What is the most appropriate initial management for insomnia in a 60‑year‑old woman being treated for hypertension?

Management of Insomnia in a 60-Year-Old Woman with Hypertension

Cognitive behavioral therapy for insomnia (CBT-I) should be initiated as first-line treatment, while simultaneously reviewing her antihypertensive medications for agents that may be causing or worsening her insomnia. 1

Initial Assessment: Medication Review

Critical first step: Identify if antihypertensive medications are contributing to insomnia. The following blood pressure medications commonly disrupt sleep and should be evaluated 1:

• β-blockers (propranolol, metoprolol, atenolol) - frequently cause insomnia and nightmares 2, 1
• Diuretics - particularly if taken in evening, causing nocturia 2, 1
• Bronchodilators, corticosteroids, decongestants - if used for comorbid conditions 2, 1

If β-blockers are identified, consider switching to alternative first-line agents such as thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, which have better sleep profiles 2. This medication adjustment alone may resolve the insomnia without additional treatment.

Assess Sleep-Impairing Behaviors

Evaluate for common behaviors that worsen insomnia in older adults 1:

• Daytime napping - limits sleep drive at night 1
• Excessive time in bed - weakens sleep-wake association 1
• Insufficient daytime physical activity - reduces sleep pressure 1
• Evening alcohol consumption - fragments sleep architecture 1
• Late heavy meals - causes discomfort and reflux 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia

CBT-I is the gold standard initial treatment, with effects sustained for up to 2 years in older adults without medication-related risks. 2, 1 This is superior to pharmacotherapy for long-term outcomes and should be implemented before any sleep medication is considered. 1

Core CBT-I Components to Implement:

Sleep Restriction/Compression Therapy 2, 1:

• Have patient maintain sleep log for 1-2 weeks to calculate mean total sleep time (TST) 2
• Set time in bed (TIB) to match TST, maintaining >85% sleep efficiency (TST/TIB × 100%) 2
• Minimum TIB should not be <5 hours 2
• Adjust weekly: increase TIB by 15-20 minutes if sleep efficiency >85-90%; decrease by 15-20 minutes if <80% 2
• Sleep compression is better tolerated than immediate restriction in elderly patients 1

Stimulus Control Instructions 2, 1:

• Use bedroom only for sleep and sex 1
• Leave bedroom if unable to fall asleep within 20 minutes 1
• Return only when sleepy 2
• Maintain consistent sleep and wake times, including weekends 1
• Avoid daytime napping 2

Sleep Hygiene Modifications (must be combined with other modalities, insufficient alone) 2, 1:

• Keep bedroom cool (60-67°F), dark, and quiet 1
• Avoid caffeine, nicotine, and alcohol in evening 1
• Avoid heavy exercise within 2 hours of bedtime 1
• Limit fluids before bed to reduce nocturia 2

Relaxation Techniques 1:

• Progressive muscle relaxation 1
• Guided imagery 1
• Diaphragmatic breathing 1

Cognitive Restructuring 2, 1:

• Challenge dysfunctional beliefs: "I can't sleep without medication," "My life will be ruined if I can't sleep" 2
• Address unrealistic sleep expectations common in elderly 1

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 about short-term medication use. 1 The bidirectional relationship between insomnia and hypertension makes treatment particularly important, as chronic insomnia with short sleep duration increases incident hypertension risk (OR 3.8) 3, and insomnia is associated with increased cardiovascular disease 4, 5.

Medication Selection Based on Symptom Pattern:

For Sleep Onset Insomnia 1:

• Ramelteon (melatonin receptor agonist) - first choice, no dependence risk 1
• Short-acting Z-drugs (zolpidem 5mg in elderly) - alternative option 2, 1

For Sleep Maintenance Insomnia 1:

• Suvorexant (orexin receptor antagonist) - first choice 1
• Low-dose doxepin 3-6mg - most appropriate for sleep maintenance in older adults, improves total sleep time and wake after sleep onset 1

For Both Onset and Maintenance 1:

• Eszopiclone 1-2mg (start at 1mg in elderly) - no short-term usage restriction 2, 1
• Extended-release zolpidem 6.25mg in elderly 2, 1

Critical Medications to AVOID in This 60-Year-Old Patient:

Benzodiazepines (including temazepam, lorazepam, clonazepam) 2, 1:

• Higher risk of falls, cognitive impairment, and dependence in elderly 2, 1
• Long-term use associated with increased dementia risk 1
• Absolutely contraindicated as first-line agents in older adults 1

Over-the-counter antihistamines (diphenhydramine, hydroxyzine) 1:

• Anticholinergic effects can accelerate cognitive decline 1
• Cause daytime hypersomnolence and poorer neurologic function 1
• Should be avoided entirely in elderly 2, 1

Sedating antidepressants (trazodone, amitriptyline, mirtazapine) 2, 1:

• Only appropriate if comorbid depression/anxiety exists 1
• No systematic evidence for effectiveness in primary insomnia 1
• Anticholinergic burden problematic in elderly 1

Barbiturates, chloral hydrate, herbal supplements (valerian) 2, 1:

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

Dosing Principles for Elderly:

• Start at lowest available dose due to reduced drug clearance and increased sensitivity 1
• Follow every few weeks initially to assess effectiveness and side effects 1
• Use lowest effective maintenance dosage 1
• Consider intermittent dosing (3 nights/week) or as-needed rather than nightly 1

Common Pitfalls to Avoid

Do not prescribe hypnotics before attempting CBT-I - behavioral interventions provide superior long-term outcomes and avoid polypharmacy risks in a patient already on antihypertensives 1

Do not assume sleep hygiene education alone will suffice - it must be combined with other CBT-I modalities for chronic insomnia 2, 1

Do not overlook medication-induced insomnia - β-blockers and diuretics are common culprits that are often missed 2, 1

Avoid long-term pharmacotherapy without concurrent CBT-I trials - medication tapering is facilitated by CBT-I 1

Monitor for worsening blood pressure control - sleeping pill use is prospectively linked to increased antihypertensive medication needs (OR 1.85) 6, suggesting underlying sleep disorders may worsen hypertension

Monitoring and Follow-Up

• Collect sleep diary data before and during treatment 7
• Clinical reevaluation every few weeks until stabilization 1
• Regular reassessment for treatment effectiveness and adverse effects 1
• Monitor blood pressure control, as treating insomnia may improve hypertension outcomes 4, 5, 3