What treatment options are available for an elderly patient with insomnia?

Treatment for Insomnia in Elderly Patients

Start with cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment before considering any medications, as it provides superior long-term outcomes with effects sustained for up to 2 years without the risks of polypharmacy. 1

Initial Assessment

Before initiating treatment, evaluate the following specific factors:

• Medication review: Identify drugs that may cause or worsen insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
• Sleep-impairing behaviors: Assess for daytime napping, excessive time in bed, insufficient physical activity, evening alcohol consumption, and late heavy meals 1
• Comorbid conditions: Determine whether insomnia is primary or secondary to other medical or psychiatric conditions 1

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

CBT-I should be implemented immediately as the primary intervention, combining multiple evidence-based components: 1

• 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 1
• Stimulus control: Use the bedroom only for sleep and sex, leave the bedroom if unable to fall asleep within 20 minutes, and maintain consistent sleep and wake times 1
• Cognitive restructuring: Identify and challenge dysfunctional beliefs about sleep and unrealistic sleep expectations 1, 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing to achieve a calm state conducive to sleep onset 1
• Sleep hygiene education: Address environmental factors such as comfortable bedroom temperature, noise reduction, and light control—most effective when combined with other modalities rather than standalone 1

Environmental Modifications

• Decrease nighttime noise and light disruption to reduce nighttime arousals 1
• Increase daytime physical activity and sunlight exposure 1

Second-Line Treatment: Pharmacological Intervention

Only consider pharmacotherapy after CBT-I has been unsuccessful, using shared decision-making to discuss benefits, harms, and costs of short-term medication use. 1

Recommended Medications (Start at Lowest Dose)

For sleep onset insomnia:

• Ramelteon (melatonin receptor agonist): First-choice medication, particularly safe in patients with glaucoma 1, 2
• Short-acting Z-drugs: Alternative option 1

For sleep maintenance insomnia:

• Suvorexant (orexin receptor antagonist): First-choice medication, particularly safe in patients with glaucoma 1, 2
• Low-dose doxepin: Alternative option 1

For both onset and maintenance insomnia:

• Eszopiclone: 1-2 mg for elderly patients (lower than the 2-3 mg adult dose), demonstrated effectiveness in elderly subjects ages 65-86 with superior results on sleep latency and maintenance measures 1, 3
• Extended-release zolpidem: Alternative option 1

Monitoring and Follow-Up

• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Use the lowest effective maintenance dosage and taper when conditions allow 1
• Regular reassessment is necessary to evaluate treatment effectiveness and monitor for adverse effects 1

Critical Medications to Avoid in Elderly Patients

Absolutely avoid or strongly discourage the following due to unfavorable risk-benefit profiles:

• Benzodiazepines (including temazepam): Higher risk of falls, cognitive impairment, dependence, worsening dementia, and paradoxical behavioral disinhibition 1, 2
• Over-the-counter antihistamines (such as diphenhydramine): Anticholinergic effects particularly dangerous in elderly 1
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Only use when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia 1
• Antipsychotics and anticonvulsants: Unfavorable risk-benefit profiles for primary insomnia 1
• Herbal supplements (valerian, melatonin): Lack of efficacy and safety data 1

Common Pitfalls to Avoid

• Do not prescribe hypnotic medications before attempting CBT-I, as behavioral interventions are more effective long-term and avoid polypharmacy risks 1
• Do not rely on sleep hygiene education alone, as it is usually insufficient for treating chronic insomnia and must be combined with other CBT-I modalities 1
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1
• Be aware that elderly patients have reduced drug clearance and increased sensitivity to peak effects, requiring lower starting doses 1
• Monitor for next-day residual effects, as eszopiclone 3 mg has been associated with next-morning psychomotor and memory impairment that can be present up to 11.5 hours after dosing, even when patients do not subjectively perceive impairment 3

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
• Medication tapering and discontinuation are facilitated by CBT-I 1