What is the recommended first‑line treatment for chronic insomnia in an elderly patient (≥ 65 years)?

Treatment of Chronic Insomnia in the Elderly

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia in elderly patients (≥ 65 years), and pharmacotherapy should only be considered after CBT-I has failed. 1, 2

Initial Assessment Before Treatment

Before initiating any therapy, evaluate the following specific factors:

• Medication review: Identify drugs that commonly cause insomnia in elderly patients, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs (particularly sertraline), and SNRIs 2
• Comorbid conditions: Determine whether insomnia is primary or secondary to medical/psychiatric conditions, as older adults typically have multiple contributing factors 2
• Sleep-impairing behaviors: Assess for daytime napping, excessive time in bed, insufficient physical activity, evening alcohol consumption, and late heavy meals 2

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia

CBT-I should be initiated as the primary treatment before any pharmacological intervention is considered. 1, 2 This represents a strong recommendation based on moderate-quality evidence from both the American College of Physicians and American Academy of Sleep Medicine 1.

Why CBT-I is Superior

• CBT-I provides sustained effects for up to 2 years in older adults, unlike medications which lose efficacy after discontinuation 1, 2
• It avoids the significant risks of polypharmacy in elderly patients, including falls, cognitive impairment, and drug interactions 2
• Moderate-quality evidence demonstrates improved global outcomes including increased remission rates, reduced Insomnia Severity Index scores, and improved Pittsburgh Sleep Quality Index scores 1

Components of CBT-I to Implement

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time, with compression being better tolerated than immediate restriction in elderly patients 2
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep/wake times 2
• Cognitive restructuring: Address unrealistic sleep expectations and anxiety about sleep 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve calm state at bedtime 2
• Sleep hygiene education: Comfortable bedroom temperature, noise reduction, light control, avoiding caffeine/nicotine/alcohol in evening, avoiding heavy exercise within 2 hours of bedtime 2

Critical caveat: Sleep hygiene education alone is insufficient for chronic insomnia and must be combined with other CBT-I modalities 1, 2

Second-Line Treatment: Pharmacotherapy (Only After CBT-I Failure)

Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term medication use. 1, 2 This is a weak recommendation based on low-quality evidence 1.

Medication Selection Algorithm Based on Symptom Pattern

For sleep-onset insomnia:

• Ramelteon (melatonin receptor agonist): First-choice option with minimal adverse effects, effective for sleep-onset latency 2, 3, 4
• Short-acting Z-drugs (zaleplon, immediate-release zolpidem): Alternative option 2, 4

For sleep-maintenance insomnia:

• Suvorexant (orexin receptor antagonist): First-choice option for sleep maintenance with mild adverse effects 2, 4
• Low-dose doxepin (3-6 mg): Most appropriate for sleep maintenance in older adults, improves total sleep time and wake after sleep onset 2, 4

For both sleep-onset and maintenance:

• Eszopiclone or extended-release zolpidem 2, 4

Critical Dosing Considerations

• Always start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak effects 2
• Follow patients every few weeks initially to assess effectiveness and side effects 2
• Employ the lowest effective maintenance dosage and taper when conditions allow 2

Medications to Absolutely Avoid in Elderly Patients

Benzodiazepines should be avoided due to higher risk of falls, cognitive impairment, dependence, worsening dementia, and paradoxical behavioral disinhibition 2, 3, 4. The American Geriatrics Society specifically recommends against their use 2.

Other medications to avoid:

• Over-the-counter antihistamines (diphenhydramine): Anticholinergic effects can accelerate dementia progression 2, 3
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Should only be used when comorbid depression/anxiety exists, not for primary insomnia 2
• Antipsychotics and anticonvulsants: Unfavorable risk-benefit profiles in elderly 2
• Herbal supplements (valerian, melatonin): Lack of efficacy and safety data 2

Important note on long-term benzodiazepine use: Even low intermittent doses are associated with increased risk of dementia, particularly with higher doses and longer half-lives 2.

Combination Therapy Approach

• 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 2
• Medication tapering and discontinuation are facilitated by concurrent CBT-I 2
• For patients requiring chronic hypnotic medication due to severe or refractory insomnia, administration may be nightly, intermittent (three nights per week), or as needed, but patients should receive an adequate trial of CBT-I during long-term pharmacotherapy 2

Common Pitfalls to Avoid

• Do not prescribe hypnotics before attempting CBT-I: Behavioral interventions are more effective long-term and avoid polypharmacy risks 2
• Do not assume sleep hygiene alone will suffice: It must be combined with other CBT-I modalities for chronic insomnia 2
• Do not overlook medication-induced insomnia: SSRIs and other common medications are frequently missed as culprits in elderly patients 2
• Do not use long-term pharmacotherapy without concurrent CBT-I trials: This is specifically advised against by the American Academy of Sleep Medicine 2

Monitoring and Follow-Up

• Collect sleep diary data before and during treatment to monitor progress 5
• Perform clinical reevaluation every few weeks until stabilization, then every 6 months 5
• Regular reassessment is necessary to evaluate treatment effectiveness, monitor for adverse effects, and assess for new or worsening comorbid disorders 2