From the Guidelines
Insomnia can be effectively treated across all age groups through a combination of behavioral strategies and, when necessary, medication, with cognitive behavioral therapy for insomnia (CBT-I) being the first-line treatment for adults, as recommended by the American College of Physicians 1.
Treatment Options
The treatment options for insomnia include:
- Behavioral strategies:
- Establishing consistent bedtime routines
- Limiting screen time before bed
- Avoiding caffeine, alcohol, and daytime napping
- Cognitive behavioral therapy for insomnia (CBT-I):
- Focusing on sleep hygiene
- Stimulus control
- Sleep restriction
- Addressing anxiety about sleep
- Medication options:
- Over-the-counter melatonin (0.5-5mg taken 1-2 hours before bedtime)
- Prescription medications like zolpidem (5-10mg), eszopiclone (1-3mg), or trazodone (25-100mg) for 2-4 weeks
Age-Specific Considerations
- For children and adolescents: establishing consistent bedtime routines and limiting screen time before bed are crucial; medication should be used cautiously, with melatonin (0.5-3mg based on age) being the safest option when necessary.
- For elderly patients: similar behavioral approaches can be used, but lower medication doses (typically half the adult dose) are recommended due to altered metabolism and increased sensitivity to side effects.
Underlying Conditions
Regardless of age, addressing underlying conditions like sleep apnea, depression, or anxiety is essential, as is avoiding caffeine, alcohol, and daytime napping. These treatments work by resetting disrupted sleep-wake cycles, reducing sleep-related anxiety, and in the case of medications, enhancing sleep-promoting neurotransmitters or hormones in the brain.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. The clinical trials performed in support of efficacy were up to six months in duration. Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™)
The treatment options for insomnia in patients of all ages include:
- Ramelteon (PO): indicated for the treatment of insomnia characterized by difficulty with sleep onset, with efficacy supported by clinical trials up to six months in duration 2, 2.
- Zolpidem (PO): evaluated in controlled studies for the treatment of patients with chronic insomnia, with efficacy demonstrated in adult outpatients with chronic insomnia 3. Key considerations:
- Ramelteon: reduced sleep latency in clinical trials, with a recommended dose of 8 mg 2.
- Zolpidem: demonstrated efficacy in reducing sleep latency and improving sleep quality, with recommended doses of 10 mg for adults and 5 mg for elderly patients 3.
From the Research
Treatment Options for Insomnia
The treatment options for insomnia in patients of all ages include:
- Non-pharmacological interventions, such as exercise and behavioral/psychoeducational therapies, which have been found to be effective and favorable 4
- Cognitive behavioral therapy for insomnia (CBT-i), which has been established as a useful treatment affecting remission, sleep onset latency, wakefulness after sleep, sleep efficiency, and sleep quality in adults with insomnia, including older adults and adolescents 5, 6, 7, 8
- Complementary and alternative therapies, such as mindfulness-based therapies, light therapy, and physical activity interventions, which have also been found to positively impact insomnia symptoms 6
- Pharmacological treatment options, including dual orexin receptor antagonist medications, which have been tested in a few studies with positive benefits for sleep and minimal side effects 4
- Sleep hygiene, stimulus control, sleep restriction, cognitive therapy, and relaxation training, which are all components of CBT-i 5, 7, 8
Non-Pharmacological Interventions
Non-pharmacological interventions for insomnia include:
- Exercise, which has been found to be an effective treatment for insomnia in older adults 4
- Behavioral/psychoeducational therapies, which have been found to be effective and favorable for treating insomnia in adults aged 55 and older 4
- CBT-i, which has been established as a useful treatment for insomnia in adults, including older adults and adolescents 5, 6, 7, 8
- Mindfulness-based therapies, which have been found to positively impact insomnia symptoms 6
- Light therapy, which has been found to positively impact insomnia symptoms 6
- Physical activity interventions, which have been found to positively impact insomnia symptoms 6
Pharmacological Treatment Options
Pharmacological treatment options for insomnia include:
- Dual orexin receptor antagonist medications, which have been tested in a few studies with positive benefits for sleep and minimal side effects 4
- Hypnotic drugs, which are commonly used to treat insomnia, but can have adverse effects and risks, particularly in the geriatric population 6, 8
- Sedative drugs, such as antidepressants, which are sometimes used to treat insomnia, but can have adverse effects and risks 8