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, as it provides superior long-term outcomes with effects sustained for up to 2 years without the risks of polypharmacy. 1, 2

Initial Assessment

Before initiating treatment, evaluate the following specific factors:

• Determine if insomnia is primary or comorbid with medical conditions (heart failure, COPD, arthritis pain) or psychiatric disorders (depression, anxiety, dementia) 2
• Review all medications that commonly cause or worsen insomnia in the elderly: β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs (including sertraline), and SNRIs 2
• Assess sleep-impairing behaviors: daytime napping, excessive time in bed (>8 hours), insufficient daytime activity, evening alcohol consumption, and late heavy meals 2

Non-Pharmacological Treatment (First-Line)

CBT-I is effective for adults of all ages, including older adults, and should be utilized as the initial intervention when conditions permit. 1

Core CBT-I Components to Implement:

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time based on a 2-week sleep diary; sleep compression is better tolerated by elderly patients than immediate restriction 2
• Stimulus control therapy: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep and wake times, avoid daytime napping 1, 2
• Sleep hygiene modifications: Ensure bedroom is cool (60-67°F), dark, and quiet; avoid caffeine, nicotine, and alcohol in the evening; avoid heavy exercise within 2 hours of bedtime 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve calm state at bedtime 2
• Cognitive restructuring: Address unrealistic sleep expectations and anxiety about sleep 1

Important caveat: Sleep hygiene education alone is insufficient for treating chronic insomnia and must be combined with other CBT-I modalities. 1, 2

Pharmacological Treatment (Second-Line)

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

Medication Selection Algorithm (Symptom-Based):

For sleep-onset insomnia:

• Ramelteon (melatonin receptor agonist) or short-acting Z-drugs (zaleplon, immediate-release zolpidem) 2, 3

For sleep maintenance insomnia:

• Suvorexant (orexin receptor antagonist) or low-dose doxepin (3-6 mg) 2

For both sleep onset and maintenance:

• Eszopiclone or extended-release zolpidem 2, 4, 5

For middle-of-the-night awakenings:

• Low-dose zolpidem sublingual tablets or zaleplon 6

Dosing Considerations for Elderly:

• Start at the lowest available dose due to reduced drug clearance and increased sensitivity to peak effects in elderly patients 2
• Eszopiclone: Start at 1 mg (elderly dose range 1-2 mg vs. adult 2-3 mg) 4
• Zolpidem: Use 5 mg (not 10 mg) for elderly patients 5
• Follow patients every few weeks initially to assess effectiveness, side effects, and need for ongoing medication 1
• Employ the lowest effective maintenance dosage and taper medication when conditions allow 1

Recommended Medication Sequence (if first agent fails):

1. Short-intermediate acting benzodiazepine receptor agonists (Z-drugs) or ramelteon 1
2. Alternate Z-drug or ramelteon if initial agent unsuccessful 1
3. Sedating antidepressants only when comorbid depression/anxiety exists (trazodone, doxepin, mirtazapine) 1, 2
4. Combined Z-drug/ramelteon and sedating antidepressant 1

Combination Therapy

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

• In the single randomized controlled trial in older adults, combination therapy was more efficacious than placebo and more efficacious than either pharmacologic or behavioral therapy alone 1
• However, sleep improvements were better sustained over time with behavioral treatment alone 1
• Combined therapy shows no consistent advantage over CBT-I alone for long-term outcomes 1

Critical Pitfalls to Avoid

The following medications should be avoided in elderly patients with insomnia:

• Benzodiazepines (except as last resort): Higher risk of falls, cognitive impairment, dependence, and increased sensitivity in elderly 1, 2
• Over-the-counter antihistamines (diphenhydramine): Not recommended due to anticholinergic effects, cognitive impairment, and lack of efficacy/safety data 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
• Trazodone for primary insomnia: No systematic evidence for effectiveness in primary insomnia; risks outweigh benefits when depression/anxiety not present 1, 2
• Antipsychotics and anticonvulsants for primary insomnia: Unfavorable risk-benefit profiles in elderly 2

Additional Safety Concerns:

• Next-day residual effects: Eszopiclone 3 mg causes psychomotor and memory impairment that persists up to 11.5 hours after dosing, even when patients don't perceive sedation 4
• Do not add hypnotic medication before attempting CBT-I, as behavioral interventions are more effective long-term and avoid polypharmacy risks 2
• Medication-induced insomnia is common and often missed in elderly patients on SSRIs and other activating medications 2
• Regular reassessment is necessary to evaluate treatment effectiveness, monitor for adverse effects (falls, confusion, memory impairment), and assess for new or worsening comorbid disorders 1, 2

Long-Term Management

• Chronic hypnotic medication may be indicated for severe or refractory insomnia or chronic comorbid illness, but patients should receive an adequate trial of CBT-I during long-term pharmacotherapy whenever possible 1
• Long-term administration may be nightly, intermittent (three nights per week), or as needed with consistent follow-up 1
• Medication tapering and discontinuation are facilitated by CBT-I 1
• Reassess every 6 months as the relapse rate for insomnia is high 1