INSOMNIA

The most common sleep disorder both in the general population and in seniors is insomnia. 

Many factors can contribute to insomnia, including psychiatric or neurological disorders, medical conditions, polypharmacy, medication adverse effects, substance use, environmental changes (home, hospital, care home), decreased sensory input (blindness, deafness), unrealistic expectations of sleep, lifestyle changes (retirement, change in daily structure), and psychosocial stressors.

The first step in treatment is to optimize management of comorbid medical, psychiatric, or substance use disorders as these often can contribute to insomnia. Without treatment of the underlying etiology, the sleep dysfunction is unlikely to resolve.

When assessing sleep, screening for psychiatric disorders is vital because many people with depression or anxiety initially present with insomnia or fatigue. In one study, 65% of patients with depression, 61% of patients with panic disorder, and 44% of patients with generalized anxiety disorder reported insomnia (1).

Improving sleep hygiene is very effective and low-risk in older adults. Interventions include establishing a consistent bedtime that is late enough to decrease early morning awakenings, finishing meals several hours before going to bed, having a relaxing bedtime routine, minimizing caffeine/alcohol/nicotine intake, managing stress, and increasing morning exercise.

When medications are considered for insomnia, shared decision-making with the patient is necessary given that the risks of medications can be severe and include delirium, agitation, falls, and drug-drug interactions

Ideally, medications should not be used alone as the only treatment, and should only be used as short-term adjuncts to behavioral management in cases where benefits of medication outweigh risks. Practical recommendations are to choose a medication with a shorter half-life to minimize daytime drowsiness, and to use the smallest effective dose for the shortest duration of time (3 to 4 weeks only) with intermittent dosing (as needed rather than daily). For older adults, use lower starting doses (half of normal dose), given the increased risk of adverse effects.

Patient education regarding timing of medications is advised, so that stimulating medications are taken in the morning and sedative medications are taken in the evening.


REFERENCE CITED: 1.Ohayon MM, Roth T. What are the contributing factors for insomnia in the general population? J Psychosomatic Res. 2001;51:745-755.