Treating Insomnia

Add to Favorites
Collapse All

Treating Insomnia - #40

Take Quiz

Identify and define treatment strategies for geriatric insomnia patients.

Assessment

There are three general treatment strategies for insomnia:

 1. Behavioural Therapy (4) - As effective as pharmacotherapy without risk of  drug interactions; should be tried before pharmacotherapy

Type Description

Stimulus Control Therapy

Go to bed when sleep is imminent, get out of bed upon waking, only allow sleeping in bedroom, set consistent waking time, avoid naps

Relaxation Therapy

Progressive muscle relaxation, guided imagery, diaphragmatic breathing, meditation, biofeedback

Sleep Restriction Therapy

Limit time in bed to number of hours spent sleeping, gradually increase time allowed until reach ideal amount

Sleep Hygiene

Exercise earlier in day, adhere to set bedtime and wake time, minimize caffeine, naps, exercise, smoking, alcohol, and heavy meals before bed

Cognitive Behavioral Therapy

Combination of above approaches

 

2. Pharmacotherapy (4) - Attempt after unsuccessful behavioral therapy, or immediately with deep stress, or disability due to lack of sleep.

1st Line: Non-benzodiazepine hypnotic drugs

Pros Cons

Zolpidem

  
  • No rebound insomnia, agitation, or anxiety upon discontinuation
  • No daytime impairment
  • Rapid onset
  • Short-term use (extended-release formulations available for long-term use)
  • Chronic use associated with risk of confusion, falls, and fractures

Zaleplon

  
Rapid onset
  • Short-term use
  • Chronic use associated with risk of confusion, falls, and fractures

Eszopiclone

  
Long-term use
  • Expensive

Ramelteon

  
  • Reduced sleep latency
  • Increased total sleep time
  • No significant rebound or withdrawal upon discontinuation
  • Expensive

Trazodone

  
  • Used off-label for insomnia with depression
  • Some orthostatic effects
  • Possible priapism

Mirtazapine

  
  • Increased appetite, may cause weight-gain
  • Some dizziness and daytime impairment

 

Avoid: Benzodiazepines

Pros

Cons

All Classes

 
  • None
  • Increased drug elimination half-life
  • More sensitive to effects on CNS; more sedating, which increases risk of confusion and falls
  • Start with lower dose
  • Rebound insomnia may be worse than baseline
  • Interrupts sleep architecture

Long- Lasting

 
  • None
  • Highest risk of falls due to daytime impairment

Short-Acting

 
  • Less daytime impairment
  • Increased risk of rebound insomnia and withdrawal

 

Avoid: OTC Sleep Aids

Pros

Cons

Antihistamines

 
  • None
  • Potent anti-cholinergic effects
  • Tolerance develops after several weeks

Alcohol

 
  • None
  • Interferes with sleep later in night

 

#3 Combination treatments (pharmacotherapy with behavioral therapy) – “improves sleep continuity and efficiency” initially relative to pharmacotherapy or behavioral therapy alone, however long-term maintenance may be better with pharmacotherapy alone.8

Context

Management of sleep disturbances in a geriatric patient

Action

List treatment strategies for insomnia and choose an appropriate strategy for an individual patient.

Definition

Insomnia: Difficulty with sleep due to prolonged sleep onset latency, frequent nocturnal awakenings, prolonged periods of wakefulness during the sleep period, or frequent transient arousals .

Incidence / Prevalence

Geriatric patients commonly experience sleeping disturbances. Although sources differ, up to 60% of geriatric patients report problems with sleeping at least a few nights per week, with 6-15% meeting diagnostic criteria for insomnia1. Higher rates of insomnia are seen in women, especially after the onset of menopause1. Despite the increased prevalence of insomnia in geriatric patients, insomnia is not normal aging. Sleep disturbances in geriatric patients are associated with decreased quality of life, daytime fatigue or low energy, cognitive decline, and mood dysphoria1.

The increased prevalence of insomnia in the geriatrics population is likely multifactorial in etiology. Patients are more susceptible to sleep disturbances if they have comorbid medical, psychiatric, or neurologic illnesses, due to the nature of the illness, as well as due to the use of medications to treat the illness. Depression and anxiety are common psychiatric contributors to insomnia.
 

Underlying Sciences

Polysomnography (PSG), a type of diagnostic sleep test, has shown that older patients experience less total nighttime sleep, spend more time in bed, have more nighttime awakenings, and take longer to fall asleep4. Physiologically, patients show increased activation of the autonomic nervous system, as indicated by increases in heart rate, blood pressure, metabolic rate, body temperature, activity of the hypothalamic-pituitary-adrenal axis, and norepinephrine secretion . This activation may explain why patients with insomnia typically have higher frequency brain waves while sleeping, a factor which may predispose them to awaking during sleep. Additionally, with age, the circadian rhythm becomes less synchronized; possibly affected by variation in bedtime, medications and dosing administration times, mealtimes and other changes in routine (timing of “lights-out/on” in long-term care facilities).4
 

Science Principles

Behavioral & Social Sciences including Bioethics

Objectives

Identify strategies for treating insomnia in a geriatric patient.

Keywords/Tags

References

  1. Roth T. Insomnia: definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine. 2007; 3(5):S7-S10.
  2. Kierlin L, Olmstead R, Yokomizo M, Nicassio P, Irwin MR. Diagnostic and Statistic Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults. Sleep Medicine. 2012; 13:958-960.
  3. McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. American Journal of Managed Care. 2009; 15(1):S14-S23.
  4. Galimi R. Insomnia in the elderly: an update and future challenges. Gerontology. 2010; 58:231-247.
  5. Morin CM, Benca R. Chronic Insomnia. Lancet. 2012; 379:1129-1141.
  6. Durso SM, Sullivan GM. Geriatrics Review Syllabus (8th edition). American Geriatrics Society, 2013.
  7. Setiati S, Laksmi PW. Insomnia in Geriatrics. Indonesian Journal of Internal Medicine. 2005; 37(4):224-229.
  8. Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and Pharmacological Therapies for Late-Life Insomnia. Journal of the American Medical Association. 1999; 281: 991-999.
This GFF ___ my competence in geriatrics.

Authors

Gretchen Wagner, Kathryn Denson

Author Affiliation

Medical College of Wisconsin

Copyright

Collapse All
Report a problem about this Fast Fact