Insomnia in the Elderly

When an older person has difficulty sleeping, the causes and treatments may be different than for a younger adult, according to Jessica Vensel Rundo, MD, MS, staff physician at Cleveland Clinic Sleep Disorders Center. For geriatric insomnia, medical conditions play a greater role as triggers, and hypnotic medications play a lesser role in treatment.

Recognizing insomnia

Some 40 to 50 percent of adults aged 60 and older experience insomnia, compared with 10 to 20 percent of younger adults, according to Dr. Rundo.

“Even so, insomnia is easy to miss if you don’t ask older patients about it. They might believe poor sleep and daytime fatigue are normal with aging,” she says.

Sleep in later life is characterized by less slow-wave sleep (deepest stage). Sleep latency — the time it takes to fall asleep — tends to increase, and more awakenings occur at night. Despite these changes, people do not need substantially more or less sleep as they age, Dr. Rundo says.

She suggests three screening questions for insomnia, which is defined as difficulty falling asleep or staying asleep for as long as desired:

1. Are you having difficulties with falling or staying asleep at night?
2. How much sleep do you think you’re getting at night?
3. Do you have daytime fatigue or sleepiness?

You could ask a family member similar questions about an individual with Alzheimer dementia who may be sundowning. This syndrome of increased confusion and agitation in the evening can interfere with sleep through the night.

“Think of insomnia if someone reports taking longer than 30 minutes to fall asleep or waking too early and being unable to go back to sleep,” Dr. Rundo says.

The seven-question Insomnia Severity Index can help quantify the severity of symptoms such as daytime fatigue and struggles with chores, work, concentration, memory or mood. This validated self-reporting scale also can help monitor treatment over time.

“If insomnia is affecting a person’s daytime functioning, it should be treated,” Dr. Rundo says.

Step one: Identify medical factors

Begin by identifying and managing medical conditions that may be interfering with sleep, Dr. Rundo recommends. Common underlying factors include chronic pain, asthma, gastroesophageal reflux, obstructive sleep apnea (OSA), restless legs syndrome, anxiety, depression and medications that affect sleep.

Bowel problems and frequent urination also can interrupt sleep.

“A pattern of getting up frequently and having difficulty falling back to sleep can develop. Even if the problem resolves, the disrupted sleep pattern may remain,”Dr. Rundo says.

Similarly, frequent awakenings by individuals with Alzheimer disease or other dementias can perpetuate insomnia.

Psychological stress manifests as several insomnia patterns.

“Anxious people tend to report ruminating thoughts and excessive worry that cause difficulty with falling asleep, whereas depressed people report sleeping for four or five hours and then having a hard time going back to sleep,” according to Dr. Rundo.

Loss of muscle tone with aging contributes to collapse of the oral pharyngeal airway and OSA. “Probably 40 to 50 percent of individuals over age 60 have some sleep-disordered breathing,” Dr. Rundo says. In her experience, OSA that develops after menopause is a frequent cause of insomnia in women.

“Individuals with OSA may complain of difficulty falling asleep, but more frequently we hear about difficulty staying asleep. They awake multiple times at night, may have been told they snore or stop breathing, and feel excessively sleepy during the day,” Dr. Rundo says. She recommends referral to a sleep specialist for further testing.

Step two: Modify behaviors

After managing medical causes, Dr. Rundo addresses behaviors and beliefs that may reinforce insomnia inpatients of all ages. “People with insomnia often lie awake in bed for hours. This conditions them to think it’s OK to be awake in bed. It also conditions them to expect poor sleep,” she says.

Dr. Rundo advises patients to leave the bedroom if they do not fall asleep after 20 minutes and to read a book or listen to relaxing music. When drowsy, they can go back to bed.

“One of those times they will fall asleep, and that is the new conditioned response. The body eventually will go into the bedroom and remember to fall asleep,” she explains.

She also recommends trying these sleep hygiene behaviors:

• Controlling stimuli: No TV or computer in the bedroom, no excess noise or light at bedtime
• Going to bed only when drowsy
• Getting up at the same time every day
• Eliminating caffeine after 2-3 p.m.
• Avoiding exercise within 3-4 hours of bedtime

Patients with insomnia often try these behaviors briefly without success. “It takes weeks to months to condition your body to behave differently,” Dr. Rundo explains. Referral to a psychologist for cognitive-behavioral therapy (CBT) can help people persevere in their efforts to change sleep behaviors and negative thoughts about sleep.

Medication options

Medication is an option for patients who decline CBT or who have severe insomnia. Dr. Rundo advises caution with sedating histamines, such as diphenhydramine, which can cause memory and cognitive problems in the elderly. As first-line medication, she suggests a sedating agent to treat a coexisting problem, such as mild depression, anxiety or chronic pain. Options include doxepin, which is indicated for depression and insomnia; other sedating antidepressants such as trazodone or amitriptyline; or the anticonvulsants gabapentin or pregabalin for neuropathic pain and insomnia.

“Ultimately, I wouldn’t be against using a small dose of a hypnotic, but I would monitor closely for side effects,” she says.

Potential risks include daytime sedation, falls and cognitive impairment. For older people, she recommends one-half the usual starting dose (e.g., zolpidem tartrate, 2.5 milligrams). Avoid combining hypnotics with other sedating agents, such as antidepressants, antihistamines, antinausea medications, opioids and benzodiazepines, Dr. Rundo advises.

“When you start medication or CBT for insomnia, follow up within a month or two. If an office visit is not possible, at least do a phone follow-up,” she says.