Insomnia has numerous, often concurrent causes, including medical conditions, medications, psychiatric disorders and poor sleep hygiene.
Poor sleep among inpatients has multiple causes, including underlying illness(es), diagnostic and therapeutic procedures, medication effects, and environmental factors. In the elderly, insomnia is complex and often difficult to relieve because the physiologic parameters of sleep normally change with age. In most cases, however, a practical management approach is to first consider depression, medications, or both, as potential causes.
Sleep apnea in elderly patients
Sleep apnea also should be considered in the differential assessment. The most common form of sleep apnea is obstructive sleep apnea (OSA), which occurs when soft tissue in the back of the throat collapses and blocks the upper airway during sleep. OSA occurrence with ageing may be driven by one or more of the physiological characteristics, such as:
- poor upper airway anatomy (i.e. a highly collapsible airway),
- ineffective upper airway dilator muscle activity/responsiveness,
- a low respiratory arousal threshold, or
- an unstable ventilatory control system.
Older adults also are at risk for central sleep apnea, which involves a repetitive absence of breathing effort during sleep caused by a dysfunction in the central nervous system or the heart. It is thought that age-related changes in chemosensitivity, and sleep architecture may promote central sleep apnoea in older people; while OSA is likely to be the result of increased collapsibility of the upper airway; possibly due to changes in upper airway anatomy and muscle function.
Advanced sleep phase syndrome
Another condition that needs to be considered in the elderly presenting with sleep concerns is that of advanced sleep phase syndrome (ASPS). Those with ASPS are known as larks as opposed to night owls. Larks greet the sunrise, are focused and active at dawn and during the ensuing hours, until the lark tires as the day goes on. Typically, they are in bed between 6.00 and 9.00 pm and awake far too early – usually around 4.00 or 5.00 am. They may feel refreshed, or simply be unable to sleep any longer. Then they experience increasing sleepiness throughout the day. People with ASPS have difficulty staying awake at night for gatherings or any social activities. Treatment includes light therapy, typically in the evening, to help advanced sleep phase persons stay up later.
Treating insomnia in the elderly
Regardless of the cause of insomnia, most patients benefit from behavioural approaches that focus on good sleep habits. An important topic to address will be the issue of caffeine ingestion. There are studies that indicate caffeine is metabolised in four to six hours. Actually, these studies were done on younger people with the majority being under 30. Studies that are more recent have shown that in the elderly population it may take 16 to 20 hours to metabolise caffeine. Eliminating caffeine for a while to see what effect it has on the elderly person’s sleep seems to be a reasonable step.
The use of non-drug interventions cannot be over-emphasised. Persons with insomnia can be encouraged to utilise relaxation techniques and drinking warm beverages at bedtime. One can also be encouraged to avoid taking frequent or prolonged daytime naps. Relaxation techniques include progressive muscle tensing and relaxing, guided imagery, paced diaphragmatic breathing, or meditation.
Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective in older adults
The American College of Physicians recommends CBT-I as first-line management for insomnia in adults. It consists of 6 to 10 sessions with a trained therapist that focus on cognitive beliefs and counterproductive behaviours that interfere with sleep.
Sleep restriction therapy involves restricting time in bed to the number of hours of actual sleep until sleep efficiency improves. If after 10 days sleep efficiency remains lower than 85%, sleep time in bed should be restricted by 15 to 30 minutes until sleep efficiency improves. Time in bed is gradually advanced by 15 to 30 minutes when the time spent asleep exceeds 85% of total time in bed.
Stimulus control therapy attempts to reassociate the use of the bed and the desired bedtime to sleep only. This includes going to bed only when one feels tired, not using the bed for reading, working, or lounging, leaving the bed if unable to sleep in 15 to 20 minutes, and maintaining a constant wake-up time each morning.
Brief behavioural therapy for insomnia
Due to financial constraints and lack of psychological resources needed for CBT-I, a shorter form of therapy known as brief behavioural therapy for insomnia is also available and involves core techniques from CBT-I, directed at improving circadian regulation of sleep in more than two sessions. It has been found to be effective in the geriatric population, with benefits persisting for 6 months and beyond. Internet-based behavioural therapies have also been found to be effective in older populations. Multicomponent cognitive behavioural therapy that involves sleep hygiene measures, relaxation techniques, sleep restriction, and stimulus control is also as effective in older adults as a stand-alone treatment.
Exposure to bright light at appropriate times
Exposure to bright light at appropriate times can help realign the circadian rhythm in patients whose sleep-wake cycle has shifted to undesirable times.
Medication
Periodic limb movements during sleep are very common in the elderly and may merit treatment if the movements cause frequent arousals from sleep. When medication is deemed necessary for relief of insomnia, a low-dose sedating antidepressant or a nonbenzodiazepine anxiolytic may offer advantages over traditional sedative-hypnotics. Long-term use of long-acting benzodiazepines should, in particular, be avoided. Melatonin may be helpful when insomnia is related to shift work and jet lag; however, its use remains controversial.
A wide variety of medication classes are used as sleep aids, including:
- first-generation antihistamines (e.g., diphenhydramine),
- benzodiazepines (e.g., lorazepam),
- antidepressants (e.g., amitriptyline),
- typical antipsychotics (e.g., haloperidol),
- atypical antipsychotics (e.g., quetiapine),
- melatonin, and
- melatonin agonists.
Common adverse effects of sleep aids include residual daytime sedation leading to increased risk for falls, altered mental status (delirium), and respiratory depression. Patients may also experience anticholinergic adverse effects, such as urinary retention and xerostomia (dry mouth), from some sleep aid medications including diphenhydramine. Patients with certain comorbid conditions may be at an increased risk for adverse effects from medications used to promote sleep. As patients age, the pharmacokinetics of many medications change due to slower metabolism and decreased clearance, which can lead to drug accumulation and a prolonged and increased effect. Since many medications are excreted by the kidneys, patients with renal dysfunction are at even higher risk for this.
