What is the best treatment approach for insomnia in an 85-year-old female?

Treatment of Insomnia in an 85-Year-Old Female

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for insomnia in an 85-year-old female, as it has demonstrated sustained efficacy for up to 2 years with minimal side effects compared to pharmacological options. 1

Initial Approach: Non-Pharmacological Interventions

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I combines multiple behavioral treatments with cognitive restructuring and has the strongest evidence for effectiveness in older adults:

• Typically involves 4-8 sessions
• Produces gradual but durable improvements beyond the end of treatment
• Has been shown to not only resolve insomnia but maintain effects for up to 2 years 1

2. Sleep Restriction and Sleep Compression

If full CBT-I is not available, these evidence-based components can be used:

• Sleep restriction: Limit time in bed to match actual sleep time (based on 2-week sleep logs)

  • Example: If spending 8.5 hours in bed but only sleeping 5.5 hours, restrict time in bed to 5.5-6 hours
  • Gradually increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 1

• Sleep compression: A gentler variant where time in bed is gradually decreased rather than immediately restricted 1

3. Stimulus Control

This approach strengthens the association between bed/bedroom and sleep:

• Go to bed only when sleepy
• Use bedroom only for sleep and sex (no TV, reading, etc.)
• Leave bedroom if unable to fall asleep and return only when sleepy
• Maintain consistent wake time regardless of sleep duration
• Avoid daytime napping (if necessary, limit to 30 minutes before 2 PM) 1

4. Sleep Hygiene Education

While not effective as a standalone treatment 1, these principles should be incorporated into the overall approach:

• Avoid sleep-disrupting substances (caffeine, alcohol, nicotine)
• Create a comfortable sleep environment (quiet, dark, comfortable temperature)
• Avoid heavy meals, stimulating activities, and screen time before bed
• Avoid clock watching and anxiety about sleep
• Get sufficient daytime activity and bright light exposure 1

Pharmacological Options (Only If Non-Pharmacological Approaches Fail)

If insomnia persists despite adequate trials of behavioral interventions, consider limited pharmacological therapy:

1. Melatonin: Consider as a first pharmacological option

   • Non-habit forming and drug-free 2
   • Start with 3mg 30-60 minutes before bedtime
   • Particularly helpful for sleep onset issues

2. Short-acting non-benzodiazepines (if melatonin ineffective):

   • Use lowest possible dose
   • Limited duration of use (avoid chronic use)
   • Monitor for side effects including falls, cognitive impairment

Important Cautions for Elderly Patients

1. Avoid long-acting benzodiazepines like lorazepam, which has a half-life of approximately 12 hours and can accumulate in elderly patients 3, 4

2. Fall risk: All sedative medications increase fall risk, particularly concerning in an 85-year-old

3. Polypharmacy: Review all current medications as many can contribute to insomnia, including:

   • Beta-blockers
   • Corticosteroids
   • Decongestants
   • Diuretics
   • SSRIs/SNRIs
   • Over-the-counter medications containing pseudoephedrine or caffeine 1

Follow-Up and Monitoring

• Assess response to behavioral interventions after 2-4 weeks
• If using medications, monitor for side effects including daytime sedation, falls, and cognitive changes
• Continue to emphasize non-pharmacological approaches even if medications are temporarily used

Common Pitfalls to Avoid

1. Starting with medication: Many providers jump to pharmacological solutions despite evidence favoring behavioral approaches

2. Using sleep hygiene alone: While important, sleep hygiene education by itself is insufficient for treating chronic insomnia 1

3. Ignoring comorbidities: Untreated medical conditions (pain, sleep apnea, restless legs) can perpetuate insomnia

4. Chronic benzodiazepine use: These medications should not be routinely used for insomnia in the elderly due to risks of falls, cognitive impairment, and dependence 5

5. Overlooking patient barriers to CBT-I: Address potential challenges like transportation to appointments or cognitive limitations that might affect treatment adherence

By prioritizing evidence-based behavioral interventions first, with judicious use of pharmacotherapy only when necessary, insomnia in an 85-year-old female can be effectively managed while minimizing risks.