Treatment of Insomnia in the Elderly
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as the first-line treatment for all elderly patients with chronic insomnia due to its proven efficacy, safety, and long-term benefits compared to pharmacological options. 1
First-Line Treatment: Psychological and Behavioral Interventions
CBT-I Components
CBT-I is a multimodal therapy that includes:
- Cognitive therapy: Addressing misconceptions and unrealistic expectations about sleep
- Stimulus control: Strengthening the association between bed and sleep
- Sleep restriction: Limiting time in bed to increase sleep efficiency
- Relaxation techniques: Reducing physical and cognitive arousal
- Sleep hygiene education: Improving sleep-related behaviors and environment 1
Efficacy in Elderly
- Moderate-quality evidence shows CBT-I improves global sleep outcomes in older adults, including:
- Improved sleep quality scores (PSQI and ISI)
- Reduced sleep onset latency
- Improved sleep efficiency
- Reduced wake time after sleep onset 1
Delivery Methods
CBT-I can be delivered through:
- Individual or group therapy
- Telephone or web-based modules
- Self-help books
- Primary care settings 1
Evidence of Superiority
A randomized controlled trial comparing CBT-I to zopiclone (a hypnotic medication) in older adults found that CBT-I:
- Improved sleep efficiency from 81.4% to 90.1% at 6-month follow-up (compared to a decrease from 82.3% to 81.9% with zopiclone)
- Increased time spent in slow-wave sleep
- Reduced nighttime wakefulness
- Provided superior long-term outcomes 2
Second-Line Treatment: Pharmacological Options
When CBT-I alone is unsuccessful, pharmacological therapy may be considered as an adjunctive treatment using a shared decision-making approach that discusses benefits, harms, and costs 1.
Recommended Medication Sequence for Elderly
Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon:
Low-dose doxepin or suvorexant:
- Particularly effective for sleep maintenance 3
Sedating antidepressants (if comorbid depression/anxiety):
- Trazodone, amitriptyline, doxepin, mirtazapine 1
Medication Selection Based on Symptom Pattern
- Sleep onset insomnia: Ramelteon or short-acting Z-drugs
- Sleep maintenance: Suvorexant or low-dose doxepin
- Both onset and maintenance: Eszopiclone or extended-release zolpidem
- Middle-of-night awakenings: Low-dose sublingual zolpidem or zaleplon 3
Important Cautions and Considerations
Medication Risks in Elderly
- Hypnotic drugs may be associated with serious adverse effects:
- Increased risk of dementia
- Falls and fractures
- Daytime impairment
- "Sleep driving" and behavioral abnormalities
- Worsening depression 1
Key Recommendations
- Avoid benzodiazepines in elderly patients when possible 3
- Use lower doses of medications than those typically prescribed for younger adults 1
- Limit pharmacological treatment to short-term use (4-5 weeks) as recommended by FDA 1
- Avoid OTC sleep aids and antihistamines due to lack of efficacy data and safety concerns 1
- Do not use sleep hygiene education alone - it should be combined with other therapies 1
Follow-up and Monitoring
- Regular clinical reassessment every few weeks during initial treatment
- Use sleep diaries to monitor progress
- Reassess every 6 months after stabilization, as relapse rates are high 1
- For those on medications, regularly evaluate the need for continued pharmacotherapy
Conclusion for Clinical Practice
The evidence strongly supports initiating treatment with CBT-I for elderly patients with insomnia, with demonstrated efficacy equal to or better than pharmacological options without the associated risks. Medications should be reserved for cases where CBT-I alone is insufficient, used at the lowest effective dose, for the shortest duration possible, and selected based on the specific sleep complaint pattern.