What are the treatment options for insomnia in the elderly?

Treatment of 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 associated with medications. 1

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), psychiatric disorders (depression, anxiety, dementia), or medication-induced, as older adults typically have multiple contributing factors 2, 1
• Review all prescription and non-prescription medications that commonly cause or worsen insomnia: β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
• Assess sleep-impairing behaviors: daytime napping, excessive time in bed (>8 hours), insufficient physical activity, evening alcohol consumption, and late heavy meals 1
• Collect sleep diary data for 1-2 weeks documenting bedtime, wake time, sleep latency, number of awakenings, and total sleep time 2

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia

CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users, and should be utilized as the initial intervention when conditions permit. 2

Core CBT-I Components to Implement:

• Stimulus control therapy: Use the bedroom only for sleep and sex; leave the bedroom if unable to fall asleep within 20 minutes; maintain consistent sleep and wake times daily 1
• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time (if sleeping 5 hours, allow only 5.5 hours in bed initially), then gradually increase as sleep efficiency improves to >85% 1
• Cognitive restructuring: Identify and challenge dysfunctional beliefs about sleep, such as "I must get 8 hours or I'll be sick" or catastrophizing about poor sleep 1
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve a calm state at bedtime 1
• Sleep hygiene modifications: Ensure bedroom is cool (60-67°F), dark, and quiet; avoid caffeine after noon, nicotine, and alcohol in the evening; avoid heavy exercise within 2 hours of bedtime 1

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

Second-Line Treatment: Pharmacological Intervention

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

Recommended Medication Selection Based on Symptom Pattern:

For sleep-onset insomnia:

• Ramelteon (melatonin receptor agonist): Preferred first choice with no significant abuse potential or motor/cognitive impairment demonstrated 2
• Short-acting Z-drugs (zaleplon): Alternative option 1

For sleep-maintenance insomnia:

• Suvorexant (orexin receptor antagonist): Preferred for middle-of-night awakenings 1, 3
• Low-dose doxepin (3-6 mg): Histamine receptor antagonist effective for sleep maintenance 1, 3

For both sleep-onset and maintenance:

• Eszopiclone: Can address both components 1, 3
• Zolpidem extended-release: Alternative for combined symptoms 3

Critical Dosing Principle:

Start all medications at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak effects. 1

Medications to Absolutely Avoid in the Elderly

The following should NOT be used due to unfavorable risk-benefit profiles:

• Benzodiazepines (including temazepam, triazolam): Higher risk of falls, cognitive impairment, dependence, and worsening dementia 2, 1
• Over-the-counter antihistamines (diphenhydramine): Anticholinergic effects, daytime sedation, and cognitive impairment 1
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Should only be used when comorbid depression/anxiety exists; no systematic evidence for effectiveness in primary insomnia 2, 1
• Antipsychotics and anticonvulsants: Risks outweigh benefits for primary insomnia 2, 1
• Barbiturates and chloral hydrate: Unfavorable safety profiles 1

Combination Therapy

Combining CBT-I with short-term pharmacotherapy may provide better outcomes than either modality alone, with medications providing rapid onset relief and behavioral therapy providing longer-term sustained benefit. 2

• One randomized controlled trial in older adults found combination therapy more efficacious than placebo or either treatment alone for short-term management 2
• Sleep improvements were better sustained over time with behavioral treatment, supporting medication taper after initial stabilization 2

Monitoring and Follow-Up

Clinical reassessment should occur every few weeks initially until insomnia appears stable or resolved, then every 6 months, as the relapse rate for insomnia is high. 2

• Continue collecting sleep diary data during treatment to monitor progress 2
• Assess for effectiveness, adverse effects (falls, daytime sedation, cognitive changes), and emergence of new comorbid disorders 2, 1
• When pharmacotherapy is used, employ the lowest effective maintenance dosage and taper when conditions allow 1
• Medication tapering and discontinuation are facilitated by concurrent CBT-I 1

Common Pitfalls to Avoid

• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities for chronic insomnia 1
• Do not overlook medication-induced insomnia—SSRIs and other common drugs frequently cause or worsen sleep disturbances in elderly patients 1
• Avoid polypharmacy—adding hypnotics before attempting CBT-I increases medication burden and associated risks 1
• Do not use herbal supplements (valerian, melatonin) routinely due to lack of efficacy and safety data, variable product quality 1, 4