Insomnia in the elderly

Brabbins CJ, Dewey ME, Copeland JRM, et al Insomnia in the elderly prevalence, gender differences and relationships with morbidity and mortality. Int J Geriatr Psychiatry 8 473-480, 1993... 

Monane M. Insomnia in the elderly. J Clin Psychiatry 1992 53(suppl) 23-28. 

Shapiro CM, Steingart A (1993) Fifty-one questions for the elderly insomniacs and why. Sleep disorders and insomnia in the elderly. Facts and Research in Gerontology 7 223-232... 

Ancoli-Israel S (2000) Insomnia in the elderly a review for the primary care practitioner. Sleep 23 S23-S30, discussion S36-S38... 

Soldatos CR, Dikcos DG (1993) Efficacy and rebound of five hypnotics in the elderly a critical review. In L Vellas, JL Albarede (eds) Sleep disorders and insomnia in the elderly. Serdi, Paris, 209-221... 

Insomnia is a common complaint in the elderly. As people age they require less sleep, and a variety of physical ailments to which the elderly are subject can cause a change in the sleep pattern (e.g. cerebral atherosclerosis, heart disease, decreased pulmonary function), as can depression. Providing sedative hypnotics are warranted, the judicious use of short half-life benzodiazepines such as temazepam, triazolam, oxazepam and alprazolam for a period not exceeding 1-2 months may be appropriate. Because of their side effects, there would appear to be little merit in using chloral hydrate or related drugs in the treatment of insomnia in the elderly. It should be noted that even benzodiazepines which have a relatively short half-life are likely to cause excessive day-time sedation. The side effects and dependence potential of the anxiolytics and sedative hypnotics have been covered elsewhere in this volume (Chapter 9). 

In addition to the benzodiazepines, there may be a role for the nonbenzodiazepine drugs such as zalaplon, zolpidem or zopiclone in the treatment of anxiety and insomnia in the elderly. These drugs appear to be well tolerated in younger populations of patients, but it is essential to await the outcome of properly conducted trials of these drugs on a substantial number of elderly patients before any conclusions may be drawn regarding their value as alternatives to the benzodiazepines. 

Antihistamines such as diphenhydramine are known for their sedating properties and are frequently used over-the-counter medications (usual doses 25-50 mg) for difficulty sleeping. Diphenhydramine is approved by the FDA for the treatment of insomnia and can be effective at reducing sleep latency and increasing sleep time.43 However, diphenhydramine produces undesirable anticholinergic effects and carryover sedation that limit its use. As with TCAs and BZDRAs, diphenhydramine should be used with caution in the elderly. Valerian root is an herbal sleep remedy that has inconsistent effects on sleep but may reduce sleep latency and efficiency at commonly used doses of 400 to 900 mg valerian extract. Ramelteon, a new melatonin receptor agonist, is indicated for insomnia characterized by difficulty with sleep onset. The recommended dose is 8 mg at bedtime. Ramelteon is not a controlled substance and thus may be a viable option for patients with a history of substance abuse. 

Zaleplon also binds to the GABAa receptor. It has a rapid onset, a half-life of about 1 hour, and no active metabolites. It does not reduce nighttime awakenings or increase the total sleep time. It may be best used for middle-of-the-night awakenings. It does not appear to cause significant rebound insomnia or next-day psychomotor impairment. The most common side effects are dizziness, headache, and somnolence. The recommended dose is 10 mg (5 mg in the elderly). 

To mimic melatonin action and increase the half-life is the goal of melatonin receptor agonists, which are the more recent addition to the insomnia therapeutic armamentarium. These compounds, in addition to use for insomnia, may have potential application in the synchronization of disturbed circadian rhythms, sleep disturbances in the elderly, seasonal depression and jet lag, to name a few. Furthermore, studies have shown that melatonin receptor agonists do not induce any of the hypothermic, hypotensive or bradycardic effects caused by melatonin in humans [27,28]. 

The use of benzodiazepines should be avoided. There are other safer pharmacological alternatives. Benzodiazepine withdrawal may play a role in the occurrence of delirium in the elderly. Other withdrawal symptoms include tremor, agitation, insomnia and seizures (Turnheim 2003). Thus, when there is long-term use of benzodiazepines abrupt discontinuation might be difficult. Discontinuation should however not be withheld but done slowly and step-wise. If benzodiazepines are used in the elderly, short-acting benzodiazepines such as oxazepam are preferred, because they do not accumulate in the elderly to the same extent (Kompoliti and Goetz 1998). If short-acting benzodiazepines are used they should be prescribed with caution, at low doses, and for short periods. As with all pharmacotherapy the effects should be evaluated. Benzodiazepines are sometimes used as a behavioural control. One should always ask if this use is for the benefit of staff or the benefit of the patient. The presence of staff may be sufficient for behavioural control. 

Triazolam (ti/2 of elimination -1.5-5.5 h) is especially likely to impair memory (anterograde amnesia) and to cause rebound anxiety or insomnia and daytime confusion. The severity of these and other adverse reactions (e.g., rage, violent hostility, hallucinations), and their increased frequency in the elderly, has led to curtailed or suspended use of triazolam in some countries (UK). 

Psychiatric/Physical disorder Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, initiate symptomatic treatment of insomnia only after careful evaluation of the patient. Because some of the important adverse effects of eszopiclone appear to be dose-related, it is important to use the lowest possible effective dose, especially in the elderly. 

Zopiclone is relatively well tolerated (137). The most common adverse reaction is taste alteration. A postmarketing analysis of 10,000 cases revealed that zopiclone has a relatively low incidence of side effects (about 8%) (138). Like BZDs, zopiclone has a dose-related hangover effect (139). Rebound insomnia has occurred after short-term use (5 to 14 days) but does not appear to be as severe, even after abrupt withdrawal (140, 141). Abuse, tolerance, and physical and psychological dependence have been reported with zopiclone (142). Zopiclone has been shown to be as effective a hypnotic as triazolam in the elderly ( 143). More comparisons with short to medium half-life BZDs for the treatment of insomnia are needed to show that zopiclone has an advantage over the BZDs. 

Studies in the elderly have been carefully reviewed by Soldatos and his colleagues [27]. Some deterioration in the soundness of sleep has been detected but the amount of rebound insomnia following zopiclone discontinuation is relatively weak. Although one would certainly expect rebound in a hypnotic with a half-life of around 5 h, the frequency and severity of such rebound seems definitely less than those observed with comparative benzodiazepines such as triazolam and temazepam [28],... 

Insomnia. Use temazepam or zopiclone (which may be less prone to cause confusion in the elderly). 

Zopiclone is a cyclopyrrolone in structure. It has a fairly fast (about 1 hour) onset of action which lasts for 6-8 hours, making it an effective drug both for initial and maintenance insomnia. It may cause fewer problems on withdrawal than benzodiazepines. Its duration of action is prolonged in the elderly and in hepatic insufficiency. About 40% of patients experience a metallic aftertaste. Care should be taken with concomitant medication that affects its metabolic pathway (see Table 19.2a). The dose is 3.75-7.5 mg p.o. 

Central nervous system adverse effects are common with felbamate, and consist mainly of insomnia, headache, impaired concentration, ataxia, dizziness, somnolence, behavioral disturbances, and mood changes. Movement disorders, psychosis, increased seizures, status epilepticus, and withdrawal seizures are less common (SEDA-19, 67) (SEDA-20, 61). The incidence of these effects is increased in the elderly, possibly owing to reduced drug clearance (4), whereas patients with mental retardation may be more prone to behavioral disorders (SEDA-19, 68). 

Adverse reactions to indometacin involving the central nervous system are frequent and come second in importance only to gastrointestinal effects. They are attributed to salt and water retention. Up to 60% of patients experience headache (often migraine-like), frontal throbbing, and vertigo. Vomiting, tinnitus, ataxia, tremor, dizziness, and insomnia follow. Somnolence, confusion, hallucinations (especially in the elderly), and psychotic symptoms have been described. Coma, clonic seizures, and myoclonic spasms (SEDA-18,101) can develop. Muscle weakness and paresthesia, that is, peripheral neuropathy, may develop in elderly patients, but recede after withdrawal (9,10). 

Insomnia is the most common complaint in general medical practice settings. Primary insomnia usually begins in young adulthood or middle age, and is rare in childhood or adolescence. More than 50% of the population complains of insomnia in their lifetime. A 1-year prevalence study of insomnia in the United States reports that one-third of the individuals surveyed complained of insomnia, and 17% reported that the symptoms were serious. Conservative estimates of chronic insomnia range from 9% to 12% in adulthood and up to 20% in the elderly. Women complain of insomnia twice as frequently as men. Individuals who are elderly, unemployed, separated or widowed, or those with a lower socioeconomic status reported a significantly higher incidence of insomnia. Forty percent with insomnia also had a concurrent psychiatric disorder (anxiety, depression, or substance abuse). ... 

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