What are the management strategies for insomnia in geriatric patients?

From the Guidelines

Insomnia management in elderly patients should begin with non-pharmacological approaches, specifically cognitive behavioral therapy for insomnia (CBT-I), as the first-line treatment. This approach is supported by moderate-quality evidence from the American College of Physicians, which recommends CBT-I as the initial treatment for chronic insomnia disorder in adults, including older adults 1. CBT-I consists of a combination of treatments that include cognitive therapy around sleep, behavioral interventions, and education, and can be performed in primary care.

Some key points to consider when implementing CBT-I in elderly patients include:

• Maintaining a regular sleep schedule
• Avoiding caffeine and alcohol before bedtime
• Limiting daytime napping
• Creating a comfortable sleep environment
• Using sleep restriction and stimulus control therapy
• Utilizing relaxation therapy or cognitive therapy

If medications are necessary, consider short-term use of melatonin (1-2 mg taken 1-2 hours before bedtime) as it has minimal side effects. For more persistent insomnia, low-dose trazodone (25-50 mg at bedtime) may be appropriate. However, it is essential to avoid benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) when possible due to increased risks of falls, cognitive impairment, and dependence in the elderly. If prescribed, use the lowest effective dose for the shortest duration (e.g., zolpidem 5 mg or less) 1.

Underlying conditions like depression, anxiety, sleep apnea, or restless leg syndrome should be identified and treated. Regular reassessment is essential to monitor for adverse effects and medication effectiveness, with the goal of tapering medications once sleep has improved. This approach balances the need for symptom relief while minimizing risks particular to the elderly population. Additionally, a study from 2008 supports the use of psychological and behavioral interventions, including CBT-I, as an initial intervention for chronic insomnia in adults, including older adults 1.

From the FDA Drug Label

The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Two of these trials were in elderly patients (n=523) Overall, at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg), eszopiclone significantly decreased sleep latency and improved measures of sleep maintenance (objectively measured as wake time after sleep onset [WASO] and subjectively measured as total sleep time). Elderly subjects (ages 65 to 86) with chronic insomnia were evaluated in two double-blind, parallel-group trials of 2 weeks duration One study (n=231) compared the effects of eszopiclone with placebo on subjective outcome measures, and the other (n=292) on objective and subjective outcome measures. The first study compared 1 mg and 2 mg of eszopiclone with placebo, while the second study compared 2 mg of eszopiclone with placebo. All doses were superior to placebo on measures of sleep latency. In both studies, 2 mg of eszopiclone was superior to placebo on measures of sleep maintenance.

Insomnia Management in Elderly Patients:

• Eszopiclone is effective in reducing sleep latency and improving sleep maintenance in elderly patients with chronic insomnia at a dose of 1 to 2 mg.
• Zolpidem is also effective in treating transient insomnia in elderly patients, with doses of 5,10,15, and 20 mg being superior to placebo on primary PSG parameters and subjective outcome measures.
• Ramelteon is indicated for the treatment of insomnia characterized by difficulty with sleep onset, but the provided text does not specify its effectiveness in elderly patients. 2, 3, 4

From the Research

Insomnia Management in Elderly Patients

• Insomnia is a common problem in elderly patients, affecting 57% of the elderly in the United States, with significant impairment of quality of life, function, and health 5.
• The main modalities in the treatment of insomnia in the elderly are psychological/behavioral therapies, pharmacological treatment, or a combination of both, with psychological/behavioral therapies viewed as the initial treatment intervention by various specialty societies 5, 6.

Non-Pharmacological Interventions

• Non-pharmacological strategies are a mainstay of treatment for chronic insomnia, including sleep hygiene practices and cognitive behavioral therapy (CBT-i) 7, 6, 8.
• CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes, and is now commonly recommended as first-line treatment for chronic insomnia 9.

Pharmacological Interventions

• Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies, with options including low-dose doxepin, melatonin, ramelteon, and dual orexin receptor antagonists 5, 6, 8.
• Current drugs for insomnia fall into different classes, including orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines, with the choice of a hypnotic agent in the elderly being symptom-based 5.
• Benzodiazepines should not be used routinely, and non-FDA-approved hypnotic agents such as melatonin, diphenhydramine, tryptophan, and valerian have limited data on benefits and harms 5, 6.

Treatment Considerations

• Risks and benefits of pharmacotherapy should be discussed with patients and caregivers prior to treatment initiation, with frequent and regular monitoring for adverse events warranted to prevent detrimental outcomes 6.
• Short-term drug therapy may be considered as an alternative or add-on treatment, with hypnotic use associated with harm and requiring close monitoring, especially in older adults 6, 8.