- Email: [email protected]
Management of Insomnia in the Geriatric Patient
UPDATE IN OFFICE MANAGEMENT
Management of Insomnia in the Geriatric Patient Jolanta Roszkowska, MD,a,c Stephen A. Geraci, MDb a
Division of Geriatric Medicine and bDivision of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Mississippi School of Medicine, Jackson; cMedical Service, Veterans Affairs Medical Center, Jackson, Miss.
ABSTRACT Insomnia in older individuals is common and often undiagnosed, and can lead to significant patient morbidity. A stepwise, thorough history and physical examination, including interviews with the bed partner and use of a sleep diary, are valuable diagnostic adjuncts. Polysomnography should be reserved for patients whose history suggests specific sleep-related breathing or movement disorders of breathing. Contributing physical or psychiatric conditions require treatment as in other geriatric patients. Improved sleep hygiene will often provide symptom relief in mild to moderate insomnia, whereas a number of non-drug treatments can be tried for more refractory cases. Most prescription and over-the-counter medications carry significant risk of adverse events and drug interactions; others demonstrate an acceptable risk to benefit profile and are preferred in older patients. © 2010 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2010) 123, 1087-1090 KEYWORDS: Diagnosis; Elderly; Geriatric; Insomnia; Treatment
Insomnia, defined as insufficient quantity or quality of sleep resulting in compromised daytime alertness and activity, is a common condition among older individuals but often goes undiagnosed or insufficiently treated. Insomnia can lead to serious adverse consequences, including attention and memory impairment, depression, falls, and perceived reduced quality of life.1 Insomnia can be classified on the basis of duration (acute [⬍4 weeks] vs chronic), severity (mild or severe), sleep components affected (impaired sleep onset, sleep maintenance, or both), and cause (situational [related to an acute life stress], primary, or secondary to other medical or psychiatric disorders), although all categories can demonstrate considerable overlap.2 Most diagnoses can be obtained through careful history, with testing reserved for patients whose history suggests a particular medical disorder. Treatment can then be focused on underlying disorders if any, in addition to more widely applicable techniques involving sleep hygiene education,
Funding: None. Conflict of Interest: Neither of the authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: Both authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Jolanta Roszkowska MD, Medical Service (111), 1500 E. Woodrow Wilson Dr, Jackson, MS 39216. E-mail address: [email protected]
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2010.04.006
nonpharmacologic interventions, and drug treatment if needed.
EVALUATION A focused sleep history should be obtained from the patient and, if possible, the bed partner. This includes duration of symptom, types and severity of resulting impairment, specific difficulties (falling or staying asleep), sleep patterns and habits, and identified triggering/promoting factors. A sleep diary (Table 1) can provide details initially unrecognized by the patient. Relevant personal and societal factors (isolation, loneliness, bereavement, change in residence, security, or financial concerns) that may indicate a temporary situational insomnia are key historical factors. Medical and psychiatric conditions that can impair sleep, including drug and alcohol history, also should be carefully investigated (Table 2). A thorough but focused physical examination, including neurologic and mental status assessment, should seek confirmation of conditions suggested in the history, including evidence of comorbid, insomnia-promoting conditions listed in Table 2. When history and physical suggest sleep apnea, restless leg syndrome, or narcolepsy, or when the diagnosis is uncertain, treatment fails, or wakening is associated with violent or injurious behavior, further testing such as survey tools and polysomnography3 should be used. Referral may
1088 Table 1
The American Journal of Medicine, Vol 123, No 12, December 2010 Sample Sleep Diary*2
Daytime Activities and Pre-sleep Ritual (Completed before bedtime) Naps (how many/how long) Exercise (what type/how long) Alcohol and caffeine (amount/how many) Food and drink (heavy or light; meal timing) Feelings (1, very tired; 2, somewhat tired; 3, fairly alert; 4, wide awake) Stress/irritability level before bedtime (1, none; 2, some; 3, moderate; 4, high) Medications or sleep aids (types/dose/timing) Activities the last hour before bedtime Bedtime routine (meditation/relaxation/how long) Bed time, time of “lights out” Sleeping and getting back to sleep (completed on awakening) Wake-up time, time of “lights on” Time to fall asleep (minutes) Sleep breaks (number of awakening and total time awake) Quality of sleep (0-10; 0 worst to 10 best ever) Total sleep time (in hours) *Data must be documented daily for a minimum sample time of 2 weeks.
be indicated for treatment (see below). Secondary insomnia from one or more causes can coexist with primary sleep disorders, and all contributing conditions must be addressed to maximize treatment benefit.
TREATMENT Clearly defining patient expectations from therapeutic intervention is important, because these will dictate much of the perceived benefit. Education is a key in virtually all sleep disorders, and some recommendations might be difficult for patients to accept or understand without careful explanation. Contributing comorbid conditions requiring specific treatments should be addressed as in other geriatric patients.
Sleep Hygiene Education Most patients will benefit from general measures to improve sleep hygiene (Table 3). Lifestyle and sleep habit changes, including keeping regular schedules, avoiding activities that prevent relaxation, optimizing the sleep environment, and eliminating stimuli that interfere with sleep may be sufficient to relieve mild or situational sleep disorders.4 Optimizing sleep hygiene should always be used as part of more complex treatment regimens.
Non-drug Therapy Patients still symptomatic after sleep hygiene education should be considered for additional interventions. Although how long cognitive behavioral techniques should be tried before prescribing medications is unclear, some attempt at most of these interventions is reasonable and safer than drugs, and may be sufficient, alone or in combination, to
avoid long-term hypnotic use.5 Some of these approaches amplify principles of sleep hygiene education through more detailed and formalized training and assessment. Implementation may take some time (several weeks or more) and require special training for the provider or referral to a sleep therapy specialist.6 Cognitive behavior therapy can produce significant, lasting improvement in all measures of insomnia and may be an effective alternative to drugs in chronic users.1,4,7 Relaxation therapy reduces physical and mental stress just before bedtime through progressive muscle relaxation (systematically tensing and relaxing all major muscle groups), meditation, and guided imagery (imagining peaceful venues and listening to calming sounds). Stimulus control removes all
Table 2 Comorbid Conditions Contributing to Secondary Insomnia1,11 Medical Illness Chronic cardiac disease (nocturnal angina, chronic heart failure, arrhythmia) Pulmonary (emphysema, chronic obstructive pulmonary disease, allergic rhinitis/sinusitis) Gastrointestinal (irritable bowel syndrome, constipation, gastroesophageal reflux) Endocrine disease (thyroid disease, menopause, diabetic polyuria) Chronic renal failure Disease-related chronic pain (arthritis, neuropathy, malignancy) Urologic disorder (incontinence, prostate hypertrophy) Other (skin, pruritus) Neurologic Illness Dementia Delirium Parkinson’s disease Nocturnal myoclonus Multiple sclerosis Seizures Stroke Psychiatric Illness Mood disorders (depression, bipolar or dysthymic disorders) Anxiety (generalized, panic attacks, posttraumatic stress disorder) Psychosis Drugs and Medications Alcohol and drugs of abuse Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, venlafaxine) Central nervous stimulants (amphetamines, methylphenidate, sympathomimetics, phenylephrine, caffeine, nicotine) Antihypertensives (beta-blockers, alpha-blockers, methyldopa, diuretics) Respiratory medications (theophylline, albuterol, ipratropium) Hormones (corticosteroids, thyroid medications) Other (phenytoin, levodopa, cimetidine, antihistamines, stimulant laxatives, quinidine)
Roszkowska and Geraci Table 3
Insomnia in the Elderly
Sleep Hygiene Education—Instruction for Patients1,3
Behavioral Patterns Keep a regular sleep/wake schedule (including weekends and holidays). Do not go to bed unless sleepy. Decrease or eliminate daytime naps (ⱕ30 min daily, no later than the early afternoon). Exercise regularly (but not within 3-5 h of bedtime). Increase exposure to natural light and bright light during day and early evening; avoid exposure to bright light close to bedtime or when awakening during night. Avoid heavy meals and liquids within 3 h of bedtime. Limit or eliminate alcohol, caffeine, and nicotine, especially before bedtime. Keep relaxing routine (wind down before bedtime, maintain a routine period of preparation for bed, use warm bath/ socks). Wear comfortable bed clothing. Avoid distressing “pillow talk” with bed partner. Do not use bed for reading or watching television. Get out of bed once awake. If unable to fall asleep within 30 min, get out of bed and relax (by listening to soft music or light reading). Sleep Environment Identify snoring or disruptive bed partners. Keep bedroom cool and dark. Eliminate as much noise from sleeping quarters as possible. Place clocks out of sight. Address pets that interfere with sleep.
non-sleeping activities from the bedroom and may require a detailed survey of the sleep environment to ensure completeness. Sleep restriction similarly focuses on allowing only sleep while in bed but adds a firm schedule of increasing nighttime sleep (average goal of 7 hours) and decreasing napping throughout the day. Cognitive control helps identify unwanted or negative feelings and thoughts and dysfunctional beliefs and attitudes (eg, excessive worry about the consequences of not sleeping) and replace them with realistic expectations about sleep and sleep deficiency; it emphasizes eliminating “sleep effort” and reducing concern about performing next-day activities should sleep be insufficient. Cognitive therapy can be assisted by on-line training resources, such as Sleep Healthy Using the Internet.8 Bright light therapy, a newer treatment that might modulate melatonin release, consists of exposure to full visible spectrum light at 3000 to 10,000 lux for gradually increasing periods (goal of 1-2 hours) in the early morning (for patients with difficulty falling asleep) or early evening (for patients with difficulty remaining asleep); protocols vary and are yet to be standardized.9 This technique requires significant patient commitment. Tolerance and efficacy are variable, as is persistence of benefit, and patients with photosensitivity, mania, or other mood disorders, or primary ophthalmologic diseases should probably not receive this intervention.4
1089
Pharmacotherapy Medications may be used early in treatment for relief of tk;4temporary/situational insomnia when an immediate response is required. More often, however, drugs are reserved for patients demonstrating significant consequences of insomnia refractory to other treatments. As with all medications prescribed to older patients, lowest doses and shortest durations of administration are preferable, and gradual dose tapering is safer and less likely to lead to rebound or withdrawal symptoms compared with abrupt discontinuation when treatment is complete. Monitoring for dependency and abuse (including patient resistance to tapering or requests for higher doses) is always required. Hypnotics are best avoided in patients with a substance abuse history, myasthenia, moderate–severe respiratory disease, and recent stroke.7 Many sleep aid medications commonly used in younger patients should be avoided in the elderly. Benzodiazepines (including temazepam and triazolam) can cause serious psychomotor symptoms, behavioral aberrations, and memory impairment resulting in injury; respiratory depression, rebound insomnia, and paradoxical agitation are not infrequent, and the potential for their abuse is high.1 Similarly, sedating antihistamines, such as diphenhydramine (the active ingredient in most over-the-counter sleep aids), are ill advised in geriatric patients who are at particular risk for severe anticholinergic side effects (dry mouth, tachycardia, visual blurring, exacerbation of glaucoma, agitation), cognitive impairment, protracted drowsiness, and delirium and hallucinations;1,10 patients should be advised to check for these ingredients in non-prescription medications to avoid additive sedation and adverse effects. Finally, antidepressants such as trazodone can produce dangerous and lifethreatening side effects from their anticholinergic, cardiovascular, and neurologic actions1,10 and are not recommended in the elderly. Table 4 lists medications presently considered the safest and most effective prescription sleep aids for geriatric patients. Zolpidem, administered at bedtime, is effective for acute insomnia and produces little if any respiratory depression; the sustained release preparation may provide additional benefit to patients with both sleep-onset and sleepmaintenance symptoms. Zaleplon may be taken immediately before bedtime for sleep-onset therapy and can be repeated or taken initially up to 4 hours before planned awakening for patients who awaken during the night because of its ultra-rapid onset of action. Eszopiclone, specifically indicated as safe and effective in elderly patients with primary insomnia, subjectively increases sleep latency, total sleep time, and quality and depth of sleep, while reducing daytime napping in most patients; a low dose (1 mg) is prescribed for sleep-induction treatment, whereas the 2 mg dose is more effective in patients requiring treatment for both sleep induction and maintenance. Ramelteon, a nonsedating melatonin receptor agonist, is the only nonscheduled medication approved to treat
1090 Table 4
The American Journal of Medicine, Vol 123, No 12, December 2010 Recommended Pharmacotherapy for Insomnia in the Elderly1,10
Agent
Geriatric Dose (mg)
Half-life (h)
Adverse Effects
Indications
Comments
Zolpidem IR* Zolpidem ER*
5 6.25
1.5-3.0 2.0-7.5
Sleep onset
Zaleplon*
5
1
Eszopiclone*
1-2
9
Low risk of tolerance, dependency, or hangover; CYP3A4 inhibitors 1 t1/2; contraindicated in SRBD/respiratory depression, advanced liver disease CYP3A4 inhibitors 1 t1/2; no tolerance, hangover or rebound Reduced number and duration of naps; less memory or psychomotor impairment
Ramelteon†
8
1.0-2.6
Abdominal pain, dizziness, headache, rebound insomnia, somnolence, memory loss ⌬ color vision; nausea, myalgias Headache, bitter taste, dry mouth, somnolence, amnesia Headache, fatigue, somnolence, dizziness
Sleep onset and sleep maintenance Sleep onset and sleep maintenance (includes 1o insomnia) Sleep-onset latency and total sleep time in chronic insomnia
Contraindicated with fluvoxamine and liver failure; least psychomotor or cognitive impairment
SRBD, Sleep-related breathing disorder. *Non-benzodiazepines. †Melatonin receptor agonist.
chronic insomnia in the elderly.1 It also is preferred in patients for whom medication abuse, cognitive impairment, or psychomotor side effects are likely from other agents, and seems reasonably safe during long-term administration. Questions often arise about herbal and dietary supplements (lavender, St John’s wort, glutamine, niacin, L-tryptophan, hops, skullcap, passion flower, lemon balm, kava) to aid sleep.7 These are to date untested for either safety or efficacy, and anecdotal reports suggest toxicities and adverse effects particularly common in the elderly. Some efficacy data are available for 2 agents, melatonin and valerian root (Valeriana officinalis), although sufficient safety and drug interaction information is lacking.10 Patients should be advised to avoid such agents, particularly when receiving prescription hypnotics.
CONCLUSIONS In geriatric patients, insomnia can affect personal wellbeing and lead to significant morbidity. Sleep assessment therefore should be considered as an integral part of a comprehensive geriatric assessment. Identification and treatment of the many potentially contributing factors are essential to effective therapy. Although education about good sleep hygiene will help many patients, more intensive treatment with cognitive behavior modification, light therapy, or med-
ications may be required to achieve adequate symptom relief.
References 1. Kamel NS, Gammack J. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006;119:463-469. 2. Breus MJ. Talking to patients about insomnia. Medscape Neurology & Neurosurgery. 2006;8(1). 3. Avidan A. The treatment of insomnia in older adults. Medscape, released June 27, 2008. Available at: www.medscape.com/viewprogram/14870. 4. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57:761-789. 5. Joshi S. Nonpharmacologic therapy for insomnia in the elderly. Clin Geriatr Med. 2008;24:107-119. 6. Espie CA, Kyle SD. Primary insomnia: an overview of practical management using cognitive behavioral techniques. Sleep Med Clin. 2009;4:559-569. 7. Ramakrishnan K. Treatment options for insomnia. Am Fam Phys. 2007;76:517-526. 8. Sleeping healthy using the internet (2010). Available at: http://www. study.shuti.net. 9. Gammack JK. Light therapy for insomnia in older adults. Clin Geriatr Med. 2008;24:139-149. 10. Tariq SH. Pharmacotherapy for insomnia. Clin Geriatr Med. 2008;24: 93-105. 11. Garcia AD. The effect of chronic disorders on sleep in the elderly. Clin Geriatr Med. 2008;24:27-38.
Management of Insomnia in the Geriatric Patient Jolanta Roszkowska, MD,a,c Stephen A. Geraci, MDb a
Division of Geriatric Medicine and bDivision of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Mississippi School of Medicine, Jackson; cMedical Service, Veterans Affairs Medical Center, Jackson, Miss.
ABSTRACT Insomnia in older individuals is common and often undiagnosed, and can lead to significant patient morbidity. A stepwise, thorough history and physical examination, including interviews with the bed partner and use of a sleep diary, are valuable diagnostic adjuncts. Polysomnography should be reserved for patients whose history suggests specific sleep-related breathing or movement disorders of breathing. Contributing physical or psychiatric conditions require treatment as in other geriatric patients. Improved sleep hygiene will often provide symptom relief in mild to moderate insomnia, whereas a number of non-drug treatments can be tried for more refractory cases. Most prescription and over-the-counter medications carry significant risk of adverse events and drug interactions; others demonstrate an acceptable risk to benefit profile and are preferred in older patients. © 2010 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2010) 123, 1087-1090 KEYWORDS: Diagnosis; Elderly; Geriatric; Insomnia; Treatment
Insomnia, defined as insufficient quantity or quality of sleep resulting in compromised daytime alertness and activity, is a common condition among older individuals but often goes undiagnosed or insufficiently treated. Insomnia can lead to serious adverse consequences, including attention and memory impairment, depression, falls, and perceived reduced quality of life.1 Insomnia can be classified on the basis of duration (acute [⬍4 weeks] vs chronic), severity (mild or severe), sleep components affected (impaired sleep onset, sleep maintenance, or both), and cause (situational [related to an acute life stress], primary, or secondary to other medical or psychiatric disorders), although all categories can demonstrate considerable overlap.2 Most diagnoses can be obtained through careful history, with testing reserved for patients whose history suggests a particular medical disorder. Treatment can then be focused on underlying disorders if any, in addition to more widely applicable techniques involving sleep hygiene education,
Funding: None. Conflict of Interest: Neither of the authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: Both authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Jolanta Roszkowska MD, Medical Service (111), 1500 E. Woodrow Wilson Dr, Jackson, MS 39216. E-mail address: [email protected]
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2010.04.006
nonpharmacologic interventions, and drug treatment if needed.
EVALUATION A focused sleep history should be obtained from the patient and, if possible, the bed partner. This includes duration of symptom, types and severity of resulting impairment, specific difficulties (falling or staying asleep), sleep patterns and habits, and identified triggering/promoting factors. A sleep diary (Table 1) can provide details initially unrecognized by the patient. Relevant personal and societal factors (isolation, loneliness, bereavement, change in residence, security, or financial concerns) that may indicate a temporary situational insomnia are key historical factors. Medical and psychiatric conditions that can impair sleep, including drug and alcohol history, also should be carefully investigated (Table 2). A thorough but focused physical examination, including neurologic and mental status assessment, should seek confirmation of conditions suggested in the history, including evidence of comorbid, insomnia-promoting conditions listed in Table 2. When history and physical suggest sleep apnea, restless leg syndrome, or narcolepsy, or when the diagnosis is uncertain, treatment fails, or wakening is associated with violent or injurious behavior, further testing such as survey tools and polysomnography3 should be used. Referral may
1088 Table 1
The American Journal of Medicine, Vol 123, No 12, December 2010 Sample Sleep Diary*2
Daytime Activities and Pre-sleep Ritual (Completed before bedtime) Naps (how many/how long) Exercise (what type/how long) Alcohol and caffeine (amount/how many) Food and drink (heavy or light; meal timing) Feelings (1, very tired; 2, somewhat tired; 3, fairly alert; 4, wide awake) Stress/irritability level before bedtime (1, none; 2, some; 3, moderate; 4, high) Medications or sleep aids (types/dose/timing) Activities the last hour before bedtime Bedtime routine (meditation/relaxation/how long) Bed time, time of “lights out” Sleeping and getting back to sleep (completed on awakening) Wake-up time, time of “lights on” Time to fall asleep (minutes) Sleep breaks (number of awakening and total time awake) Quality of sleep (0-10; 0 worst to 10 best ever) Total sleep time (in hours) *Data must be documented daily for a minimum sample time of 2 weeks.
be indicated for treatment (see below). Secondary insomnia from one or more causes can coexist with primary sleep disorders, and all contributing conditions must be addressed to maximize treatment benefit.
TREATMENT Clearly defining patient expectations from therapeutic intervention is important, because these will dictate much of the perceived benefit. Education is a key in virtually all sleep disorders, and some recommendations might be difficult for patients to accept or understand without careful explanation. Contributing comorbid conditions requiring specific treatments should be addressed as in other geriatric patients.
Sleep Hygiene Education Most patients will benefit from general measures to improve sleep hygiene (Table 3). Lifestyle and sleep habit changes, including keeping regular schedules, avoiding activities that prevent relaxation, optimizing the sleep environment, and eliminating stimuli that interfere with sleep may be sufficient to relieve mild or situational sleep disorders.4 Optimizing sleep hygiene should always be used as part of more complex treatment regimens.
Non-drug Therapy Patients still symptomatic after sleep hygiene education should be considered for additional interventions. Although how long cognitive behavioral techniques should be tried before prescribing medications is unclear, some attempt at most of these interventions is reasonable and safer than drugs, and may be sufficient, alone or in combination, to
avoid long-term hypnotic use.5 Some of these approaches amplify principles of sleep hygiene education through more detailed and formalized training and assessment. Implementation may take some time (several weeks or more) and require special training for the provider or referral to a sleep therapy specialist.6 Cognitive behavior therapy can produce significant, lasting improvement in all measures of insomnia and may be an effective alternative to drugs in chronic users.1,4,7 Relaxation therapy reduces physical and mental stress just before bedtime through progressive muscle relaxation (systematically tensing and relaxing all major muscle groups), meditation, and guided imagery (imagining peaceful venues and listening to calming sounds). Stimulus control removes all
Table 2 Comorbid Conditions Contributing to Secondary Insomnia1,11 Medical Illness Chronic cardiac disease (nocturnal angina, chronic heart failure, arrhythmia) Pulmonary (emphysema, chronic obstructive pulmonary disease, allergic rhinitis/sinusitis) Gastrointestinal (irritable bowel syndrome, constipation, gastroesophageal reflux) Endocrine disease (thyroid disease, menopause, diabetic polyuria) Chronic renal failure Disease-related chronic pain (arthritis, neuropathy, malignancy) Urologic disorder (incontinence, prostate hypertrophy) Other (skin, pruritus) Neurologic Illness Dementia Delirium Parkinson’s disease Nocturnal myoclonus Multiple sclerosis Seizures Stroke Psychiatric Illness Mood disorders (depression, bipolar or dysthymic disorders) Anxiety (generalized, panic attacks, posttraumatic stress disorder) Psychosis Drugs and Medications Alcohol and drugs of abuse Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, venlafaxine) Central nervous stimulants (amphetamines, methylphenidate, sympathomimetics, phenylephrine, caffeine, nicotine) Antihypertensives (beta-blockers, alpha-blockers, methyldopa, diuretics) Respiratory medications (theophylline, albuterol, ipratropium) Hormones (corticosteroids, thyroid medications) Other (phenytoin, levodopa, cimetidine, antihistamines, stimulant laxatives, quinidine)
Roszkowska and Geraci Table 3
Insomnia in the Elderly
Sleep Hygiene Education—Instruction for Patients1,3
Behavioral Patterns Keep a regular sleep/wake schedule (including weekends and holidays). Do not go to bed unless sleepy. Decrease or eliminate daytime naps (ⱕ30 min daily, no later than the early afternoon). Exercise regularly (but not within 3-5 h of bedtime). Increase exposure to natural light and bright light during day and early evening; avoid exposure to bright light close to bedtime or when awakening during night. Avoid heavy meals and liquids within 3 h of bedtime. Limit or eliminate alcohol, caffeine, and nicotine, especially before bedtime. Keep relaxing routine (wind down before bedtime, maintain a routine period of preparation for bed, use warm bath/ socks). Wear comfortable bed clothing. Avoid distressing “pillow talk” with bed partner. Do not use bed for reading or watching television. Get out of bed once awake. If unable to fall asleep within 30 min, get out of bed and relax (by listening to soft music or light reading). Sleep Environment Identify snoring or disruptive bed partners. Keep bedroom cool and dark. Eliminate as much noise from sleeping quarters as possible. Place clocks out of sight. Address pets that interfere with sleep.
non-sleeping activities from the bedroom and may require a detailed survey of the sleep environment to ensure completeness. Sleep restriction similarly focuses on allowing only sleep while in bed but adds a firm schedule of increasing nighttime sleep (average goal of 7 hours) and decreasing napping throughout the day. Cognitive control helps identify unwanted or negative feelings and thoughts and dysfunctional beliefs and attitudes (eg, excessive worry about the consequences of not sleeping) and replace them with realistic expectations about sleep and sleep deficiency; it emphasizes eliminating “sleep effort” and reducing concern about performing next-day activities should sleep be insufficient. Cognitive therapy can be assisted by on-line training resources, such as Sleep Healthy Using the Internet.8 Bright light therapy, a newer treatment that might modulate melatonin release, consists of exposure to full visible spectrum light at 3000 to 10,000 lux for gradually increasing periods (goal of 1-2 hours) in the early morning (for patients with difficulty falling asleep) or early evening (for patients with difficulty remaining asleep); protocols vary and are yet to be standardized.9 This technique requires significant patient commitment. Tolerance and efficacy are variable, as is persistence of benefit, and patients with photosensitivity, mania, or other mood disorders, or primary ophthalmologic diseases should probably not receive this intervention.4
1089
Pharmacotherapy Medications may be used early in treatment for relief of tk;4temporary/situational insomnia when an immediate response is required. More often, however, drugs are reserved for patients demonstrating significant consequences of insomnia refractory to other treatments. As with all medications prescribed to older patients, lowest doses and shortest durations of administration are preferable, and gradual dose tapering is safer and less likely to lead to rebound or withdrawal symptoms compared with abrupt discontinuation when treatment is complete. Monitoring for dependency and abuse (including patient resistance to tapering or requests for higher doses) is always required. Hypnotics are best avoided in patients with a substance abuse history, myasthenia, moderate–severe respiratory disease, and recent stroke.7 Many sleep aid medications commonly used in younger patients should be avoided in the elderly. Benzodiazepines (including temazepam and triazolam) can cause serious psychomotor symptoms, behavioral aberrations, and memory impairment resulting in injury; respiratory depression, rebound insomnia, and paradoxical agitation are not infrequent, and the potential for their abuse is high.1 Similarly, sedating antihistamines, such as diphenhydramine (the active ingredient in most over-the-counter sleep aids), are ill advised in geriatric patients who are at particular risk for severe anticholinergic side effects (dry mouth, tachycardia, visual blurring, exacerbation of glaucoma, agitation), cognitive impairment, protracted drowsiness, and delirium and hallucinations;1,10 patients should be advised to check for these ingredients in non-prescription medications to avoid additive sedation and adverse effects. Finally, antidepressants such as trazodone can produce dangerous and lifethreatening side effects from their anticholinergic, cardiovascular, and neurologic actions1,10 and are not recommended in the elderly. Table 4 lists medications presently considered the safest and most effective prescription sleep aids for geriatric patients. Zolpidem, administered at bedtime, is effective for acute insomnia and produces little if any respiratory depression; the sustained release preparation may provide additional benefit to patients with both sleep-onset and sleepmaintenance symptoms. Zaleplon may be taken immediately before bedtime for sleep-onset therapy and can be repeated or taken initially up to 4 hours before planned awakening for patients who awaken during the night because of its ultra-rapid onset of action. Eszopiclone, specifically indicated as safe and effective in elderly patients with primary insomnia, subjectively increases sleep latency, total sleep time, and quality and depth of sleep, while reducing daytime napping in most patients; a low dose (1 mg) is prescribed for sleep-induction treatment, whereas the 2 mg dose is more effective in patients requiring treatment for both sleep induction and maintenance. Ramelteon, a nonsedating melatonin receptor agonist, is the only nonscheduled medication approved to treat
1090 Table 4
The American Journal of Medicine, Vol 123, No 12, December 2010 Recommended Pharmacotherapy for Insomnia in the Elderly1,10
Agent
Geriatric Dose (mg)
Half-life (h)
Adverse Effects
Indications
Comments
Zolpidem IR* Zolpidem ER*
5 6.25
1.5-3.0 2.0-7.5
Sleep onset
Zaleplon*
5
1
Eszopiclone*
1-2
9
Low risk of tolerance, dependency, or hangover; CYP3A4 inhibitors 1 t1/2; contraindicated in SRBD/respiratory depression, advanced liver disease CYP3A4 inhibitors 1 t1/2; no tolerance, hangover or rebound Reduced number and duration of naps; less memory or psychomotor impairment
Ramelteon†
8
1.0-2.6
Abdominal pain, dizziness, headache, rebound insomnia, somnolence, memory loss ⌬ color vision; nausea, myalgias Headache, bitter taste, dry mouth, somnolence, amnesia Headache, fatigue, somnolence, dizziness
Sleep onset and sleep maintenance Sleep onset and sleep maintenance (includes 1o insomnia) Sleep-onset latency and total sleep time in chronic insomnia
Contraindicated with fluvoxamine and liver failure; least psychomotor or cognitive impairment
SRBD, Sleep-related breathing disorder. *Non-benzodiazepines. †Melatonin receptor agonist.
chronic insomnia in the elderly.1 It also is preferred in patients for whom medication abuse, cognitive impairment, or psychomotor side effects are likely from other agents, and seems reasonably safe during long-term administration. Questions often arise about herbal and dietary supplements (lavender, St John’s wort, glutamine, niacin, L-tryptophan, hops, skullcap, passion flower, lemon balm, kava) to aid sleep.7 These are to date untested for either safety or efficacy, and anecdotal reports suggest toxicities and adverse effects particularly common in the elderly. Some efficacy data are available for 2 agents, melatonin and valerian root (Valeriana officinalis), although sufficient safety and drug interaction information is lacking.10 Patients should be advised to avoid such agents, particularly when receiving prescription hypnotics.
CONCLUSIONS In geriatric patients, insomnia can affect personal wellbeing and lead to significant morbidity. Sleep assessment therefore should be considered as an integral part of a comprehensive geriatric assessment. Identification and treatment of the many potentially contributing factors are essential to effective therapy. Although education about good sleep hygiene will help many patients, more intensive treatment with cognitive behavior modification, light therapy, or med-
ications may be required to achieve adequate symptom relief.
References 1. Kamel NS, Gammack J. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006;119:463-469. 2. Breus MJ. Talking to patients about insomnia. Medscape Neurology & Neurosurgery. 2006;8(1). 3. Avidan A. The treatment of insomnia in older adults. Medscape, released June 27, 2008. Available at: www.medscape.com/viewprogram/14870. 4. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57:761-789. 5. Joshi S. Nonpharmacologic therapy for insomnia in the elderly. Clin Geriatr Med. 2008;24:107-119. 6. Espie CA, Kyle SD. Primary insomnia: an overview of practical management using cognitive behavioral techniques. Sleep Med Clin. 2009;4:559-569. 7. Ramakrishnan K. Treatment options for insomnia. Am Fam Phys. 2007;76:517-526. 8. Sleeping healthy using the internet (2010). Available at: http://www. study.shuti.net. 9. Gammack JK. Light therapy for insomnia in older adults. Clin Geriatr Med. 2008;24:139-149. 10. Tariq SH. Pharmacotherapy for insomnia. Clin Geriatr Med. 2008;24: 93-105. 11. Garcia AD. The effect of chronic disorders on sleep in the elderly. Clin Geriatr Med. 2008;24:27-38.