What is the best course of treatment for an elderly female patient experiencing sleepless nights and fatigue, with normal blood reports and no underlying medical conditions?

Management of Insomnia in an Elderly Female with Normal Blood Work

Initiate cognitive behavioral therapy for insomnia (CBT-I) immediately as first-line treatment, as it provides superior long-term outcomes sustained for up to 2 years in older adults without medication-related risks. 1

Initial Assessment: Rule Out Reversible Causes

Before implementing treatment, systematically evaluate for common contributors to insomnia in elderly patients:

Medication Review:

• Review all prescription and over-the-counter medications that commonly disrupt sleep, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics (which cause nocturia), SSRIs, and SNRIs 2, 1
• Diuretics taken later in the day specifically cause sleep fragmentation through nocturia 3
• If the patient is on any sedating medications, paradoxically these may cause daytime sedation leading to increased napping, which then disrupts nighttime sleep 2

Behavioral Factors:

• Assess for excessive daytime napping, too much time in bed, insufficient physical activity, evening alcohol consumption, and late heavy meals 1
• These behaviors are extremely common in elderly patients and directly impair nighttime sleep 1

Medical Conditions:

• While blood work is normal, evaluate for cardiac and pulmonary symptoms (shortness of breath, orthopnea), as these are the most common medical contributors to insomnia in elderly patients 2
• Screen for depression (patients with depression are 2.5 times more likely to report insomnia) and anxiety disorders 2

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

CBT-I is the gold standard and should be implemented before any pharmacotherapy. 1, 3 This multicomponent approach combines several evidence-based techniques:

Sleep Restriction/Compression Therapy:

• Have the patient keep a 2-week sleep diary to determine actual sleep time 1
• Limit time in bed to match actual sleep time (sleep compression is better tolerated in elderly than abrupt restriction) 1
• Gradually increase time in bed as sleep efficiency improves 1

Stimulus Control:

• Use the bedroom only for sleep and sex 1
• Leave the bedroom if unable to fall asleep within 20 minutes 1
• Maintain consistent sleep and wake times, even on weekends 1
• Avoid daytime napping or limit to two short 15-20 minute naps (one around noon, another around 4-5 PM) 4

Sleep Hygiene Modifications:

• Ensure bedroom is cool, dark, and quiet 1
• Avoid caffeine, nicotine, and alcohol in the evening 1
• Avoid heavy exercise within 2 hours of bedtime 1
• Avoid heavy meals throughout the day 4

Relaxation Techniques:

• Teach progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve a calm state at bedtime 1

Cognitive Restructuring:

• Address unrealistic sleep expectations and anxiety about sleep 1

Important Note: Sleep hygiene education alone is insufficient for chronic insomnia and must be combined with other CBT-I components 1

Pharmacotherapy: Only If CBT-I Fails

Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making about benefits, harms, and short-term use. 1

Medication Selection Based on Symptom Pattern:

For Sleep Onset Insomnia:

• Ramelteon (melatonin receptor agonist) is first choice 3
• Short-acting Z-drugs (zolpidem immediate-release) as alternative 1

For Sleep Maintenance Insomnia:

• Low-dose doxepin (3-6 mg) is the most appropriate medication for sleep maintenance in older adults, with demonstrated improvement in total sleep time, wake after sleep onset, and sleep quality 1
• Suvorexant (orexin receptor antagonist) as alternative 3

For Both Onset and Maintenance:

• Eszopiclone or extended-release zolpidem 1, 3

Dosing Principles:

• Start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity 1
• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Use the lowest effective maintenance dosage 1
• Taper and discontinue when conditions allow (medication discontinuation is facilitated by concurrent CBT-I) 1, 3

Critical Medications to AVOID in Elderly Patients

Benzodiazepines (including temazepam):

• Absolutely avoid due to higher risk of falls, cognitive impairment, dependence, worsening dementia, and paradoxical behavioral disinhibition 1, 3
• Long-term use is associated with increased risk of dementia, particularly with higher doses and longer half-lives 1

Over-the-Counter Antihistamines (diphenhydramine, hydroxyzine):

• Avoid due to anticholinergic effects that can accelerate dementia progression and cause daytime hypersomnolence 1, 3

Sedating Antidepressants (trazodone, amitriptyline, mirtazapine):

• Only use when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia 1, 3

Herbal Supplements (valerian, melatonin supplements):

• Not recommended due to lack of efficacy and safety data in elderly 1

Common Pitfalls to Avoid

• Do not add hypnotic medication before attempting CBT-I – behavioral interventions are more effective long-term and avoid polypharmacy risks 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 medications as the culprit – medication-induced insomnia is common and often missed in elderly patients 1
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1

Long-Term Management

• Regular reassessment is necessary to evaluate treatment effectiveness, monitor for adverse effects, and assess for new or worsening comorbid disorders 1
• For patients requiring chronic hypnotic medication due to severe or refractory insomnia, administration may be nightly, intermittent (three nights per week), or as needed, with consistent follow-up 1
• 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