Best Treatment Options for Insomnia in Older Adults
Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for insomnia in older adults due to its proven efficacy, safety, and long-term benefits compared to pharmacological options. 1, 2
Initial Assessment
- Determine if insomnia is primary or comorbid with other conditions, as older adults often have multiple contributing factors 1
- Evaluate medications that may cause or exacerbate insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
- Assess for behaviors that impair sleep, such as daytime napping, excessive time in bed, insufficient activity, evening alcohol consumption, and late heavy meals 1
- Recognize that older adults are more likely to report problems with sleep maintenance (waking after sleep onset) rather than sleep onset (time to fall asleep) 3
First-Line Treatment: Non-Pharmacological Interventions
- CBT-I combines multiple behavioral treatments with cognitive restructuring and has demonstrated effectiveness with effects sustained for up to 2 years in older adults 1, 2
- CBT-I can be delivered through various methods, including in-person individual or group therapy, telephone- or web-based modules, and self-help books 3
- Key components of behavioral interventions include:
- Stimulus control therapy: using the bedroom only for sleep and sex, leaving the bedroom if unable to fall asleep within 20 minutes, and maintaining consistent sleep-wake times 1, 2
- Sleep restriction/compression therapy: limiting time in bed to match actual sleep time, with sleep compression being better tolerated by elderly patients than immediate restriction 1, 2
- Relaxation techniques: progressive muscle relaxation, guided imagery, and diaphragmatic breathing to achieve a calm state conducive to sleep onset 1, 2
- Sleep hygiene education: addressing environmental factors such as comfortable bedroom temperature, noise reduction, and light control (most effective when combined with other modalities) 1, 2
Second-Line Treatment: Pharmacological Options
- Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using a shared decision-making approach that discusses benefits, harms, and costs of short-term medication use 3, 1, 2
- Medication selection should be symptom-based, starting at the lowest available dose in elderly patients 1, 2:
Specific Pharmacological Options
- Non-benzodiazepine receptor agonists (Z-drugs):
- Eszopiclone has shown efficacy in elderly patients at doses of 1-2 mg, with 2 mg being superior to placebo on measures of sleep maintenance 5
- Zolpidem has demonstrated efficacy for sleep latency and efficiency in elderly patients, but should be used at reduced doses (5 mg) 6, 4
- Z-drugs carry risks of next-day psychomotor and memory impairment, confusion, and falls, especially in older adults 5, 6
- Orexin receptor antagonists (suvorexant): improve sleep maintenance with mild adverse effects, though residual daytime sedation has been reported 4, 7
- Melatonin receptor agonists (ramelteon): effective for sleep-onset latency with minimal adverse effects 4, 7
- Low-dose doxepin: improves sleep maintenance with fewer side effects than other antidepressants 8, 4
Common Pitfalls to Avoid
- Benzodiazepines should be avoided when possible in older adults due to higher risk of adverse effects such as falls, cognitive impairment, and dependence 1, 2, 7
- Sleep hygiene education alone is usually insufficient for treating chronic insomnia 1, 2
- Over-the-counter antihistamines like diphenhydramine should be avoided in the elderly due to anticholinergic side effects 7
- Continuing ineffective treatments without reassessment or failing to address underlying medical or psychiatric conditions contributing to insomnia 2
- Pharmacological treatments should be limited to short-term use when possible, with regular reassessment to evaluate effectiveness and potential adverse effects 1, 2