How to manage insomnia in an elderly woman with hypertension on Hydrochlorothiazide (HCTZ)?

Managing Insomnia in an Elderly Woman with Hypertension on HCTZ

Assess HCTZ as a Direct Cause of Insomnia

First, evaluate whether HCTZ is causing the insomnia by reviewing the timing of administration, as diuretics taken later in the day can cause nocturia and sleep disruption. 1

• If HCTZ is being taken in the evening or afternoon, switch administration to morning upon awakening to minimize nighttime urination and sleep interruption 1
• Diuretics are specifically identified as medications that interfere with sleep in nursing home and elderly populations when taken near bedtime 1
• Consider whether nocturia from HCTZ is the primary mechanism disrupting sleep—if the patient reports frequent nighttime urination, this strongly implicates the diuretic timing 1

Review All Other Medications Contributing to Insomnia

• Systematically evaluate all prescription and over-the-counter medications for sleep-disrupting effects, including β-blockers, bronchodilators, corticosteroids, decongestants, SSRIs, and SNRIs 1, 2
• Assess for use of caffeine-containing drugs, nicotine products, pseudoephedrine, or phenylpropanolamine in over-the-counter preparations 1
• If the patient is on β-blockers for hypertension (in addition to or instead of HCTZ), recognize that these suppress endogenous melatonin secretion and commonly cause insomnia 3

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

CBT-I must be implemented immediately as the primary treatment, providing superior long-term outcomes with effects sustained for up to 2 years in older adults without adding medication-related risks. 2, 4

• Implement sleep restriction/compression therapy by having the patient keep a 2-week sleep log, then limiting time in bed to match actual sleep time (sleep compression is better tolerated than immediate restriction in elderly) 2
• Apply stimulus control instructions: use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep and wake times 2
• Provide sleep hygiene modifications: avoid caffeine, nicotine, and alcohol in the evening; avoid heavy exercise within 2 hours of bedtime; ensure bedroom is cool, dark, and quiet 2
• Teach relaxation techniques such as progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve a calm state at bedtime 2
• Include cognitive restructuring to address unrealistic sleep expectations and anxiety about sleep 2, 4

Consider Pharmacotherapy Only After CBT-I Failure

• Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making to discuss benefits, harms, and costs of short-term medication use 2, 4
• Start at the lowest available dose due to reduced drug clearance and increased sensitivity to peak effects in elderly patients 2

Medication Selection Based on Insomnia Pattern:

• For sleep onset insomnia: Use ramelteon (melatonin receptor agonist) as first choice 2, 4
• For sleep maintenance insomnia: Use suvorexant (orexin receptor antagonist) or low-dose doxepin 2
• For both onset and maintenance: Use eszopiclone or extended-release zolpidem 2

If Patient is on β-Blockers:

• Consider melatonin supplementation (2.5 mg nightly), which has been shown to significantly increase total sleep time (+36 minutes), increase sleep efficiency (+7.6%), and decrease sleep onset latency in hypertensive patients on β-blockers 3

Critical Medications to Avoid in Elderly

• Absolutely avoid benzodiazepines (including temazepam) due to higher risk of falls, cognitive impairment, dependence, worsening dementia, and paradoxical behavioral disinhibition 2, 4
• Avoid over-the-counter antihistamines (diphenhydramine) due to anticholinergic effects and unfavorable risk-benefit profile 2
• Avoid sedating antidepressants (trazodone, amitriptyline, mirtazapine) unless comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia 2
• Avoid antipsychotics and anticonvulsants for primary insomnia due to unfavorable risk-benefit profiles 2

Monitor and Follow-Up

• Follow patients every few weeks initially to assess effectiveness and side effects, then employ the lowest effective maintenance dosage 2
• Regularly reassess for treatment effectiveness, potential adverse effects, and new or worsening comorbid disorders 2
• Taper and discontinue medications when conditions allow, as medication discontinuation is facilitated by concurrent CBT-I 2

Common Pitfalls to Avoid

• Do not add hypnotic medication before attempting CBT-I, as behavioral interventions are more effective long-term and avoid polypharmacy risks 2
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities for chronic insomnia 2
• Do not overlook medication-induced insomnia, particularly from diuretics taken at the wrong time of day or from β-blockers suppressing melatonin 1, 3
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 2