What are the recommended treatments for insomnia in older adults with a history of mental health disorders, chronic pain, or other medical conditions?

Treatment of Insomnia in Older Adults with Comorbidities

Cognitive behavioral therapy for insomnia (CBT-I) should be the initial treatment for all older adults with chronic insomnia, regardless of mental health disorders, chronic pain, or other medical conditions, before considering any pharmacological intervention. 1

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

CBT-I is the most effective treatment with sustained benefits lasting up to 2 years in older adults. 2 This approach combines multiple evidence-based components:

• Sleep hygiene instruction and education 2
• Stimulus control therapy 2
• Sleep restriction or sleep compression therapy 2
• Cognitive restructuring to address anxiety about sleep 2

CBT-I can be delivered through in-person sessions, telephone/web-based modules, or self-help books, making it accessible for most patients. 1 The American College of Physicians provides a strong recommendation (moderate-quality evidence) that CBT-I be used as initial treatment before medications. 1

Critical Assessment: Identify and Treat Underlying Causes

Most insomnia in older adults is comorbid rather than primary, requiring identification of contributing factors before treatment. 2

Psychiatric Comorbidities

• Depression increases insomnia risk 2.5-fold and requires concurrent treatment 2, 3
• Anxiety disorders perpetuate sleep disturbance and warrant clinical attention 3
• Both the insomnia and psychiatric condition require simultaneous treatment—treating one alone is insufficient 2

Medical Conditions Contributing to Insomnia

• Cardiac and pulmonary diseases are the most common medical contributors 3
• Chronic pain from osteoarthritis, cancer, or diabetes directly disrupts sleep 2
• Patients with respiratory symptoms are 40% more likely to report insomnia 3
• COPD or heart failure causing shortness of breath fragments sleep 3

Medication-Induced Insomnia

Conduct a thorough medication review—many commonly prescribed drugs cause or worsen insomnia: 2, 3

• β-blockers (e.g., propranolol) 2, 3
• SSRIs and SNRIs used for depression can paradoxically worsen insomnia 2
• Bronchodilators and corticosteroids 2
• Diuretics causing nocturia 2, 3
• Decongestants containing pseudoephedrine 2
• Over-the-counter caffeine-containing preparations 2

Substances and Habits Impairing Sleep

Address these modifiable factors through sleep hygiene education: 2

• Frequent daytime napping 2
• Spending excessive time in bed 2
• Insufficient daytime physical activity 2
• Late evening exercise 2
• Insufficient bright light exposure 2
• Excess caffeine consumption 2, 3
• Evening alcohol use 2, 3
• Smoking, especially in the evening 2, 3
• Late heavy meals 2
• Stimulating activities at night (television, clock-watching) 2
• Poor sleep environment (too warm, noisy, bright, pets in bed) 2

Pharmacological Treatment When CBT-I Alone Is Insufficient

Use shared decision-making when adding medications, discussing benefits, harms, and costs of short-term use. 1

First-Line Pharmacological Options

Short-acting benzodiazepine receptor agonists are preferred first-line medications: 1

• Zolpidem 5-10 mg at bedtime for sleep-onset insomnia (use 5 mg in elderly due to increased sensitivity and fall risk) 1, 4, 5
• Eszopiclone 2-3 mg at bedtime for both sleep-onset and maintenance insomnia, with no short-term usage restriction 1, 6

Alternative Pharmacological Options

Low-dose sedating antidepressants can be added to existing antidepressant therapy: 1, 4

• Trazodone 25-50 mg at bedtime (lower dose for elderly) can be added to SSRIs like escitalopram or fluoxetine 1, 4
• Doxepin 3-6 mg is FDA-approved specifically for sleep maintenance difficulties but can help with sleep onset 1, 4
• Mirtazapine is sedating and may help both depression and insomnia, though weight gain is a concern 4

Critical Pitfalls to Avoid

Benzodiazepines should be avoided in older adults due to increased risk of falls, cognitive impairment, and decreased cognitive performance. 4

Over-the-counter antihistamines and herbal supplements (valerian, melatonin) are NOT recommended for chronic insomnia due to lack of efficacy and safety data. 1

Older sedatives including barbiturates and chloral hydrate should never be used. 1

Monitoring and Medication Management

• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Use the lowest effective maintenance dose 1
• Attempt to taper medication when conditions allow 1
• Medication tapering is facilitated by concurrent CBT-I 1
• All hypnotics carry risks including daytime impairment, complex sleep behaviors, falls, fractures, and cognitive impairment 4

Special Considerations for Older Adults

Elderly patients require lower doses of all sleep medications due to increased sensitivity and fall risk. 4 For example, zolpidem should be reduced to 5 mg in elderly patients rather than the standard 10 mg dose. 4

Next-day residual effects are a significant concern: eszopiclone 3 mg causes psychomotor and memory impairment that persists up to 11.5 hours after dosing, even when patients don't subjectively perceive sedation. 6

Treatment Algorithm

1. Initiate CBT-I as first-line treatment for all patients 1
2. Simultaneously identify and treat comorbid conditions (depression, anxiety, chronic pain, medical illnesses) 2, 3
3. Review and modify medications that may cause insomnia 2, 3
4. Address sleep hygiene and modifiable lifestyle factors 2
5. If CBT-I alone is insufficient after adequate trial, add pharmacotherapy using shared decision-making 1
6. Select medication based on insomnia pattern: zolpidem for sleep-onset, eszopiclone for onset and maintenance, or low-dose sedating antidepressant if already on SSRI 1, 4
7. Use lowest effective dose, especially in elderly 1, 4
8. Monitor closely and attempt tapering when appropriate, facilitated by ongoing CBT-I 1