insomnia in the elderly

Etiology

• see insomnia

Management

• cognitive behavioral therapy (CBT) & sleep hygiene first-line treatment
  • more effective than medications for long-term management of insomnia
• CBT & sleep hygiene in combination with medication
• the choice of a hypnotic agent in the elderly is based on symptoms
  • sleep-onset insomnia: ramelteon or short-acting Z-drugs
  • sleep maintenance: suvorexant or low-dose doxepin
  • both sleep onset & sleep maintenance: eszopiclone or zolpidem extended release
  • middle-of-the-night awakenings: Low-dose zolpidem sublingual tablets or zaleplon
  • other
    • benzodiazepines not for routine use
    • trazodone improves sleep quality & sleep continuity, risk considered significant
    • tiagabine is not effective
    • melatonin slightly improves sleep onset & sleep duration
      • product quality & efficacy may vary
      • extended-release melatonin first line in post menopausal women
      • the American Academy of Sleep Medicine recommends against use of melatonin due to lack of evidence of effectiveness
      • melatonin should be tried first while awaiting sleep study
    • tryptophan diminishes sleep onset in adults
      • data in the elderly are not available
    • valerian is safe but benefits on sleep quality are equivocal
    • dual orexin receptor antagonist lemborexant may improve sleep maintenance & sleep continuity
    • oral magnesium < 1 g up to 3 times/day may be of benefit

More general terms

• insomnia