What treatment options are available for a 65-year-old female patient with insomnia who has not responded to multiple non-hypnotic/benzodiazepine (BZ) medications?

Treatment Options for a 65-Year-Old Female with Persistent Insomnia Despite Multiple Non-Hypnotic/Benzodiazepine Medications

For a 65-year-old female with persistent insomnia who has failed multiple non-hypnotic/benzodiazepine medications, cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment, with consideration of adding low-dose doxepin (3-6mg) or a non-benzodiazepine receptor agonist as short-term pharmacotherapy if CBT-I alone is unsuccessful. 1, 2

First-Line Approach: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is recommended as the first-line treatment for chronic insomnia in older adults due to its proven efficacy, long-lasting effects, and minimal side effects compared to pharmacological options 2
• CBT-I has demonstrated effectiveness with effects sustained for up to 2 years in older adults, while pharmacotherapy benefits tend to diminish over time 2, 3
• CBT-I can be delivered through various methods including in-person individual or group therapy, telephone or web-based modules, and self-help books 1
• CBT-I combines multiple components including:
  • Sleep restriction/compression therapy - limiting time in bed to match actual sleep time 2
  • Stimulus control - strengthening the association between bedroom and sleep 2
  • Cognitive restructuring - addressing negative thoughts about sleep 1
  • Sleep hygiene education - addressing environmental factors 1, 2

Pharmacological Options (If CBT-I Alone Is Unsuccessful)

If CBT-I alone is unsuccessful, consider adding pharmacological therapy using a shared decision-making approach 1, 2:

Recommended First-Line Medications:

• Low-dose doxepin (3-6mg):

  • Improved sleep outcomes in older adults with minimal adverse effects 1
  • Particularly effective for sleep maintenance issues 2
  • Start at the lowest effective dose (3mg) 2

• Non-benzodiazepine receptor agonists (Z-drugs):

  • Improved sleep efficiency, sleep onset latency, sleep quality, and total sleep time compared to placebo 1
  • Should be administered at the lowest effective dose and shortest possible duration 1
  • Consider eszopiclone or extended-release zolpidem for both sleep onset and maintenance issues 2

• Ramelteon:

  • Effective for reducing sleep latency in older adults 2, 4
  • Has minimal adverse effect profile, making it valuable for elderly patients 2, 5
  • Particularly useful for sleep onset insomnia 2

Alternative Medications:

• Suvorexant:
  • Improves sleep maintenance with mild adverse effects 2
  • May cause residual daytime sedation 2

Medications to Avoid in This Population

• Benzodiazepines should be avoided in older adults due to higher risk of adverse effects including falls, cognitive impairment, and dependence 2, 5
• Diphenhydramine and other antihistamines should be avoided in the elderly 5
• Sedating antidepressants should only be used when the patient has comorbid depression 5

Important Considerations

• Evaluate prescription and non-prescription medications that may be contributing to insomnia (β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs) 2
• Assess for behaviors that impair sleep, including daytime napping, excessive time in bed, insufficient activity, evening alcohol consumption, and late heavy meals 2
• Sleep hygiene education alone is usually insufficient for treating chronic insomnia 2, 6
• Medication side effects may be more pronounced in elderly patients due to reduced clearance and increased sensitivity 2, 5
• Regular reassessment is necessary to evaluate treatment effectiveness and potential adverse effects 2

Treatment Algorithm

1. Start with comprehensive CBT-I (8 weeks is standard course) 3, 6
2. If insufficient response after adequate trial of CBT-I:
   • For sleep onset problems: Add ramelteon 2, 4
   • For sleep maintenance: Add low-dose doxepin (3-6mg) 1, 2
   • For both onset and maintenance: Consider eszopiclone or extended-release zolpidem at lowest effective dose 2
3. Limit pharmacotherapy to short-term use when possible 2, 5
4. Continue behavioral components of CBT-I even when using medication 3