What is the recommended treatment for insomnia in the elderly?

Treatment for Insomnia in the Elderly

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for elderly patients with chronic insomnia, with pharmacotherapy reserved only for cases where CBT-I has failed or is unavailable. 1, 2

Initial Treatment Approach

Non-Pharmacological Interventions (First-Line)

Psychological and behavioral interventions are effective for adults of all ages, including older adults, and should be utilized as the initial intervention. 1

The most effective behavioral approaches include:

• Stimulus control therapy: Use the bedroom only for sleep and sex, leave the bedroom if unable to fall asleep within 20 minutes, and maintain consistent sleep/wake times 2

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time, with sleep compression being better tolerated by elderly patients than immediate restriction 2

• Cognitive behavioral therapy for insomnia (CBT-I): Combines cognitive therapy, stimulus control, and sleep restriction with or without relaxation therapy, demonstrating sustained effects for up to 2 years in older adults 1, 2

• Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing help achieve a calm state conducive to sleep 2

Sleep hygiene alone is insufficient for treating chronic insomnia and should only be used in combination with other therapies. 1, 2 Address environmental factors including comfortable bedroom temperature, noise reduction, and light control 2

When to Consider Pharmacotherapy

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. 2

Pharmacological Treatment Algorithm

First-Line Medications

When pharmacotherapy is necessary, the recommended sequence is 1, 2:

For sleep-onset insomnia:

• Ramelteon or short-acting Z-drugs (zolpidem, zaleplon) 2, 3

For sleep-maintenance insomnia:

• Suvorexant (orexin receptor antagonist) or low-dose doxepin 2, 3

For both onset and maintenance:

• Eszopiclone or extended-release zolpidem 2, 3

For middle-of-the-night awakenings:

• Low-dose zolpidem sublingual tablets or zaleplon 3

Critical Dosing Considerations

• Start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak drug effects 2, 3
• Follow patients every few weeks initially to assess effectiveness and side effects 1, 2
• Employ the lowest effective maintenance dosage and taper medication when conditions allow 1

Second-Line Options

If initial agents are unsuccessful, consider 1:

• Alternate short-intermediate acting benzodiazepine receptor agonists or ramelteon 1
• Sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine) only when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia and risks outweigh benefits 1, 2, 3

Critical Pitfalls to Avoid

The following medications should be avoided in elderly patients:

• Benzodiazepines: Higher risk of falls, cognitive impairment, and dependence in elderly 2, 3
• Over-the-counter antihistamines (diphenhydramine): Should be avoided due to unfavorable risk-benefit profiles 1, 2
• Barbiturates and chloral hydrate: Not recommended for treatment of insomnia 1
• Herbal supplements (valerian, melatonin): Not recommended due to lack of efficacy and safety data 1, 2
• Antipsychotics and anticonvulsants for primary insomnia: Risks outweigh benefits 1, 2

Combination Therapy

Combining CBT-I with pharmacotherapy may provide better outcomes than either modality alone, with medications providing short-term relief and behavioral therapy providing longer-term sustained benefit. 1

In one randomized controlled trial in older adults, combination therapy was more efficacious than placebo and more efficacious than either pharmacologic or behavioral therapy alone, though sleep improvements were better sustained over time with behavioral treatment 1

Long-Term Management

For patients requiring chronic hypnotic medication due to severe or refractory insomnia 1:

• Administration may be nightly, intermittent (three nights per week), or as needed 1
• Maintain consistent follow-up with ongoing assessment of effectiveness 1
• Monitor for adverse effects and evaluate for new onset or exacerbation of comorbid disorders 1
• Whenever possible, patients should receive an adequate trial of CBT-I during long-term pharmacotherapy 1
• Medication tapering and discontinuation are facilitated by CBT-I 1

Pre-Treatment Assessment

Before initiating treatment, evaluate 2:

• Whether insomnia is primary or comorbid with other conditions 2
• Prescription and non-prescription medications that may cause or exacerbate insomnia (β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs) 2
• Common behaviors that impair sleep: daytime napping, excessive time in bed, insufficient activity, evening alcohol consumption, late heavy meals 2