Managing Insomnia in the older adult.

Jane, a 75-year-old woman presents to your office for routine follow-up after being recently discharged from the hospital. She reports poor sleep since discharge and wants a renewal of Zopiclone, a sedative-hypnotic. Her past medical history indicates mild cognitive impairment, hypertension, type 2 diabetes mellitus and osteoarthritis.

Issue

Sedative-hypnotics are commonly prescribed for insomnia despite a lack of evidence for their long-term effectiveness and an increase in adverse events in older adults.

Bottom line

Insomnia is common among older adults and is usually comorbid with medical and psychiatric illnesses complicated by multiple medication use. Significant improvement in quality of life and daytime functioning is seen in patients who:

• Undergo behavioral therapy, including multi-component cognitive behavioral therapy and single component interventions, such as sleep restriction-compression therapy.
• Avoid the use of sedative- hypnotic therapies that are associated with significant adverse effects (Bloom et al, 2009).

Background

Insomnia refers to reduced ability to fall asleep or stay asleep or reduction in sleep quality that interferes with daytime functioning. In a study of 9,000 older adults aged 65 years and older, 42% had difficulty staying asleep or falling asleep with a higher prevalence found in patients with poor health and on multiple medications (Foley, Monjan & Brown, 1995). Insomnia is associated with significant morbidity and mortality. Older adults with difficulty sleeping report depressive symptoms and poor quality of life (Barbar et al., 2000). Cognitive decline and difficulty ambulating with poor balance has been associated with poor sleep even after controlling medication use (Brassington, King, & Bliwise, 2000; Cricco, Simonsick & Foley, 2001). Recognition, assessment and proper management of insomnia in adults is critical to reducing morbidity and mortality associated with poor sleep.

Assessment

To assess insomnia, the medical professional should first take a thorough history of sleep difficulties, including possible predisposing, precipitating and perpetuating factors. Following that, a physical exam should be administered to rule out any underlying medical disorders causing sleep difficulties. Further investigations are dictated by findings on history and physical exam.

Management

Management of underlying medical and psychiatric conditions can help manage sleep problems.

• Underlying anxiety and depression can be managed with appropriate therapy.
• Optimizing pain management patients with osteoarthritis or other musculoskeletal- related disorders can help improve sleep difficulties.
• A medication review can be completed to limit sleep disrupting medications such as an evening dose of diuretics.
• The following strategies can be used to manage insomnia in the older adults once predisposing and perpetuating factors have been addressed.

Behavioral therapy

• Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be the most effective. CBT-I combines multiple behavioral approaches such as sleep hygiene instructions, including stimulus control and sleep restriction in addition to cognitive restructuring. CBT- I trials in older adults showed an improvement in insomnia that was sustained for up to two years (Morin, Colecchi & Stone, 1999).
• Sleep restriction-sleep compression therapy: This involves limiting the time in bed to consolidate actual sleeping time. The patient is advised to reduce the amount of time in bed to correlate closely with actual sleeping time that is derived from two weeks of a sleep log. A number of studies have demonstrated the efficacy of sleep restriction- sleep compression therapy as a treatment of chronic insomnia in older adults (Riedel, Lichstein & Dwyer, 1995).
• Exercise, complementary and alternative treatment strategies: The impact of these approaches on sleep is not well-understood. Some studies have shown benefits with walking, Tai- Chi and acupressure for some individuals (Bloom et al, 2009).

Pharmacological therapy

When first-line therapy fails and insomnia impacts the patient’s quality of life, pharmacological therapy can be considered for short term use (TOP, 2010). Benzodiazepines and non-benzodiazepines receptor agonists (Z- drugs) commonly used in managing insomnia in adults (Fleming, 2014) should generally be avoided in the elderly given the risk of adverse events. Older adults are at an increased risk of adverse effects from sedative-hypnotic drugs given reduced clearance of some drugs and a greater sensitivity to peak drug effects (Bloom et al, 2009).

• Sedative-hypnotic drugs pose significant risk in the older adult such as falls and hip fractures, cognitive decline and delirium (Bloom et al, 2009). Choosing wisely Canada recommends avoiding these classes of drugs as first-line therapy in managing insomnia in the older adult. CBT-I and other behavioral interventions are recommended instead.
• Trazodone is frequently prescribed for managing Insomnia. It is sedating, can cause orthostatic hypotension and lacks evidence of sustained effectiveness (AHRQ, 2014; McCall, 2005).
• Doxepin in low doses at 3- 6 mg has moderate evidence of being effective in managing chronic insomnia in older adults, but it may cause next day drowsiness and has significant drug interactions (AHRQ, 2014).
• There is some evidence that slow-release Melatonin can improve sleep onset latency and sleep quality in adults older than 55 years of age (Wilson, Nutt & Alford, 2010).
• Associated with significant adverse effects in the older adult, antidepressants, antipsychotics, antihistamines and anticonvulsants are not recommended for treatment of primary insomnia (TOP, 2010).

Recommendation: Combination therapy

Combining behavioral and pharmacological therapy provides better outcomes compared to either modality alone. While pharmacological therapy provides short term relief, behavioral therapy provides longer term sustained benefit (Morin et al, 1999).

References

1. Agency for Healthcare Research and Quality (AHRQ) (2014). Clinical guideline for the treatment of primary insomnia in middle aged and older adults. Guideline summary NGC- 104414
2. Babar, S. I., Enright, P. L., Boyle, P., Foley, D., Sharp, D. S., Petrovitch, H., & Quan, S. F. (2000). Sleep disturbances and their correlates in elderly Japanese American men residing in Hawaii. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 55(7), M406-M411..
3. Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli‐Israel, S., Buysse, D. J., Kryger, M. H., ... & Zee, P. C. (2009). Evidence‐based recommendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761-789.
4. Brassington, G. S., King, A. C., & Bliwise, D. L. (2000). Sleep Problems as a Risk Factor for Falls in a Sample of Community‐Dwelling Adults Aged 64–99 years. Journal of the American Geriatrics Society, 48(10), 1234-1240.
5. Choosing wisely Canada. Accessed March 21, 2016 http://www.choosingwiselycanada.org/recommendations/geriatrics/
6. Cricco, M., Simonsick, E. M., & Foley, D. J. (2001). The impact of insomnia on cognitive functioning in older adults. Journal of the American Geriatrics Society, 49(9), 1185-1189.
7. Fleming JAE(2014). Psychiatric disorders – Insomnia. CTC 7 Compendium of Therapeutic Choices. 7th Eds. Canadian Pharmacists Association. Accessed March 21, 2016. https://www.pharmacists.ca/cphaca/assets/File/CTC7_Sample%20Chapter_Insomnia.pdf
8. Foley, D. J., Monjan, A. A., Brown, S. L., & Simonsick, E. M. (1995). Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep: Journal of Sleep Research & Sleep Medicine.
9. McCall WV (2005). Diagnosis and management of insomnia in older people. Journal of the American Geriatric Society. 53: S272-S277.
10. Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. Jama, 281(11), 991-999.
11. Riedel, B. W., Lichstein, K. L., & Dwyer, W. O. (1995). Sleep compression and sleep education for older insomniacs: Self-help versus therapist guidance. Psychology and Aging, 10(1), 54.
12. Toward Optimized Practice (TOP) Program 2010 Guideline for adult insomnia. Edmonton, Alberta http://www.topalbertadoctors.org/download/437/adult_insomnia_pda.pdf. Accessed March 14, 2016
13. Wilson, S. J., Nutt, D. J., Alford, C., Argyropoulos, S. V., Baldwin, D. S., Bateson, A. N., ... & Gringras, P. (2010). British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias