Management of Insomnia in the Elderly
Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for elderly patients with chronic insomnia due to its proven efficacy, long-lasting effects, and minimal side effects compared to pharmacological options. 1
Assessment and Contributing Factors
- Determine if insomnia is primary or comorbid with other conditions, as older adults often have multiple contributing factors 1
- Evaluate prescription and non-prescription medications that may cause or exacerbate insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
- Common behaviors that impair sleep in the elderly include daytime napping, excessive time in bed, insufficient daytime activities, evening exercise, insufficient bright light exposure, excess caffeine, evening alcohol consumption, late heavy meals, and stimulating nighttime activities 2
Non-Pharmacological Interventions
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- 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
- This approach is recommended by both the American College of Physicians and American Geriatrics Society as first-line treatment 2, 1
Sleep Restriction/Compression Therapy
- Limits time in bed to match actual sleep time, gradually increasing as sleep efficiency improves 2
- Sleep compression (gradually decreasing time in bed) is better tolerated by elderly patients than immediate restriction 2, 1
- Studies support the efficacy of this approach for older patients with chronic insomnia 2
Stimulus Control
- Strengthens the association between the bedroom and sleep 2
- Key instructions include:
Relaxation Techniques
- Methods include progressive muscle relaxation, guided imagery, diaphragmatic breathing, meditation, and biofeedback 2
- These techniques help achieve a calm state conducive to sleep onset 1
Sleep Hygiene Education
- Addresses environmental factors such as comfortable bedroom temperature, noise reduction, and light control 1
- Most effective when combined with other modalities rather than as a standalone treatment 1, 3
Pharmacological Interventions
- 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 1
- FDA-approved medications for insomnia should be started at the lowest available dose in elderly patients 1
- Medication selection should be based on symptoms:
- For elderly or debilitated patients, an initial dosage of 1-2 mg/day of lorazepam in divided doses is recommended when appropriate, to be adjusted as needed and tolerated 4
- Dual orexin receptor antagonist medications have shown positive benefits for sleep with minimal side effects in recent studies 5
Common Pitfalls and Considerations
- Benzodiazepines should be avoided when possible due to higher risk of adverse effects in elderly, such as falls, cognitive impairment, and dependence 1
- Sleep hygiene education alone is usually insufficient for treating chronic insomnia 1, 3
- Pharmacological treatments should be limited to short-term use when possible 1, 6
- Medication side effects may be more pronounced in elderly due to reduced clearance and increased sensitivity 1, 6
- If benzodiazepines are used, gradual tapering is essential to reduce the risk of withdrawal reactions 4
- Combined treatments, including benzodiazepines with CBT or with acupuncture, may be superior to monotherapies in some cases 7
- Non-pharmacological treatments have been shown to be effective for reducing hypnotic usage among older adults who are dependent on sleep medications 8