What's the Best Treatment for Insomnia in the Elderly?

Current estimates of insomnia in the elderly is around 40% or greater (1).

This is an even higher rate than the general population. There’s a common but unsupported belief that you need much less sleep as you get older, which can lead to older people with insomnia avoiding getting it treated.

I’ve summarized the latest research in how insomnia is typically treated in older patients in this short guide.

How Insomnia in the Elderly Differs From Others

Insomnia occurs and is treated in elderly patients fairly similarly to younger patients, although there are a few differences.

There are a few reasons that it’s more common in the first place in older people:

• Circadian rhythm issues - For reasons that still aren’t fully known, older people have a greater chance to experience a circadian rhythm shift, which can make it more difficult to maintain a sleep schedule.
• Physical changes due to age - Injury and obesity are much more common as people age, and these can both lead to sleep trouble and eventually insomnia.
• New stresses in life - While stress about work goes away after retiring, there are new sources of stress for the elderly that come from things like losing freedom, death, and isolation. Stress is one of the most common causes of insomnia.

Other Causes Of Insomnia in Older Patients

In order to treat insomnia, it’s helpful to determine the root cause.

On top of the potential causes outlined above, there are other “normal” causes of insomnia that are relevant for older patients, including:

• Medical conditions - Anxiety disorders, depression, cardiovascular disease, dementia, Parkinson’s, and many other conditions can cause sleep problems.
• Medications - Sleep problems are a common side effect of medications like antidepressants, decongestants, cardiovascular drugs (e.g. beta blockers), diuretics, and others. Elderly people are more likely to regularly take one or more medications that can potentially interfere with sleep.
• Poor sleep hygiene - Having a noisy or bright sleep environment, combined with habits like eating before bed or watching TV can lead to insomnia. This can be common if someone elderly starts living in a long term care home where they have limited control over the environment.

Treatment Options for Insomnia in the Elderly

Since the causes of insomnia in older people are similar to the general population, treatment options are also similar. However, they should be tailored based on the variations we looked at above.

Note that insomnia, especially in the elderly, needs to be treated by a doctor. It’s a serious condition that can have adverse health effects, and is not the easiest to correct without help (2).

Let’s go over the standard treatment options in this situation.

Sleep Hygiene Education

Sleep hygiene is the easiest thing to fix in the case of sleep issues. This involves things like:

• Not napping
• Having a consistent sleep schedule
• Having a good sleeping environment (i.e. stimulus control, light, noise)
• Avoiding stimulants like caffeine
• Reducing drinking
• Clock watching

When someone retires or moves into a new care home when they’re older, it’s easier for these habits to creep and affect sleep. They often have a small effect at first, that snowballs into insomnia later.

Cognitive Behavioral Therapy (CBT)

CBT is a cornerstone of more insomnia treatment plans.

It’s highly effective with very little risk of downsides, and doesn’t take too long to produce some results.

It involves some aspects of sleep hygiene education along with examining mistaken beliefs and attitudes that can lead to insomnia.

However, there are some challenges:

• Cost - CBT is best done with a professional, but that comes with a significant cost in most countries. It can be done online fairly effectively at a reduced cost.
• Access to materials - If in-person therapy is the only option that a patient will adhere to, it’s not always easy to get access to trained CBT professionals.

Studies have shown that brief behavioral treatment has similar effectiveness that can last past 6 months (3). This is a modified form of CBT run by trained nurses that can be more accessible.

Pharmacological Treatments

Medication is typically a last resort when it comes to treating insomnia.

There’s no single medication that’s reliably effective while also having limited side effects, so any of the above treatment methods are preferred.

In addition, elderly people are more likely to already be taking medication, producing opportunities for unwanted interactions.

There are some over the counter options like:

• Melatonin - Arguably the safest option that can help certain types of insomnia, but isn’t always effective.
• Antihistamines - Certain allergy medications like Benadryl contain antihistamines that can promote sleep. However, people can develop tolerances to these in as few as 4 nights. They are a short-term crutch, but not a solution.

In addition, doctors can prescribe a wide variety of medications with hypnotic effects, including (4):

• Benzodiazepines
• Benzodiazepine receptor agonists
• Melatonin receptor agonists

However, these come with risks.

For example, benzodiazepines are associated with side effects such as higher risk of falls, daytime sleepiness, rebound insomnia, and substance abuse (5).

The Best Treatment Plan for Insomnia in the Elderly

With all that information, here’s the general treatment plan that a doctor will prescribe and oversea for an older patient with insomnia:

1. Address and manage any other underlying conditions
2. Address any drug or substance use
3. Try non-drug treatment for insomnia, including:
4. CBT
5. Sleep hygiene education
6. Stimulus control therapy
7. Relaxation therapies
8. Prescribe sleep medication if needed

Difficulties in Treating Insomnia in the Elderly

There are a few challenges that make treating older insomnia patients even harder sometimes:

• Lack of control - If the patient lives in a LTC facility or somewhere else where they have limited control over the environment (e.g. lights, sounds), it can be hard to treat sleep hygiene issues.
• Adherence to treatment plan - If treatment involves going to therapy appointments, it can be difficult for seniors with mobility problems to attend appointments. Online therapy options are a potential solution, although lack of comfort with technology can be an additional hurdle.
• Access to medication - It can be difficult for a patient to take medication on a particular schedule if medication is handled and given by staff, or if the patient has memory problems.

Given all the potential nuances of treating insomnia in elderly patients that we’ve looked at, it’s important for a physician to craft a tailored plan for the individual patient.

References

1. Sleep and sleep disorders in older adults
2. Insomnia in the Elderly: A Review
3. Efficacy of brief behavioral treatment for chronic insomnia in older adults
4. Review of insomnia pharmacotherapy options for the elderly: implications for managed care
5. Insomnia in Elderly Patients: Recommendations for Pharmacological Management