What is the recommended treatment approach for insomnia in the elderly?

Treatment of Insomnia in the Elderly

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for elderly patients with chronic insomnia, and pharmacotherapy should only be considered when CBT-I has been unsuccessful. 1, 2

Initial Assessment

Before initiating treatment, evaluate the following specific factors:

• Determine if insomnia is primary or secondary to other medical conditions, as elderly patients typically have multiple contributing factors 1
• Review all medications that may cause or worsen insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
• Assess sleep-impairing behaviors such as frequent daytime napping, excessive time in bed (>8 hours), insufficient daytime activity, evening alcohol consumption, late heavy meals, caffeine after noon, and smoking in the evening 3, 1
• Evaluate environmental factors including bedroom temperature, noise levels, light exposure, and presence of pets or disruptive bed partners 3

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

CBT-I should be implemented as the initial treatment approach because it demonstrates proven efficacy with effects sustained for up to 2 years in older adults, has minimal side effects compared to medications, and addresses the underlying behavioral patterns perpetuating insomnia 1, 2. The American College of Physicians and American Geriatrics Society both prioritize this approach over pharmacotherapy 1, 2.

Core Components of CBT-I

Stimulus Control Therapy (strengthens the bed-sleep association):

• Go to bed only when sleepy, not by the clock 3, 2
• Use the bedroom exclusively for sleep and sex—no television, reading, or work in bed 3, 1
• Leave the bedroom if unable to fall asleep within 15-20 minutes and return only when sleepy 3, 2
• Maintain consistent wake-up times every morning regardless of sleep duration the previous night 3, 2
• Avoid daytime napping; if necessary, limit to 30 minutes before 2 PM 3

Sleep Restriction/Compression Therapy (consolidates sleep):

• Have patients keep a 2-week sleep diary to determine actual time sleeping versus time in bed 3
• Limit time in bed to match actual sleep time (e.g., if sleeping 5.5 hours but in bed 8.5 hours, restrict bed time to 5.5-6 hours) 3
• Use sleep compression rather than immediate restriction in elderly patients, as gradual reduction is better tolerated 1
• Increase time in bed by 15-20 minute increments every 5 days as sleep efficiency improves 3

Sleep Hygiene Education (optimize sleep environment):

• Establish a 30-minute relaxation period before bedtime 3
• Ensure comfortable bedroom temperature, minimal noise, and darkness 3, 1
• Avoid heavy exercise within 2 hours of bedtime 3
• Eliminate caffeine, nicotine, and alcohol in the evening 3
• Note: Sleep hygiene alone is insufficient for chronic insomnia and must be combined with other behavioral interventions 3, 1

Relaxation Techniques:

• Progressive muscle relaxation (tensing and releasing muscle groups sequentially) 3, 2
• Guided imagery and meditation 3
• Diaphragmatic breathing exercises 3, 1

Second-Line Treatment: Pharmacotherapy

Medications should only be initiated after CBT-I has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term use 1, 2.

Medication Selection Algorithm Based on Symptom Pattern

For Sleep-Onset Insomnia:

• Ramelteon (melatonin receptor agonist) or short-acting Z-drugs (zaleplon) 1, 4
• Start at the lowest available dose due to reduced drug clearance in elderly 1

For Sleep-Maintenance Insomnia:

• Suvorexant (orexin receptor antagonist) or low-dose doxepin (3-6 mg) 1, 4
• These specifically address middle-of-the-night awakenings and early morning awakening 4

For Both Sleep-Onset and Sleep-Maintenance:

• Eszopiclone or extended-release zolpidem 1, 4

For Middle-of-the-Night Awakenings:

• Low-dose zolpidem sublingual tablets or zaleplon 4

Critical Medications to Avoid

Benzodiazepines should be avoided due to higher risk of falls, cognitive impairment, dependence, and fractures in elderly patients 1, 2. The American Geriatrics Society specifically recommends against using benzodiazepines as first-line agents 1.

Over-the-counter antihistamines (diphenhydramine) should not be used in elderly patients 1, 2.

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, 4.

Herbal supplements (valerian, melatonin) are not recommended due to lack of efficacy and safety data in elderly populations 1.

Monitoring and Follow-Up

• Reassess patients every few weeks initially to evaluate effectiveness and side effects 1
• Use the lowest effective maintenance dosage and taper when conditions allow 1
• Continue follow-up every 6 months once insomnia stabilizes 2
• Limit pharmacotherapy to short-term use whenever possible, as long-term efficacy and safety remain undetermined 5

Common Pitfalls to Avoid

• Do not rely solely on sleep hygiene education, as it is insufficient for chronic insomnia without other behavioral interventions 3, 1, 2
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1
• Do not continue ineffective treatments without reassessment of underlying medical or psychiatric conditions 2
• Do not use antihistamines, antipsychotics, or anticonvulsants for primary insomnia due to unfavorable risk-benefit profiles 1
• Monitor regularly for adverse effects, particularly falls, cognitive impairment, and daytime sedation, as elderly patients have increased sensitivity to peak medication effects 1, 2

Emerging Evidence

Recent systematic reviews indicate that dual orexin receptor antagonists show positive benefits for sleep with minimal side effects in older adults, and non-pharmacological interventions including exercise and behavioral therapies remain effective and favorable 6.