What are the recommended treatments for sleep disturbances in older adults?

Treatment of Sleep Disturbances in Older Adults

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for sleep disturbances in older adults, with pharmacotherapy reserved only for cases where CBT-I has failed, using the lowest effective doses for the shortest duration possible. 1

Initial Assessment

Before initiating treatment, identify whether insomnia is primary or secondary to comorbid conditions, as older adults typically have multiple contributing factors 1:

• Evaluate all medications that may disrupt sleep, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1, 2
• Screen for primary sleep disorders such as obstructive sleep apnea (24% prevalence), restless legs syndrome (12% prevalence), and periodic limb movements (45% prevalence) 3
• Assess sleep-impairing behaviors including excessive daytime napping, prolonged time in bed, insufficient physical activity, evening alcohol consumption, and late heavy meals 1
• Identify medical comorbidities such as pain, nocturia, gastroesophageal reflux, and neurodegenerative disorders that exacerbate sleep disruption 3

First-Line Treatment: Non-Pharmacological Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as first-line therapy due to proven efficacy with sustained effects for up to 2 years and minimal side effects compared to medications 1, 2. The multicomponent approach includes:

Sleep Restriction/Compression Therapy:

• Limit time in bed to match actual sleep time to consolidate sleep 1
• Sleep compression (gradual reduction) is better tolerated than immediate restriction in elderly patients 1

Stimulus Control Therapy:

• Use the bedroom only for sleep and sex 1, 4
• Leave the bedroom if unable to fall asleep within 20 minutes 1
• Maintain consistent sleep and wake times, even on weekends 1, 4
• Avoid daytime napping or limit to 30 minutes before 2 PM 4

Sleep Hygiene Education:

• Ensure comfortable bedroom temperature with noise reduction and light control 1
• Avoid caffeine, nicotine, and alcohol, especially in the evening 4
• Most effective when combined with other CBT-I components rather than as standalone treatment 1, 2

Relaxation Techniques:

• Progressive muscle relaxation, guided imagery, and diaphragmatic breathing can facilitate sleep onset 1, 4

Environmental and Behavioral Modifications for Circadian Rhythm Disorders

Bright Light Therapy:

• Expose patients to 3,000-5,000 lux of bright light for 2 hours in the morning over 4 weeks to decrease daytime napping and increase nighttime sleep 3
• Avoid bright light exposure in the evening 3

Structured Physical and Social Activity:

• Encourage at least 30 minutes of sunlight exposure daily 3
• Increase daytime physical and social activities to provide temporal cues for sleep-wake regulation 3
• Reduce time in bed during the day 3

Second-Line Treatment: Pharmacological Interventions

Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term medication use 1. All medications should be started at the lowest available dose due to reduced drug clearance and increased sensitivity in elderly patients 1, 4.

Medication Selection Based on Symptom Pattern

For Sleep Onset Insomnia:

• Ramelteon (melatonin receptor agonist) is the preferred first choice due to safer profile and minimal adverse effects 1, 2, 4
• Short-acting Z-drugs (zolpidem, zaleplon) may be considered as alternatives 1, 2

For Sleep Maintenance Insomnia:

• Low-dose doxepin (3-6 mg) is effective with minimal side effects 1, 2
• Suvorexant (orexin receptor antagonist) is an alternative option 1, 2

For Both Onset and Maintenance Insomnia:

• Eszopiclone or extended-release zolpidem at the lowest effective dose 1, 2

Monitoring and Follow-Up

• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Use the lowest effective maintenance dosage and taper when conditions allow 1
• Monitor for adverse effects including excessive daytime somnolence, confusion, delirium, falls, and cognitive impairment 4
• Limit duration to short-term use whenever possible, with gradual tapering to avoid withdrawal 4

Critical Pitfalls to Avoid

Benzodiazepines should be avoided due to higher risk of falls, cognitive impairment, dependence, and worsening dementia in elderly patients 1, 2, 4. The American Geriatrics Society explicitly recommends against their use as first-line agents 1.

Over-the-counter antihistamines (diphenhydramine) should be avoided in elderly patients due to anticholinergic effects and lack of efficacy data 1, 2, 4.

Sedating antidepressants (trazodone, amitriptyline, mirtazapine) should only be used when comorbid depression or anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia and risks outweigh benefits 1, 2.

Sleep hygiene education alone is usually insufficient for treating chronic insomnia and should be combined with other CBT-I components 1, 2.

Avoid prescribing long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1.

Special Considerations for Nursing Home Residents

For institutionalized older adults, a multidimensional nonpharmacologic approach is particularly effective 3:

• Increase sunlight exposure and social activity during the day 3
• Decrease time in bed during the day 3
• Reduce nighttime noise and light interruptions 3
• Improve incontinence care to minimize nighttime awakenings 3
• Implement structured bedtime routines 3

When to Refer to a Sleep Specialist

Referral is indicated when 2:

• Narcolepsy, idiopathic hypersomnia, or other primary sleep disorders are suspected
• The cause of sleepiness remains unknown despite evaluation
• Insomnia persists despite appropriate CBT-I and pharmacological interventions
• Complex patients are unresponsive to initial or subsequent therapy