From the Guidelines
Treatment Options for Insomnia in a 70-year-old Patient with Sudden Onset Dementia and a History of Alcohol Abuse
The most appropriate treatment option for insomnia in a 70-year-old patient with sudden onset dementia and a history of alcohol abuse is cognitive behavioral therapy for insomnia (CBT-I), as it is a non-pharmacological approach with minimal adverse effects 1.
Pharmacologic Treatment Options
Pharmacologic treatments such as eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but their comparative effectiveness and long-term efficacy are not known 1.
- Benzodiazepines are not recommended due to their risks of dependency, falls, and cognitive impairment in older patients 1.
- Trazodone has a low-quality evidence supporting its efficacy and is outweighed by its adverse effect profile 1.
- Antihistamines and antipsychotics are not recommended due to their antimuscarinic adverse effect profile and limited evidence supporting their use for insomnia treatment 1.
Considerations for Older Adults
When treating insomnia in older adults, it is essential to consider the potential risks and benefits of pharmacologic treatments, including the increased risk of dementia, fractures, and major injury associated with hypnotic use 1.
- The FDA recommends lower doses of benzodiazepine and nonbenzodiazepine hypnotics in women and in older or debilitated adults 1.
- Doxepin and ramelteon may be considered as alternative options, but their efficacy and safety in older adults with dementia and a history of alcohol abuse need to be carefully evaluated 1.
Non-Pharmacologic Interventions
Non-pharmacologic interventions such as CBT-I and complementary and alternative treatments may be beneficial for older adults with insomnia, but more research is needed to determine their efficacy and safety in this population 1.
From the Research
Treatment Options for Insomnia
The treatment options for insomnia in a 70-year-old patient with sudden onset dementia and a history of alcohol (ethanol) abuse are limited due to the patient's complex medical history.
- Non-pharmacological interventions, such as cognitive behavioral therapy for insomnia (CBT-I) and sleep education, are recommended as the first-line treatment for insomnia in older adults with alcohol use disorder 2 and those with dementia 3.
- Pharmacological options, such as melatonin, ramelteon, and low-dose doxepin, may be considered for older adults with insomnia, but their use should be carefully evaluated due to potential adverse effects 4, 5, 6.
- Benzodiazepines and other GABA-A agonists should be avoided in older adults with insomnia due to their high risk of adverse effects, such as dementia, serious injury, and fractures 4, 2.
- Dual orexin receptor antagonists, such as suvorexant, may be effective for improving sleep onset and maintenance in older adults with insomnia, but their use should be carefully monitored due to potential adverse effects 4, 3.
- Antipsychotic agents, pramipexole, and tiagabine have been used off-label for insomnia, but their use is not recommended due to their considerable adverse effects 4.
- Gabapentin may be useful in patients with restless leg syndrome or chronic neuropathic pain and insomnia, but its use should be carefully evaluated due to potential adverse effects 4, 2.
Considerations for Patients with Alcohol Use Disorder
- Abstinence or reduction in alcohol use may improve insomnia symptoms in patients with alcohol use disorder 2.
- Patients who use alcohol to help fall asleep are at higher risk of relapse after stopping treatment, and therefore require close monitoring 2.
Considerations for Patients with Dementia
- Non-pharmacological interventions, such as CBT-I and sleep education, are recommended as the first-line treatment for insomnia in patients with dementia 3.
- Pharmacological options, such as trazodone and melatonin, may be considered for patients with dementia, but their use should be carefully evaluated due to potential adverse effects 3.