Insomnia In The Elderly: A Clinician's Useful Guide

What is insomnia?

Persistent sleep problems are defined as insomnia.

Insomnia in the elderly is a common sleep disorder where you may find it difficult to either fall asleep, stay asleep, or fall back asleep after waking.

Hence, you are unable to get a full night’s rest.

Insomnia is a common condition affecting 10 to 15% of adults.

If you struggle with insomnia, you know that it affects everything, including your health, mood, performance, quality of life, and cognition.

Insomnia in the elderly can also increase your risk for mental health disorders such as depression and anxiety.

Though often debilitating, numerous treatment options are available involving nonpharmacologic and pharmacologic methods, which will be discussed later in this article.

You must meet multiple criteria to receive a diagnosis of insomnia, including all of the following:

• Poor sleep quality is accompanied by one of the following symptoms:
  • Trouble falling asleep
  • Trouble staying asleep
  • Trouble falling back asleep upon waking
• Poor sleep resulting in social, behavioral, occupational, or academic-related impairment
• Poor sleep occurs at least three nights each week
• Poor sleep occurring for at least three months
• Poor sleep occurs despite adequate opportunity for sleep
• Poor sleep that cannot be attributed to another sleep-wake disorder (e.g. narcolepsy)
• Poor sleep not occurring due to side effects of a substance (e.g. medication)
• Poor sleep that is not a result of mental illness or other medical conditions

What age group does insomnia affect the most?

Insomnia affects people aged 60 and older the most.

Many different factors play a role:

• Older adults are at higher risk for medical and psychiatric problems
• Circadian rhythm sleep disorder in elderly
• Restless Leg Syndrome

 

Consequences of lack of sleep in elderly

As demonstrated by budding research over the past decade, sleep plays an important role in our health and well-being.

Poor sleep can increase your risk of developing infectious disease, cardiovascular disease, cancer, and depression.

Diabetes

Studies show that sleep disturbances can increase your risk of developing type 2 diabetes.

Specifically, the length and quality of your sleep can predict important disease measures such as Hemoglobin A1c (HbA1c), which relates to blood sugar control.

Recent studies have shown that improving sleep duration and quality can improve blood sugar control in type 2 diabetes patients.

Cardiovascular disease

Cardiac conditions such as hypertension, coronary heart disease, stroke, and irregular heartbeats are more prevalent amongst those with sleep disturbances when compared to those without sleep disorders.

Therefore, conditions such as insomnia in the elderly can increase your risk of developing cardiovascular disease.

Specifically, sleep apnea and atherosclerosis (hardening of the arteries) have similar underlying mechanisms.

This link further emphasizes the potential relationship between cardiac conditions and poor sleep.

Obesity

Research has also demonstrated a link between sleep deprivation and metabolic dysfunction.

Likewise, poor sleep is associated with obesity, particularly in children.

Sleep is essential to developing a structure known as the hypothalamus because of the profound brain development that occurs throughout childhood and adolescence.

The hypothalamus is involved in appetite and energy levels, therefore playing a role in gaining or losing weight.

Depression

While depression can cause sleep disorders, sleep disturbances can also aggravate symptoms of depression.

One study evaluated the relationship between suicidal thoughts and behaviors and trouble sleeping.

Insomnia, nightmares, and other sleep disturbances increase your risk of having suicidal thoughts and behaviors.

This interconnectedness emphasizes the importance of adequate sleep if you have a mental illness.

Therefore, if you have depressive symptoms, you should be monitored for the existence of a sleep disorder.

Pain and Inflammation

There also exists a connection between sleep and inflammation for chronic pain sufferers.

The body contains substances known as IL-6 and TNF-a, which can initiate inflammation.

These substances are triggered by stress, pain, aging, and poor sleep.

One study found that those who struggled with sleeping had low circulating levels of IL-6 and TNF-a.

This suggests a possible link between insomnia and inflammation in the body.

How is insomnia diagnosed?

The first step in treatment is to address insomnia’s underlying psychological or medical causes.

Once those have been identified and addressed, then the basic approach to insomnia treatment is as follows:

Before treating this disorder, you must have a confirmed diagnosis of chronic insomnia.

Chronic insomnia is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as having symptoms persisting for at least three nights a week, lasting for three months, and impacting functional ability.

Though many experience insomnia symptoms, only 6 to 10% of people meet the criteria for insomnia.

Your provider should run a series of exams and interviews to determine if you have chronic insomnia.

Your provider must obtain a full patient history and conduct a few tests to evaluate you for poor sleep.

These assessments may include the following:

• Mental health interview
• Medical history, including the medications you take
• Screening questionnaire for sleep disorders (primary sleep disorders, obstructive sleep apnea, etc)
• Sleep diary (to document sleep-wake cycle, sleep complaints, excessive daytime sleepiness, etc)

Let’s dive a bit deeper into some of these assessments:

Insomnia screening questionnaires

Two popular screening questionnaires include the Epworth Sleepiness Scale (ESS) and the Insomnia Severity Index (ISI).

Epworth Sleepiness Scale (ESS)

The ESS includes eight different scenarios, ranging from sitting down to driving a car.

If administered, you would rank the likelihood that they may feel drowsy during one of these activities.

Greater than ten indicates that you should be further evaluated for a sleep disorder.

Insomnia Severity Index (ISI)

The ISI evaluates the severity of existing insomnia and includes seven ranked items.

A score of less than or equal to 10 indicates a normal or minimal sleep impairment.

A Sleep Diary

Providers will often have you maintain a log of your sleep patterns in a diary format.

You will track things like when you went to bed, when you fell asleep, how many times you woke up, total sleep time, sleep quality (circadian rhythm, etc), etc.

These entries provide a clearer picture of your unique insomnia symptoms and the frequency with which you experience them.

How is chronic insomnia treated in elderly people?

The good news is that insomnia is treatable, both through medication and non-pharmacologic measures.

The American College of Physicians and American Academy of Sleep Medicine outline recommendations for insomnia management as follows:

1. First-line treatment includes Cognitive-Behavioral Therapy for Insomnia (CBT-I).
2. If CBT-I is not successful, you and your provider should discuss the benefits and risks of medication therapy and possibly initiate pharmacologic methods.

First-line treatment of insomnia: Effective treatment without medications

Cognitive-behavioral therapy for insomnia

The CBT model has three core features for treating insomnia: behavioral, cognitive, and educational approaches.

All three of these should be implemented for maximal treatment effect.

Cognitive intervention

Cognitive intervention involves talking through your beliefs and anxiety surrounding sleep.

Through these discussions, it is the hope you can become self-aware and take action to negate these roadblocks.

CBT is an incredibly effective method to battle your insomnia.

It aims to change your ideas and attitudes surrounding sleep.

Usually, CBT involves communication with a therapist or counselor to work through the self-limiting beliefs that prevent you from getting a good night’s sleep.

CBT seeks to identify your personal mental blocks, challenge them with talk-back methods, and replace them with more productive behaviors.

It is one of the most effective methods of combating insomnia.

Common beliefs of insomniacs include:

• Having unattainable expectations for sleep (e.g. “I must sleep for at least 8 hours)
• Having misconceptions about why insomnia happens (e.g. “My insomnia is never going away because that’s just how my body is”)
• Exacerbating the consequences of insomnia (e.g. “Tomorrow is going to go horribly because I can’t sleep)
• Having performance anxiety after trying to normalize sleep patterns

Behavioral intervention

• A core feature of the behavioral facet of CBT includes stimulus control. Stimulus control relates to basic human conditioning principles. The goal is to create a positive association between your bed and sleep and “unlearn” negative associations between your bed and sleep.
• In simple terms, the brain needs to be taught that a bed equals sleep. So, what does this look like? You should only use your bed for sleep and sex. Additionally, you should only go to bed when you are sleepy and get out of bed if you have trouble sleeping.
• This “tricks” the brain into associating lying in bed with sleep, making it easier to fall and stay asleep.

Sleep restriction therapy

Sleep restriction is another method of behavioral intervention.

Contrary to its name, sleep restriction aims not limit actual sleep time.

Sleep restriction aims to increase sleep efficiency (SE) by stopping extended awakenings in the middle of the night.

You start by limiting your time spent in bed to the duration you normally stay asleep.

For example, if you are in bed for 8 hours but only asleep for 6 hours, you would start being in bed for only 6 hours each night.

Once improvements in sleep quality are seen, you should gradually increase your time spent in bed by 15 to 30 minutes each week.

This method helps to improve sleep efficiency.

Relaxation therapies

Insomniacs usually exhibit high levels of both mental and bodily arousal at night.

These symptoms may manifest as your mind racing or tossing and turning.

Relaxation interventions aim to lessen arousal to calm both the body and mind.

There are various relaxation techniques out there, some of which are detailed below:

Breathing exercises:

Focusing on breathing is one of the easiest ways to ground yourself and begin to relax.

Relaxation by breathing can be as simple as taking ten deep breaths.

Another method, called 4-7-8 breathing, is a bit more complex.

First, you should inhale for 4 seconds through your nose and hold it for 7 seconds.

Next, you should exhale for 8 seconds through your mouth.

Then, the process repeats.

Progressive muscle relaxation:

Progressive muscle relaxation is exactly what it sounds like.

It aims to relax each muscle group one by one.

This is best done through guided meditation.

Biofeedback:

This method involves technology, such as a smartwatch or fitness tracker.

These devices help you evaluate your bodily processes like heart rate, breathing, and body temperature and how they affect your mental state.

Imagery training:

This technique requires you to create mental images to bring peace and calmness to your body.

For example, you can try visualizing the tension in your body leaving through a breath.

Music and meditation:

Music and/or meditation can be incredibly healing to both the body and mind.

White noise involving natural sounds such as rain, wind, or waves crashing can soothe the brain.

You could also try a guided meditation for relaxation and sleep.

These will often integrate many of the above techniques, such as breathing and progressive muscle relaxation.

Educational intervention: Sleep hygiene

Education is incredibly important for understanding your insomnia and taking control of it.

A major part of education involves counseling on proper sleep hygiene.

Sleep hygiene refers to developing your sleep schedule and daily routine to optimize sleep patterns.

Simply put, you stick to a routine and don’t deviate from it.

Elements of proper sleep hygiene include:

• Having the same wake-up time every day
• Making sleep a priority
• Making small changes at a time
• Limiting naps
• Stopping the use of electronics 30-60 minutes before bed
• Having a consistent bedtime routine
• Restricting caffeine intake in the evening
• Being physically active and getting sunlight during the day
• Restricting in-bed activities when not sleeping

 

Second-line treatment: Medications for insomnia in the elderly

There are multiple options for pharmacological treatments, including the use of:

• FDA-approved sleep medication
• Off-label use of other sedating medications
• Over-the-counter (OTC) medications (Tylenol PM, Advil PM, ZzzQuil, NyQuil, etc)
• “Natural” remedies

Several medications are indicated for treating Insomnia in the elderly.

These include:

• Orexin receptor agonists: suvorexant
• BZD receptor agonists: eszopiclone, zaleplon, zolpidem
• BZDs: triazolam, temazepam
• Melatonin agonists: ramelteon
• Heterocyclics: doxepin

Geriatric considerations

Older adults can be significantly more sensitive to medications than their younger counterparts, particularly sedative medications.

The American Geriatrics Society publishes what’s known as the Beers Criteria®, which contains recommendations on what types of drugs to avoid in seniors.

For insomnia, in particular, guidelines suggest that providers avoid:

1. Anticholinergics [e.g. hydroxyzine, diphenhydramine, doxylamine (found in NyQuil)]).
2. Benzodiazepines (BZD).
3. Certain non-BZD drugs (e.g. zolpidem, zaleplon, eszopiclone).

The medications can be a higher risk for older adults who have a history of falls or fractures, dementia, delirium, or cognitive impairment.

Prescription medications

Prescription medications should only be taken as a last resort when non-pharmacological methods have failed or insomnia has not been fully resolved.

The main reason for this is that all medications indicated for insomnia will cause overt or carry-over sedation during daytime hours, impair cognition, and increase the risk for falls and fractures.

These risks must be balanced with getting restful sleep, which is vital to health and life.

Various prescription options are available, and your appropriate therapy will depend on patient-specific factors.

Drugs will vary in terms of sleep latency and sleep maintenance.

Sleep latency refers to how long it takes you to fall asleep.

Sleep maintenance refers to how long you can stay asleep.

First-Line Agents:

Typically, controlled-release melatonin and doxepin will be first-line treatments for older adults with insomnia.

The “Z-drugs”, zolpidem, eszopiclone, and zaleplon, should be used if first-line agents are ineffective.

However, melatonin and Z-drugs are both good options for the general population.

Second-Line Agents:

Benzodiazepines (BZDs) are not suggested because of associated side effects, abuse potential, and the availability of safer alternatives.

Specifically, BZDs are not recommended in older adults.

They can disrupt the natural sleep cycle or circadian rhythm, causing increased time spent in theta and spindle sleep and decreased time in slow-wave delta sleep (sleep architecture).

This phenomenon decreases time spent in deep sleep and can increase feelings of tiredness.

Suvorexant is effective. However, it is significantly more expensive than Z-drugs.

Antihistamines, such as diphenhydramine, exhibit anticholinergic effects.

These effects are numerous and potentially debilitating, specifically in older adults.

Other options include antiepileptics and atypical antipsychotics, but these are also not recommended.

See the table below for additional details on common agents:

Prescription Medications

Prescription Medications

Drug	Mechanism	Adverse Drug Reactions	Pros	Cons
Eszopiclone	Non-benzodiazepine hypnotic	Unpleasant taste, dry mouth, fatigue, rash, dizziness, headache, cold symptoms	Improves sleep latency and maintenance (long half-life)	Unpleasant taste, short-term use, dependence, tolerance
Zolpidem	Non-benzodiazepine hypnotic	Headache, fatigue, dizziness, diarrhea, dry mouth, chest pain, palpitations, muscle pain	Improves sleep latency and maintenance	Short-term use, dependence, tolerance
Zaleplon	Non-benzodiazepine hypnotic	Fatigue, dizziness, loss of appetite, lack of coordination, vision problems, numbness or tingling	Improves sleep latency	No effect on sleep maintenance, short-term use, dependence, tolerance
Doxepin	Tricyclic antidepressant (TCA)	Nausea, vomiting, weakness, fatigue, dizziness, dry mouth, mouth sores, enlarged pupils	Improves sleep maintenance	No effect on sleep latency
Ramelteon	Melatonin receptor agonist	Dizziness, fatigue, nausea	Improves sleep latency	No effect on sleep maintenance
Temazepam Triazolam Estazolam Flurazepam Quazepam	Benzodiazepines	Memory impairment, loss of coordination, daytime sleepiness	May improve sleep latency and maintenance	Abuse potential, dependency, sleep cycle disruption, not recommended in older adults
Suvorexant	Orexin receptor antagonist	Fatigue, dizziness, headache, dry mouth, cough	Improves sleep latency and maintenance	Moderate addiction potential

Non-Prescription Medications

Non-Prescription Medications

Drug	Mechanism	Adverse Drug Reactions	Pros	Cons
Melatonin	Melatonin receptor agonist	Headache, dizziness, nausea, fatigue	Improves sleep latency	Variations in purity (not FDA regulated)
Valerian root	Likely GABA modulator (mechanism not fully understood)	Headache, stomach pain, dizziness	May improve sleep latency and quality	Variable effectiveness, not FDA regulated
Diphenhydramine (OTC) Doxylamine (OTC) Hydroxyzine	Antihistamines	Decreased secretions, blurred vision, elevated heart rate, sedation, confusion	May help with short-term sleep (sedating effect)	Anticholinergic effects, not recommended in older adults, tolerance with repeated use

Millions of people take melatonin to help them sleep better.

However, not all supplements have the same quality, potency, and efficacy.

I have noticed that my sleep patterns have changed as I grow older.

I have good and bad nights.

Bad nights are when I lie in bed for hours, ruminate about the day’s events, or dread what awaits me at work the next morning.

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Conclusion

• The importance of sleep is undeniable. Insomnia not only affects your day-to-day life but also increases your risk of developing chronic illnesses.
• Despite this fact, many people don’t prioritize sleep or seek treatment when it becomes a problem.
• Yet, many pharmacologic and non-pharmacologic solutions are available for those who struggle.
• It is important that you first try out nonpharmacologic methods.
• Treatment methods such as Cognitive Behavioral Therapy (CBT), relaxation techniques, and proper sleep hygiene effectively improve sleep duration and quality.
• If symptoms still persist, talk to your provider about the various prescription and non-prescription medications available.
• Concerning medication therapy, each drug has its own benefits and risks – Discuss carefully with your medical provider which agent is right for you.