Insomnia and the Elderly: Causes, Treatment, and Approach

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buy restroil online Insomnia can be a problem for older people. Many people mistakenly believe that sleep problems are a part of getting older. Insomnia is the most common form of sleep disorder. It’s a subjective description of inadequate or nonrestorative rest despite having ample opportunity to sleep. Insomnia affects more than half of the elderly, but it is undertreate, and healthcare practitioners rarely use nonpharmacological interventions. This article will discuss the causes of elderly insomnia, the evaluation of patients, and nonpharmacologic and pharmacologic treatments of insomnia.


The physiologic need to sleep is influenced by the amount of sleep you get (8 hours per 24-hour period on average) and your daily circadian rhythm.  The Sleep patterns and requirements change as we age, but sleeping problems are not part of normal aging. Research is need to determine whether older people require less sleep or cannot get the amount of sleep they need.  There is no standard gold for the amount of sleep considere normal for older adults. Instea it is determined by the patient’s perceptions and their functional status. Recent consensus statements from the National Institutes of Health addressed the diagnosis of chronic insomnia among adults, its risks, effects, and treatment.  The American Academy of Sleep Medicine has also published practice guidelines on insomnia management and evaluation. There needs to be more high-quality research to guide practitioners when treating older adults with insomnia.

Sleep architecture

buying restroil online Sleep architecture is the progression of sleep throughout the night. It is show as a histogram or hypnogram.  The sleep architecture is divid into three segments. The first segment is light sleep (stages 1-2), and the second is deep sleep (stages 3-5). Stages 3 and 4 are slow wave sleep (SWS) or delta sleep. SWS is considere to the most rejuvenating part of sleep. Non-rapid eye movements (non-REM) are the first four stages. The third segment of sleep includes REM sleep. REM sleep is most common in the second half of sleep. Stages 3 and 4 are more commonly observe during the first. Typically, subjects alternate between non-REM and REM stages every 90 to 120 seconds. 

 Sleep Architecture for the Elderly

Sleep architecture is significantly altere in healthy older individuals . The difficulty of establishing sleep is increase; the total amount of sleep time and sleep quality is decrease; delta waves or SWS is reduce; sleep fragmentation is increase; and more time in bed is spend awake after retiring. Many older people are influence by natural physiologic changes to their circadian rhythm to go to sleep earlier and wake up earlier. These factors may contribute to poorer sleep quality or less sleep overall.  The duration of REM sleeping tends to increase with age.  Sleep latency in older people is lower than in the younger population.  Older adults have a more challenging time staying awake during the day. The frequency of daytime napping increases, as does the duration. However, the duration increase is relatively small compare to the significant increase in frequency. Overnight naps can lead to the sleep-wake cycles being reverse.  Some patients may experience day-night reversed sleep, where the first sleep begins at dawn and continues until midday.  The Multiple Sleep Latency Test can used to evaluate daytime sleepiness. This test measures the subject’s ability to fall asleep in 4 to 5 periods of 20 minutes throughout the day.  Epworth sleepiness is another helpful screening tool. 


Insomnia can be classified into three types: transient (a few days), acute (3-4 weeks), and chronic (4 weeks or more). Transient or acute insomnia is more common among people who have never experience sleep problems and can trace to a specific cause. Acute insomnia results from many factors, including acute illness, hospitalizations, changes to the sleeping environment, and medications. Jet lag can also be a factor, as well as acute or recurring stressors. Several medical, behavioral, and environmental conditions can cause 10 Chronic or long-term insomnia.

Sleep impairment: What are the effects?

Sleep impairment is characterize by difficulty falling asleep, maintaining sleep, waking up early, and excessive sleepiness during the day. Insomniacs can become anxious, irritable, and physically and mentally tired. As bedtime approaches, insomniacs get more anxious and tense. They worry about their health, their death, or personal issues.  Sleep disorders can hurt a person’s health by increasing their risk of accidents, malaise, and chronic fatigue.  A lack of sleep is link to poor performance in psychomotor tests and decrease concentration and memory.  A sleep disturbance is also associate with a higher risk of falling.  cognitive decline, A higher mortality rate.  Sleep deprivation is link to increased appetite and hunger in healthy young men. Elevated blood pressure is a result.  High-sensitivity C reactive protein concentrations are predictive of cardiovascular mortality.  Even after excluding patients with insomnia, a sleep duration of less than 6 hours is associate with an increased prevalence of diabetes. 

Sleeping disorders: A guide to help you cope

Sleep problems in older people: The first step to assessing them ( Table 2) is determining if the person has insomnia.  Next, you need to identify the predominant sleep disorder. It is essential to consider the patient’s sleeping pattern, including its quality, duration, and number of wakings. Sometimes, asking the patient to complete a 1-week,  Two-week vacation sleep diary is helpful. This record should include the patient’s regular bedtime, the time they usually rise, the timing and amount of their meals, the use of alcohol and exercise, the medications prescribed and non-prescribed, and the length and quality of their sleep. Table 2An Approach to the Elderly Patients with Insomnia

When taking a general medical history and medication list, the doctor should look for conditions and medications that cause disturbed sleep.  All patients with sleep disorders should evaluated for the potential confounding effect of alcohol and other substances. If insomnia occurs after the introduction of a medication, it should be attribute to that medication unless proven otherwise. A detail mental examination and psychiatric evaluation, laboratory investigations, including thyroid function and serum chemistry panels, cardiopulmonary studies, if indicated, as well as an assessment of the sleeping environment, should include in further evaluation. A sleep specialist may be require to evaluate the patient. 


Treatment aims to improve the quality of life and reduce morbidity for the patient and their family. The treatment of insomnia can reverse the morbidities associated with insomnia, such as depression, disability, and reduced quality of life.  In addition, the optimal management of insomnia can improve productivity and cognition and reduce healthcare costs and accidents.


Healthcare practitioners rarely use nonpharmacological interventions to treat insomnia. Treatment of secondary insomnia, such as shortness of breath or pain, should begin with the primary illness. Adjusting the dosage and timing of medication administration  Also, anxiety can affect sleep quality. When counseling an insomniac, setting reasonable expectations is essential. Explaining how stress contributes to the vicious cycle that perpetuates and exacerbates the condition can be helpful. When there is minimal or no impairment of daytime functions, reassuring the patient that these symptoms are not harmful or pathologic may be necessary.  In this situation, nonpharmacologic sleep hygiene interventions can used first. They should continue even if medication becomes necessary. Insomnia can be treat with physiologic interventions, such as a walk during the daytime at the right time. 

Behavioral Therapy

Behavioral therapy aims to alter maladaptive sleeping habits, reduce autonomic stimulation, and change dysfunctional beliefs and attitudes that can cause insomnia. Cognitive therapies, relaxation therapy, and sleep restriction are all behavioral interventions. The progressive muscle relaxation technique is designe to reduce somatic arousal. Attention-focusing techniques, such as imagery training and meditation, reduce pre-sleep cognitive arousal. Relaxation techniques are especially suitable for people with tension or anxiety. Sleep restriction is recommend When excessive amounts of time are spend in bed. The therapy takes 4 to 6 weeks to cause a mild loss of sleep, improving the ability to fall and stay asleep.  The Stimulus Control Therapy involves limiting sexual and sleeping activities in the bedroom so bedtime is perceive as an opportunity to sleep.  Patients with irregular sleep-wake patterns or those who engage in sleep-incompatible activity should consider this technique. Cognitive therapy aims to reassure patients that sleeping less than 8 hours per night isn’t necessarily unhealthy and doesn’t always have dramatic consequences for the following day. If a patient cannot sleep, they should be aware that it is okay to get up, read, shower, and then return to bed to try again. Morin et al.  A randomize, control placebo trial was conduct on 78 adults with chronic and primary insomnia (mean age 65 years). The cognitive-behavior treatment was compare to temazepam or placebo. Cognitive-behavior treatment (55%) reduced awake time after sleep onset more than temazepam (46.5%). The following are some ways to get in touch with someone else Both.01). The cognitive-behavioral therapy showed better sleep improvement over time.  The short-term outcomes of treatment for primary insomnia were similar when comparing pharmacotherapy with behavior therapy.  Exposure to light has a strong influence on a person’s daily rhythm.Bright-light therapy can be an effective method to create a healthy cycle of sleep and wakefulness. The pattern of sleep-wake disturbance determines the timing of light therapy. Several studies have shown that 60-120 minutes of artificial lighting at a suitable intensity between 6000 and 8000 LUX can improve sleep quality in healthy individuals and those with dementia. 


The rational use of pharmacotherapy to treat insomnia is based on five basic principles: the use of the lowest dose effective, intermittent dosing (2-4 times per week), short-term prescribing of medication (regular medication for no more than 3-4 weeks) and gradual discontinuation of medication to reduce rebound insomnia. Twenty-eight medications with shorter half-lives of elimination are preferre to minimize daytime sedation.  The selection of medication should be based on the severity and presence of symptoms during the day and the impact of these symptoms on daily functioning and the patient’s quality of life. The expected pharmacologic outcome includes improved sleep initiation and maintenance without a hangover effect and next-day function.  It is important to first agree on the length of treatment. This can be a few weeks, as stopping treatment after a long period may be challenging. The appropriate administration is short-term (no more than 2-3 weeks), acute use in conjunction with behavioral therapy. This approach reduces the risk of misuse, as fewer medications are need. Many patients can benefit from long-term treatment, not requiring nightly doses but medication administered in response to symptoms.


Benzodiazepines improve insomnia by reducing REM, decreasing sleep latencies, and decreasing nocturnal wakings.  Age does not affect the absorption of BZDs. Still, the reduction in lean mass, decrease in plasma proteins, and increase in fat in older adults results in an increased concentration and longer half-life of drug elimination.  It is best to avoid long-acting BZDs. Rebound insomnia may occur within 1 to 2 weeks after use. This condition is characterize by a decline in sleep compare with baseline.  BZDs can cause a hangover. Even short-acting BZDs can impair memory and psychomotor performance the following day.  It is essential to consider the tolerance of BZDs’ hypnotic effects. BZDs initially induce and prolong sleep very effectively, but tolerance develops quickly with repeated administration.  BZDs can also cause addiction, dizziness, falls, hip fractures, and car accidents. Accidents occur more often with preparations that have a long half-life or with patients who are sleep-impaire due to long-term usage. Temazepam is a BZD that is commonly prescribe for sleep maintenance insomnia. It has a half-life of 8 to 25 and can take between 15 and 30 mg per night.

Non-Benzodiazepine Medications


Zolpidem, a hypnotic, binds to the omega-1 receptor subclass in the brain. It is the most common hypnotic prescribe in the United States and Europe.  Zolpidem is use to treat insomnia with sleep onset. It is available in dosages of 5-10 mg. Contraindications include sleep-related breathing problems: Acute pulmonary dysfunctions, severe hepatic failure, and respiratory depression. Thirty-six older people tolerate zolpidem well. The most common side effects are nausea, dizziness, and drowsiness. Zolpidem doesn’t alter sleep architecture. The same risks apply to this drug as BZDs. This includes dependence if used for more than four weeks.  Zolpidem does not cause significant side effects such as a hangover or tolerance. However, rebound insomnia has report.


Zaleplon, a new hypnotic, binds specifically to the omega-1 receptor subclass in the brain. It is use to treat sleep-onset insomnia and only has a one-hour half-life. The usual dose is between 5 and 10 mg. There have not any significant side effects report. Ancoli-Israel et al. The safety and efficacy of older adults were demonstrat in both short-term and long-term treatments. There was no pharmacologic toleration during treatment and no signs of withdrawal or rebound insomnia after discontinuing the medication.


Zopiclone is not available in America. It’s a cyclopyrrolone that works at the GABA receptor. Orally, it is easily absorbe, and the liver metabolizes it.The drug is a powerful hypnotic sedative with anticonvulsant and myorelaxant properties. When compared to placebo, Zopiclone at bedtime reduces sleep latency and the number of nocturnal wakings. The drug increases sleep duration but does not alter sleep architecture. Comparing Zopiclone to BZDs, Zopiclone produces minimal impairments in daytime performance and short-term and long-term memory. Eszopiclone

Eszopiclone (cyclopyrrolone) is a new anti-insomnia drug that does not contain BZD. Scharf conducted a randomized, double-blinded trial.The study, which included 231 elderly patients (72.3 +-4.9), showed that Eszopiclone (2.5 mg) significantly improved subjective sleep endpoints such as sleep latency and quality, sleep depth, total sleep time, reduced wake time following sleep onset, and increased sleep time. The following are some ways to get in touch with someone else <.05). Eszopiclone reduced both the frequency and duration of napping. The most common adverse effect was headache (15%) in the placebo and active groups. A meta-analysis of 5 randomized-controlled trials demonstrated safety and efficacy in the elderly population. 


Indiplon, a novel non-BZD pyrazolopyrimidine sedative/hypnotic drug, is mediat by GABA-A receptor antagonist. The Food and Drug Administration has not approved it. A randomized double-blinded study of 60 subjects (mean age: 69.1 +- 3.1 years) showed that Dillon modified-release at the 20 mg to 35 mg dose significantly improved sleep maintenance and sleep-onset polysomnographic measures of diagnosed primary insomnia in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). A similar study (42 patients; mean age 70 years) showed similar results with doses up to 20 mg. Next-day residual effects were similar to placebo.



Trazodone is a nontricyclic antidepressant with sedative properties often use in low doses as a hypnotic. The actual therapeutic efficacy of this drug in nondepressed insomniacs remains unknown. Trazodone is one of the most sedating antidepressant drugs and has reported to increase SWS.  It is often use to treat depressed patients with significant insomnia. Data present by Walsh and Schweitzer  showed that trazodone is use for insomnia more often than any other prescription drug. Preliminary evidence suggests that low-dose trazodone may benefit patients with psychotropic-induced insomnia, monoamine oxidase inhibitor-induced insomnia, or contraindications for BZDs.  In a review of 58 studies, in which 1621 patients received trazodone at doses of 75 to 500 mg per day, the most common side effects were drowsiness (5.6%), tiredness (3.1%), gastrointestinal disorders (3%), dizziness (2.6%), dry mouth (2.5%), insomnia (1.6%), headache (1.6%), hypotension (1.2%), agitation (1.1%), and tachycardia (1%). These side effects could be severe in older patients. Compared with older tricyclic antidepressants, trazodone seems to have a more benign cardiovascular risk profile.

MT1/MT2 Receptor Agonist

The Food and Drug Administration approves Ramelteon for treating chronic insomnia in the elderly. It is a highly selective melatonin MT 1 and MT 2 receptor agonist. A randomized, double-blind study included 829 patients (mean age 72.4 years) with chronic primary insomnia. They received 4 mg, 8 mg, or placebo for five weeks. Patients reported a significant reduction in sleep latency at week 1 ( P = .009) and week 5 ( P <.001) and an increase in total sleep time at week 1. No withdrawal effect was notice. 

Nonprescription Medications


It is frequently use to promote sleep but can significantly cause sleep disruption. Alcohol causes decreased sleep onset latency, increased SWS, and fell REM sleep during the first part of the night. As alcohol levels decline during the second half of the night, increased REM sleep rebound, sleep fragmentation, and early morning awakening occur. 


Antihistaminics, such as diphenhydramine, may used for their sedating effects. They are associate with cognitive impairment, daytime drowsiness, and anticholinergic effects.  There are no specific data to show that antihistamines either improve insomnia or prolong sleep, and in general, these medications are avoid in the elderly because of potential side effects. 


Large-scale efficacy studies of melatonin still need to improve, although small, short-term trials have reported encouraging sleep quality and latency results.  Caution is require in advising patients about the potential lack of quality control in over-the-counter melatonin, the timing of ingestion, and the appropriate dosing. 

Herbal Preparations

Other nonprescription herbal medications such as valerian, chamomile, hops, kava-kava, and passionflower are well-describe sleep aids in the herbal medicine arena. Although randomize control trials have most frequently perform on valerian, efficacy and safety data for most herbal preparations are mix or lacking. 


Given the prevalence of insomnia in the elderly population and the availability of effective treatment, screening older individuals for sleep disorders is essential. Patients must educated on regular sleep-related changes and aware that sleep problems are not a part of normal aging. Sleep impairment may hurt health and health-related quality of life.

A comprehensive assessment for insomnia includes:

  • A complete history of medical illness.
  • A review of medications.
  • A thorough physical examination.
  • Appropriate blood work.

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