Management of Insomnia in Older Adults: Canadian-Aligned Recommendations
Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for older adults with chronic insomnia, as it provides sustained long-term benefits without the significant risks of pharmacotherapy in this vulnerable population. 1
Initial Assessment
Before initiating treatment, evaluate these specific factors:
- Medication review: Identify drugs that disrupt sleep including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
- Sleep-impairing behaviors: Look for daytime napping, excessive time in bed, insufficient physical activity, evening alcohol use, and late heavy meals 1
- Comorbid conditions: Determine if insomnia is primary or secondary to medical/psychiatric disorders, as older adults typically have multiple contributing factors 2, 1
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I demonstrates superior long-term outcomes compared to pharmacotherapy, with sustained effects up to 2 years in older adults. 1, 3
Core CBT-I Components:
- Sleep restriction/compression therapy: Limit time in bed to match actual sleep time; sleep compression is better tolerated than immediate restriction in elderly patients 1
- Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to sleep within 20 minutes, maintain consistent sleep/wake times 1
- Cognitive restructuring: Address dysfunctional beliefs about sleep that perpetuate insomnia 1
- Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing to facilitate sleep onset 1
Evidence Supporting CBT-I Priority:
A landmark randomized controlled trial demonstrated that behavioral therapy sustained clinical gains at long-term follow-up, whereas pharmacotherapy alone did not maintain benefits after discontinuation 3. Recent data confirm CBT-I effectiveness even when delivered via mobile applications, with 94% completion rates in older adults 4.
Sleep hygiene education alone is insufficient as monotherapy but should be combined with other CBT-I modalities, addressing comfortable bedroom temperature, noise reduction, and light control 1.
Second-Line Treatment: Pharmacotherapy
Medications should only be considered after CBT-I has been unsuccessful, using shared decision-making that explicitly discusses short-term use, benefits, harms, and costs. 1
Medication Selection Algorithm by Symptom Pattern:
- Sleep onset insomnia: Ramelteon (first choice due to minimal adverse effects) or short-acting Z-drugs (zaleplon, zolpidem) 1, 5
- Sleep maintenance insomnia: Suvorexant or low-dose doxepin 1
- Both onset and maintenance: Eszopiclone or extended-release zolpidem 1
Dosing Principles:
- Start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak effects 2, 1
- Follow patients every few weeks initially to assess effectiveness and side effects 2
- Employ the lowest effective maintenance dosage and taper when conditions allow 2
Medication-Specific Considerations:
Ramelteon emerges as the preferred first-line pharmacologic option due to minimal adverse effects, effectiveness for sleep-onset latency, and increased total sleep time without significant safety concerns in older adults 5.
Benzodiazepines should be avoided due to higher risk of falls, cognitive impairment, dependence, and fractures in elderly patients 1, 5. While non-benzodiazepine receptor agonists (Z-drugs) have improved safety profiles compared to benzodiazepines, they still carry risks of dementia, serious injury, and fractures that should limit their use 5.
Sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine) should only be used when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia and risks outweigh benefits 2.
Over-the-counter antihistamines (diphenhydramine) should be avoided in elderly patients 5. Herbal supplements (valerian, melatonin) are not recommended due to lack of efficacy and safety data 2.
Combination Therapy
When combining CBT-I with pharmacotherapy, behavioral treatment provides better sustained outcomes over time. 2, 3
A randomized controlled trial in older adults showed combination therapy was more efficacious than either modality alone in the short term (63.5% reduction in time awake after sleep onset versus 55% for CBT-I alone and 46.5% for pharmacotherapy alone), but sleep improvements were better sustained with behavioral treatment 3. Subjects rated behavioral approaches as more effective and were more satisfied compared to drug therapy alone 3.
Critical Pitfalls to Avoid:
- Never use benzodiazepines or barbiturates as first-line agents in older adults 2, 1, 5
- Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 2
- Avoid antihistamines, antipsychotics, and anticonvulsants for primary insomnia due to unfavorable risk-benefit profiles in elderly 2, 5
- Monitor regularly for adverse effects, particularly cognitive impairment, falls, and daytime sedation, which are more pronounced in elderly due to pharmacokinetic and pharmacodynamic changes 2, 1
Long-Term Management:
For patients requiring chronic hypnotic medication due to severe or refractory insomnia, administration may be nightly, intermittent (three nights per week), or as needed, with consistent follow-up and ongoing assessment 2. Medication tapering and discontinuation are facilitated by concurrent CBT-I 2.