment due to their efficacy and safety profile. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a highly recommended approach, as it has been shown to have longer-lasting therapeutic effects compared to pharmacologic agents alone 3. Other effective nonpharmacological interventions include:
Pharmacological Interventions: While nonpharmacological methods are preferred, pharmacological treatments can be used adjunctively, especially when symptoms persist or when patients cannot pursue cognitive behavioral therapies. The choice of a hypnotic agent in the elderly is symptom-based, with options including:
- Ramelteon or short-acting Z-drugs for sleep-onset insomnia
- Suvorexant or low-dose doxepin for sleep maintenance
- Eszopiclone or zolpidem extended release for both sleep onset and maintenance
- Low-dose zolpidem sublingual tablets or zaleplon for middle-of-the-night awakenings 7
- It's also noted that benzodiazepines should not be used routinely due to potential risks and side effects 7.
Considerations for Treatment
When considering treatment for insomnia in the elderly, it's crucial to evaluate the safety of pharmacotherapies, especially in the context of the Beers Criteria for Potentially Inappropriate Medications in the Elderly 3. Nonpharmacological treatments are generally safer and can be highly effective, making them a preferable first-line approach. The role of placebo effect and the challenges in determining clinical significance in sleep studies also need to be considered 3.