Let’s Sleep on It
Insomnia is the most common sleep disturbance older adults experience, with a prevalence ranging from 20% to 40%. Lack of sleep can cause daytime somnolence, cognitive decline, depression, and an increased risk of falls. By definition, insomnia can include difficulty falling asleep or maintaining sleep or not feeling rested upon waking. The clinical diagnosis of insomnia designates that at least one of these symptoms exists and causes impairment concerning work-related or social activities.
Numerous factors can contribute to sleep problems. Older adults experience decreased total sleep time, more frequent awakenings throughout the night, and decreased sleep efficiency. Sleep disturbances may also result from chronic medical conditions, medications, and primary sleep disorders such as sleep apnea, restless leg syndrome, and periodic limb movements. Psychosocial factors, such as grief or bereavement, can also play a role.
CBT consists of maintaining a regular sleep schedule and ensuring a comfortable sleep environment (i.e., dim lighting and noise elimination). Stimulus-control therapy encourages using the bedroom for sleep only; patients should not watch television or eat while in bed. Relaxation therapy may be effective for older adults for whom hyperarousal is suspected as a cause of insomnia. Relaxation techniques include imagery and meditation.
When considering benzodiazepines for use in older adults, it’s best to choose one with a rapid onset of action, no active metabolites, a relatively short duration of action, and minimal drug-drug interactions. The half-lives of benzodiazepines may be prolonged in older adults, which can lead to a “hangover” effect. Benzodiazepines are associated with tolerance, dependency, and rebound insomnia. They can also impair cognition, decrease daytime alertness, and increase risk of falls, and older adults are especially sensitive to these effects.
Zolpidem is indicated for the short-term management of insomnia (less than 10 days). It has a rapid onset and a relatively short duration of action. Zolpidem controlled release consists of a two-layer tablet: two thirds of the total dose is released immediately, and one third is released after three hours. Zolpidem controlled release is indicated for a longer duration of use, up to three weeks. Adverse events include dizziness, drowsiness, nausea, and upset stomach.
Zaleplon has a faster onset and shorter duration of action than zolpidem. Because of its short duration of action, it may be taken after the patient has gone to bed and experienced difficulty falling asleep, as long as there are at least four hours of sleep remaining. There are no published studies that look at during-the-night use of zaleplon in older adults. Adverse events include dizziness, headache, nausea, and somnolence.
Eszopiclone has an onset and duration of action similar to zolpidem. Like zolpidem controlled release, eszopiclone is not restricted to short-term use. Adverse effects include somnolence, headache, and unpleasant taste.
Melatonin Receptor Agonists
Other Sleep Aids
There are several nutraceutical products marketed for the treatment of insomnia. Melatonin is an endogenous hormone that regulates circadian rhythm. Although melatonin may be effective in circadian rhythm disorders (e.g., jet lag), there is little evidence for efficacy in the treatment of insomnia.
Valerian is a plant derivative that is touted for promoting sleep. However, several case reports describe the incidence of hepatotoxicity with its use. And L-tryptophan is an endogenous amino acid that has been used as a hypnotic despite limited evidence.
Drugs should be used at the lowest effective dose, and intermittent dosing (two to four times weekly) is preferred. Additionally, it’s advisable to attempt dosage reductions, and the medication should be gradually tapered and discontinued whenever possible.
— Jennifer M. Voisine, PharmD, BCPS, is a geriatric pharmacy resident at the VA Connecticut Healthcare System in West Haven and an adjunct professor at the University of Connecticut School of Pharmacy.
— Sean M. Jeffery, PharmD, CGP, FASCP, is an associate clinical professor at the University of Connecticut School of Pharmacy and a clinical specialist in geriatrics at the VA Connecticut Healthcare System department of pharmacy.