Insomnia

Insomnia is difficulty falling or staying asleep. The cause is determined by history and may be psychologic, physical, or related to poor sleep hygiene. Treatment includes optimal sleep hygiene and sometimes short-term or intermittent use of sedative-hypnotics.

Geriatric Essentials

• Most elderly people have some degree of insomnia.
• Insomnia usually has multiple causes.
• Pain commonly interferes with sleep.
• Insomnia may be an early symptom of depression.
• In patients with dementia, insomnia with nocturnal agitation may be a symptom of a disorder that causes nocturnal symptoms (eg, pain, orthopnea).
• Sleep deprivation can impair cognition and sometimes overall function.
• Nondrug treatments are often key if insomnia is chronic.
• Drugs to treat insomnia should be used in the short term or, if longer-term use is required, should be used only intermittently.
• Long-acting benzodiazepines, antihistamines, or alcohol should not be used to treat insomnia in the elderly; sedating antidepressants should not be used unless depression is present.

Most elderly people occasionally have difficulty falling or staying asleep. Insomnia may be transient, short-term, or chronic (see Table 47-2). It requires treatment only if it is persistent, is severe, or interferes with functioning.

Etiology

The cause of insomnia is often multifactorial. Common causes of insomnia in the elderly include most symptomatic disorders, many drugs (see Table 47-1), and other sleep disorders. Pain is a common cause of insomnia. Pain due to some disorders (eg, gastroesophageal reflux) worsens at night, interfering with sleep. Other symptoms also worsen at night; examples are dyspnea (eg, due to emphysema), orthopnea (eg, due to heart failure), and symptoms of Parkinson's disease. Nocturnal agitation is often the presenting symptom in patients with dementia and heart failure. Infection may cause nocturnal symptoms. Nocturia (eg, due to benign prostatic hypertrophy, urinary incontinence, certain stages of heart or renal failure, or certain drugs) may cause frequent awakenings. Uremia can cause insomnia; severity of symptoms may be proportional to the BUN level. Alzheimer's disease can cause insomnia by damaging brain structures that control sleep. Patients with hyperthyroidism often report insomnia, but sleep studies may show increased stages 3 and 4 sleep time, which seems to return to normal after hyperthyroidism is treated.

Stress may cause a form of insomnia called adjustment sleep disorder, which may occur in otherwise fair to good sleepers. Disturbance of circadian rhythm can cause insomnia. Going to bed and awakening too early (advanced sleep phase syndrome) is a particularly common circadian rhythm disturbance in the elderly, who may make the disorder worse by napping during the day.

Mental disorders, most commonly depression, can cause insomnia. Winter or seasonal depression (seasonal affective disorder) is characterized by annual recurrent symptoms of depression, daytime fatigue, and increased sleep. The underlying mechanism is unknown.

Institutional policies can contribute to insomnia. In nursing homes, residents are usually required to go to bed based on the nursing home schedule rather than on their needs or preferences. This schedule may not be conducive to good sleep. In hospitals, patients often are awakened throughout the night (eg, to be checked or given drugs), and many have difficulty going back to sleep. In both these settings, noise, lack of privacy, uncomfortable beds, rooms that are too warm or too cold, daytime inactivity, lack of daytime light exposure, and excessive daytime napping can also contribute to insomnia. Patients who required sedative-hypnotics for sleep in the hospital may inappropriately continue taking them after hospital discharge. Good sleep hygiene can help prevent insomnia in these settings.

Regardless of cause, decreased sleep time and frequent awakenings tend to decrease the proportion of sleep spent in REM sleep and deep (stage 3 and 4) NREM sleep, thus decreasing sleep quality.

Symptoms

Most patients with a sleep problem report difficulty falling asleep, frequent awakenings, or both. Some report that sleep is not restful; this statement usually indicates frequent awakenings, many of which may not be remembered. Early morning awakening occurs, particularly in patients with depression. Other symptoms include daytime symptoms of sleep deprivation (eg, fatigue, irritability, poor concentration). Sleep deprivation can reduce concentration at any age, but it can reduce the ability to function in elderly people who already have some degree of cognitive impairment.

The history should be taken from the patient and the bed partner. The partner may be able to report relevant observable symptoms (eg, snoring, turning, grimacing, moaning, unusual movements or behaviors) during sleep.

Diagnosis

Initially, the cause is often determined through the history. The history determines whether the main problem is difficulty falling asleep or staying asleep. Use of prescription, OTC (which usually contain an antihistamine or another sedating drug), and recreational drugs (including alcohol and tobacco) is recorded, as is caffeine use. Current disorders, degree of stress, mood, level of physical activity, and evening eating habits are also evaluated. Sleep hygiene must be reviewed (see Table 47-3), particularly when insomnia is chronic. The degree of daytime sleepiness can be quantified using a standard, validated scale such as the Epworth Sleepiness Scale (see Table 47-4), but this and other scales developed for the community setting may not work well for elderly people in institutional settings.

Complete physical examination is done; it focuses on disorders possibly causing symptoms that interfere with sleep. For example, the examination should include joints and extremities (eg, to check for signs of painful musculoskeletal disorders) and, in men with frequent nocturia, the prostate. Patients should be checked for signs of heart failure, respiratory disorders, thyroid dysfunction, Parkinson's disease, other brain disorders, and infection. Because patients with dementia cannot report symptoms accurately, their examination should be particularly thorough; in them, insomnia (and nocturnal agitation) may result from another, possibly treatable disorder that causes nocturnal symptoms (eg, pain, orthopnea). Heavy snoring sometimes indicates sleep apnea.

Specialized testing, such as polysomnography done in a sleep laboratory, is usually indicated if sleep apnea, narcolepsy (rare in the elderly), periodic limb movement disorder, or an unusual parasomnia is suspected. Polysomnography may be considered when the diagnosis is uncertain or when treatments have been ineffective.

Treatment

For most elderly patients, treatment does not require consultation with a sleep specialist, unless a primary sleep disorder (most often, sleep apnea) is suspected. Any disorders that may interfere with sleep should be optimally controlled.

Nondrug treatment: Patient education about age-related changes in sleep can alter patients' expectations. An example is when patients realize that an occasional sleepless night does not indicate a health problem.

Patients should be encouraged to improve sleep hygiene and use behavioral interventions (see Table 47-3). For example, to improve sleep hygiene, patients are reminded not to consume stimulants (eg, caffeine) for several hours before bedtime.

Behavioral interventions include sleep restriction therapy (limiting the time spent in bed and minimizing daytime napping). This therapy increases sleep efficiency; it may deprive patients of some sleep, but usually only at first. Patients are instructed to awaken at the same time each morning; they determine when to go to bed based on their usual total nightly sleep time, estimated using a sleep diary. The time spent in bed is gradually increased as sleep efficiency increases.

Other behavioral interventions can be used alone or together. In progressive muscle relaxation, patients are taught to tense and relax different muscle groups. Relaxation methods using a metronome, meditation, or hypnosis may help, as may biofeedback. Use of these interventions often requires referral to a specialist.

Bright light therapy may help patients with an advanced or a delayed sleep phase. Early evening bright light therapy (exposure to 5,000 to 10,000 lux light for about 30 to 120 min) helps patients with advanced sleep phase syndrome by resetting their biologic clock; it is given when patients would otherwise go to bed. Before bright light therapy is begun, elderly patients should probably have an eye examination. In sunny climates, outdoor bright light exposure may work just as well. A clinician should review all drugs that patients are taking to check whether any may induce photosensitivity and should determine whether patients have other disorders that may be exacerbated by this therapy.

Drug treatment: Sedative-hypnotics only relieve symptoms. Regular nightly use of sedative-hypnotics is less effective in the long term than are behavioral techniques. In general, the lowest effective dose is used, and continuous use is limited to about 2 wk. If these drugs are used longer, they should not be taken more often than 3 times/wk. Prescription refills must be monitored to ensure adherence to the dosing regimen.

Relative contraindications to sedative-hypnotic use include a history of drug or alcohol abuse, sleep apnea, and possibly depression and pulmonary insufficiency. Long-term use often leads to tachyphylaxis, which eventually results in use of higher doses. These drugs have increased risks for the elderly. Even small doses can cause restlessness, excitement, or worsening of delirium or dementia. Risk of falls, fractures, and death is increased. Harmful drug-drug interactions may occur (eg, with other sedative-hypnotics, alcohol, -blockers, -agonists, antihistamines, or analgesics). Continuous nightly use, particularly of longer-acting drugs, can lead to drug accumulation, which results in clinically significant drug levels during the day; thus, daytime functioning may be impaired.

Continuous long-term use of sedative-hypnotics becomes more common with aging, particularly among women. Such use makes evaluation and treatment difficult because the drug may cause the same symptoms that it is supposed to relieve (eg, difficulty sleeping, poor sleep quality, excessive daytime sleepiness). Long-term users should be weaned slowly from the drug and should be monitored for and warned about withdrawal symptoms and rebound insomnia, which are more likely with a benzodiazepine or with abrupt drug withdrawal. If long-term users do not want to stop a sedative-hypnotic, referral to a specialist may be indicated.

The sedative-hypnotics commonly used in the elderly (see Table 47-5) tend to have predictable adverse effects, and overdoses are rarely fatal unless alcohol or other CNS depressant drugs are simultaneously ingested. Abuse is relatively uncommon.

The main differences among sedative-hypnotics are pharmacodynamic. Short-acting drugs are preferred for the elderly; these drugs are less likely to accumulate in blood and thus are less likely to cause daytime sleepiness than are long-acting drugs. Short-acting drugs, especially those without active metabolites, are less likely to have drug-drug interactions. However, higher doses than necessary increase the risk of falls and fractures. Also, short-acting drugs, except perhaps for zolpidem, are more likely to result in rebound insomnia when they are stopped. Some newer sedative-hypnotics (eg, zaleplon) have a rapid onset of action; thus, if patients try to walk soon after taking these drugs, falls can occur; patients should be advised to take precautions (eg, to take the drug after they are in bed).

Long-acting benzodiazepines (eg, chlordiazepoxide, diazepam, flurazepam, quazepam) should not be used in the elderly. For these drugs, half-life typically approaches or exceeds 96 h. Patients > 65 who use long-acting benzodiazepines are twice as likely to fracture a hip as nonusers. Long-term use of flurazepam or quazepam in patients > 75 can cause symptoms resembling those of Alzheimer's disease.

Sedating antidepressants (eg, trazodone), although sometimes used to treat insomnia in elderly people, should be restricted to patients with depression that requires drug treatment; even for such patients, these drugs are usually not recommended. When sedating antidepressants are used, doses should be low.

Use of melatonin is controversial. Little data support long-term use, and there are virtually no studies in the elderly. Oral preparations are widely available OTC but are unregulated, so their quality is unknown.

Some drugs should not be used to treat insomnia in the elderly (see Table 47-6). Alcohol should not be used to treat insomnia. Alcohol ingested at bedtime initially causes drowsiness, but it disrupts sleep structure, resulting in poor sleep quality. OTC drugs are generally not recommended for insomnia because of their adverse effects. Many OTC sleep aids contain antihistamines, which have strong anticholinergic effects, and can cause dry eyes, dry mouth, constipation, urinary retention and confusion in the elderly. Barbiturates should not be used to treat insomnia; they have a long duration of action, induce hepatic enzymes, and are highly addictive.

Transient or short-term insomnia: Usually, this type of insomnia resolves when the cause is corrected, and no drug treatment is required. If a drug is needed, the lowest effective dose of the safest sedative-hypnotic, usually a short- or intermediate-acting drug (eg, zolpidem 5 mg, zaleplon 5 mg, temazepam 7.5 mg, eszopiclone 1 mg), is given orally at bedtime. Sedative-hypnotics should not be used continuously, but limited use (eg, daily for 2 or 3 wk, followed by intermittent use and early discontinuation) in carefully selected elderly patients (eg, those who seldom have insomnia, those who are unlikely to have adverse effects to sedative-hypnotics) may be useful. In frail elderly patients, particularly those at risk of falls, sedative-hypnotics should be used very cautiously because safety has not been studied in these patients. Some experts believe that short-term use of a sedative-hypnotic for short-term insomnia can help restore a normal sleep pattern more rapidly, but evidence for this effect in elderly patients is unclear.

Chronic insomnia: Nondrug treatments are particularly important for elderly patients with chronic insomnia. Sometimes all that is needed is explaining that with aging, some difficulty sleeping is normal. Social activities and interaction with friends and family members should be encouraged because social isolation and inactivity can interfere with the sleep-wake cycle. Activities should occur during the day rather than at night.

Improving sleep hygiene and using behavioral interventions may lessen chronic insomnia (see Table 47-3) and are almost always indicated. Daytime naps should be avoided if they seem to contribute to nocturnal wakefulness. However, if naps result from a need for rest rather than from boredom, they can be refreshing and usually do not disrupt nocturnal sleep, especially if they are part of a comprehensive treatment plan. Such naps should be limited to about 30 min. Sleep restriction therapy is indicated when napping is excessive and appears to be related to nocturnal wakefulness.

This topic was last updated March 2006.