Insomnia in Elders

In seniors, insomnia is an often overlooked chronic condition that can have serious health consequences.

Insomnia—defined as difficulty in falling asleep, staying asleep, or early morning awakening that results in decreased sleep and the inability to feel refreshed the following morning—is among the most prevalent sleep disorders, impacting 33% to 50% of adults.^1,2 Insomnia accompanied by significant daytime impairments affects 10% to 15% of adults.

Impairments due to insomnia include 1 or more of the following: fatigue; attention, concentration, and memory problems; poor work or school performance; mood disturbances; poor motivation; tension headaches; gastrointestinal symptoms; being prone to accidents; and daytime sleepiness.³ Insomnia is a chronic condition, and up to 85% of sufferers continue to have symptoms at follow-up periods ranging from 1 to several years.¹

The Sleep Cycle

Several stages comprise normal sleep.

Stage 1: Transition from wakefulness to light sleep, characterized by reduced brain wave activity and slow eye movements.

Stage 2:

Transition from light sleep into a deeper sleep, characterized by muscle relaxation and decreased body temperature and heart rate.

Stages 3 and 4:

Characterized by deep sleep and high-voltage, low-frequency brain waves.

Rapid Eye Movement (REM) Stage:

Rapid eye movements accompanied by vivid dreaming; increased brain wave activity, heart rate, and respiratory rate; and inhibition of voluntary muscles.

⁴

Stages 3 and 4 are necessary for restorative sleep. Individuals cycle through these stages approximately every 90 minutes.⁵ REM sleep is critical; during REM sleep, the brain replenishes neurotransmitters that organize neural networks essential for cognitive functioning.⁴

Sleep and Elders

Sleeping needs change over time. Elders in their 70s require 30 to 60 minutes less sleep than adults in their early 20s.² Several age-related changes affecting sleep include decreased total nocturnal sleep times; delayed onset of sleep; advanced circadian phase (early to bed, early to rise); reduced slow brain wave sleep, REM sleep, or threshold to noise; and increased fragmented sleep.⁴

Elders are disproportionally impacted by insomnia, with up to 57% affected (higher incidence observed in women).^4,6 Although primary insomnia may be linked to age-related changes, the majority of insomnia in elders is secondary to comorbid conditions, especially coronary disease, dementia, arthritis and other musculoskeletal disorders, chronic pain, and psychiatric disorders, including depression.^4,6,7 Additionally, a direct relationship exists between the number of comorbid conditions and sleep disturbances.⁸ Medications and psychosocial factors also contribute to insomnia.⁴

Treating Elders

Treatment’s objectives are 2-fold: increase quality and quantity of sleep and minimize or eliminate insomnia-related daytime impairments.¹ Five principles guide pharmacotherapy: use the lowest effective dose; use intermittent dosing (2 to 4 times weekly); employ short-term pharmacotherapy treatment (3 to 4 weeks); discontinue medication gradually to reduce rebound effect; and select agents with short elimination half-lives.³

Benzodiazepines, nonbenzodiazepines, melatonin receptor agonists, and antidepressants comprise FDA-approved agents for insomnia. Benzodiazepines are avoided in elders due to increased tolerance and their association with dizziness, hypotension, and cognitive impairment.⁹

Nonbenzodiazepines (zolpidem, zolpidem extended-release, eszopiclone, and zaleplon) are considered first-line treatments because they have less potential for producing tolerance and do not possess anticonvulsant or anxiolytic properties at hypnotic doses. Zaleplon is preferred because of its 1-hour halflife.⁹

Ramelteon is a melatonin agonist that helps with sleep onset insomnia, but has no impact on maintaining sleep.² Unlike many other agents, there is no rebound effect when ramelteon is discontinued.¹⁰

Although effective, antidepressants (trazodone, nefazodone, amitriptyline, and nortriptyline) are not first-line agents because of their association with daytime sleepiness, dizziness, blurred vision, and hypotension. ⁹ When antidepressants are used, trazodone is preferred because of its more benign cardiovascular risk profile.³

Along with prescription agents, OTC products containing diphenhydramine and doxylamine are marketed as sleep aids. Because of their prolonged sedating and anticholinergic properties, the potential for drug—drug interactions, and increased tolerance, these are not recommended for elders.¹⁰ Tolerance to antihistamines may occur only after 3 days.²

Valerian, chamomile, and melatonin supplements are likewise marketed as sleep aids. Too little research has been conducted on their use in elders to warrant their use.¹¹

Regarding nonpharmacologic agents, research confirms cognitive behavioral therapy’s (CBT’s) efficacy, which equals that of prescription medications.¹² CBT typically occurs over an 8-week session, but positive results have been reported with fewer sessions.¹³

Counseling Guidelines

Counseling begins with a discussion of the patient’s expectations and their willingness to adhere to treatments. Emphasize the importance of treatment, noting that sleep disturbances are associated with decreased memory, impaired concentration and functional performance, and increased risk for falls, accidents, and chronic fatigue.³

Final Thought

When treating elders, nonbenzodiazepines are safer and better tolerated than antidepressants, antihistamines, and benzodiazepines.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Virginia.

References

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• Townsend-Roccichelli J, Sanford JT, VandeWaa E. Managing sleep disorders in the elderly. Nurse Pract. 2010;35:30-37.
• Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006;119:463-469.
• Wolkove N, Elkholy O, Baltzan M, Palayew M. Sleep and aging: 1. Sleep disorders commonly found in older people. CMAJ. 2007;176:1299-1304.
• Sleep disorders (PDQ). National Cancer Institute website. www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders/HealthProfessional/page1. Accessed November 2012.
• McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. Am J Manag Care. 2009;15(suppl):s14-s23.
• Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res. 2004;56:497-502.
• Roepke SK, Ancoli-Israel S. Sleep disorders in the elderly. Indian J Med Res. 2010;131:302-310.
• Hulisz D, Duff C. Assisting seniors with insomnia: a comprehensive approach. US Pharm. 2009;34:38-43.
• Lieberman JA. Update on the safety considerations in the management of insomnia with hypnotics: incorporating modified-release formulations into primary care. Prim Care Companion J Clin Psychiatry. 2007;9:25-31.
• Gooneratne NS. Complementary and alternative medicine for sleep disturbances in older adults. Clin Geriatr Med. 2008;24:121-138, viii.
• Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult—a mini-review. Gerontology. 2010;56:181-189.
• Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012;10:266-279.
• Campbell SS, Stanchina MD, Schlang JR, Murphy PJ. Effects of a month-long napping regimen in older individuals. J Am Geriatr Soc. 2011;59:224-232.