MANAGEMENT OF INSOMNIA IN ELDERLY
Dr Jai Singh Yadav,* Dr
*Department of psychiatry
IMS BHU**S.L.N.M Hospital, Varanasi
Insomnia is defined as difficulty in initiating or maintaining
sleep. It is more commonly under diagnosed in the geriatric
population.1 There are many factors associated with aging, such as
retirement, health problems, death of spouse/family members, loss, grief,
loneliness, anxiety, depression as well as changes in circadian rythym.2
Insomnia, affect the quality of life (including excessive daytime
sedation, physical, psychological, cognitive problems affecting overall health
of the patient4), Unfortunately, the number of medications increases
with age, which in itself can lead to more morbidity, side effects such as
falls5. Cognitive impairment, financial stressors, and even sleep
disturbances6 the biggest sleep problem in
older people is a feeling of not getting enough sleep (Insomnia) or not being
rested. Treating insomnia in the elderly can improve the overall health of
the patient, but care must be taken when medications are used in the elderly.1Sleep
disorders also are linked with premature death. Normal duration of
sleep in elderly gradually decreases up 5 to 7 hours and it is basic
requirement of body. The disturbances of sleep may related to
More than one half of people older than 64 years who live at home and two
thirds of people older than 64 years who reside in a long-term care facility
are estimated to have some form of sleep disturbance. Older women are more
likely to experience insomnia than older men. In a large epidemiological study
of people older than 70 years, 35% of women reported moderate-to-severe
insomnia, compared to only 13% of men.1
insomnia is defined as sleeplessness that is not attributable to a medical,
psychiatric or environmental cause.17 Treatment of primary insomnia in older
patients should take into account the psychological changes in sleep associated
with age, described in part 1 of this review. In most cases, the initial
approach should be behavior modification.18
disruption, is common among older people due to medical conditions that cause
sleepiness are so frequent in this subpopulation. Pain related to
musculoskeletal disorders, including arthritis, constitutes one of the most
common causes of insomnia in this subpopulation. In addition to
anti-inflammatory medication, bedtime acetaminophen often promotes more restful
sleep. Nocturia is also a common cause of sleep loss (and therefore, daytime
fatigue) in elderly patients. Nocturnal is a primary contributor to nocturnal
falls and related hip fractures.14 When present, nocturia should prompt the
search for sleep apnea, diabetes, prostatic disease (in men) and bladder
prolapsed (in women), and appropriate treatment thereof. Gastrointestinal
reflux that disturbs sleep should prompt dietary counseling and may require
therapy, such as use of a proton pump inhibitor.
may be the presenting complaint in older patients who have depression or early
dementia. Depressed patients who have insomnia will often improve with
antidepressant medication in doses appropriate for the older patient.15 since
older patients are the greatest consumers of medications, a thorough drug
history is important. Consider over-the-counter medications, as well; these
often contain ingredients that interfere with sleep (e.g., caffeine). Whenever
possible, medications that may interfere with sleep should be eliminated.
for sleep disorders include over-the-counter and prescription medications,
behavioral treatments, relaxation techniques, sleep hygiene, sleep restriction,
light therapy7, cognitive behavioral therapies3,8 , valerian,
Tai Chi, yoga, meditation, acupuncture, and acupressure9
are several effective non pharmacological treatment approaches in insomnia.
Phototherapy is an interesting non pharmacological therapy for insomnia. As
already described, older people often have a phase advance in their circadian
rhythm that leads to earlier sleep onset and earlier, often nighttime,
awakening. Evening light therapy appears to be a particularly effective
treatment for early-morning insomnia from a phase-advanced circadian rhythm.19
Timed exposure to bright light has improved sleep (REM) sleep and slow-wave
sleep in older people.20 Light therapy may be effective even when given earlier
in the day: bright light exposure at lunchtime improved disturbed sleep in non
demented residents of a geriatric facility.21 In patients with dementia, bright
light therapy was also effective in reducing daytime sleep.22
hygiene reducing and limiting intake of caffeine, tobacco, avoiding alcohol and
other stimulants to the early part of the day, maintain consistent life
routine, including the sleep -wake schedule, mea times and exercise time,
avoiding strenuous physical activity.
Stimulus control technique: Go to bed only when sleepy, use the bed
only for sleep and avoid other activity in bed (sexual activity being the only
exception), and avoid day time naps unless take them regularly.
Restriction Therapy-This technique increases homeostatic sleep drive and
consolidates sleep. In this therapy reduced their time in bed to equal the
amount of time they sleep as established by sleep diary.
Relaxation Techniques: Relaxation techniques have great utility in
treating insomnia. Progressive muscle relaxation; involves tensing and relaxing
a series of muscles. .These techniques provide a positive sleep promoting
behavior and reduce the focus on insomnia. First few weeks, should be practice
outside of bed time. Once mastered, these techniques are implemented as part of
pre sleep ritual.
Cognitive Behavior Therapy: CBT was effective in reducing sleep
latency, walking up, early morning awakening and increasing sleep efficiency
(Morin, 1993). These therapies provide course introduction, sleep architecture,
physiology, Stimulus control and restriction, hypnotic medication taper, case
examples of patients with insomnia, and heightened physical and psychological
arousal, relaxation techniques and the concept of scheduled worry time.
have been the most common hypnotics used by older patients. They can be divided
roughly into 3 groups: long-acting, intermediate-acting and short-acting
(Benzodiazepines suppress stages 3, 4 and REM sleep, and increase stage 2
sleep. Clinically, they decrease sleep latency and nocturnal awakenings. In
general, when administering benzodiazepines to elderly patients, adhere to the
familiar admonition, “Start low, go slow.” Begin with no more than half the
maximal dose recommended for younger adult patients, titrate slowly, and
prescribe the drug for short periods only. Because continued use can produce
drug tolerance, dependence and the potential for withdrawal symptoms, encourage
patients to limit their use to 2 or 3 nights per week. Use of benzodiazepines
by geriatric patients has been associated with mobility problems and decreased
ability to perform the activities of daily living.12 older patients taking
these medications should be carefully monitored for daytime sedation and
impaired motor coordination; they are at increased risk of falling, with
resultant hip fracture.25Older patients who have been taking benzodiazepines
long-term are more likely to experience postoperative confusion.27Because
hypnotic agents, especially benzodiazepines, can contribute to upper-airway
obstruction during sleep, avoid prescribing them for patients with known or
suspected obstructive sleep apnea. The benefits of the drugs may not justify
the increased risk in people over 60 years of age, especially if the patient
has additional risk factors for adverse cognitive or psychomotor events (e.g.,
sleep-onset insomnia, a short-acting agent such as triazolam or oxazepam may be
effective. However, case reports of confusion, amnesia and behavior problems
with triazolam have been reported.18 Long-acting benzodiazepines such as
diazepam, flurazepam and chlordiazepoxide are not recommended for elderly
patients. Clonazepam should rarely be used, because of its potency and long
duration of action. New non-benzodiazepine agents are now becoming increasingly
popular and have been shown to be effective in the short-term treatment of
insomnia. Non-benzodiazepine drugs generally disrupt normal sleep architecture
less than do benzodiazepines.28 Examples of non-benzodiazepine agents include
zolpidem, zaleplon, zopiclone and eszopiclone.29,31 Amitriptyline is sometimes
prescribed as a sleep inducer, particularly when there is a suggestion of
underlying depression. Curtis and associates, 20 using criteria based on risk
of adverse events, found amitriptyline to be one of the most commonly
prescribed drugs that they concluded should be avoided for elderly patients.
Trazadon role in the treatment of primary insomnia.33
relative melatonin deficiency that accompanies aging may therefore contribute
to insomnia. Promoted by some as a more “natural” sleep remedy, some studies22
have in fact shown melatonin administration to be modestly effective in
improving sleep quality in elderly patients, However, Buscemi and
coauthors,23,24 in their meta-analysis, concluded that melatonin, although
safe, is of limited value in treating most primary or secondary sleep disorders.
There was some evidence that short-term use of melatonin was useful in treating
delayed sleep-phase syndrome,26 a disorder of sleep timing in which people are
able to fall asleep only at late times, and then have difficulties waking up
for morning activities.
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