To Sleep or Not to Sleep? Management of Insomnia and the Elderly

By Sarah Albanese, PharmD and Lisa Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Approximately, 50% of older adults report trouble falling and staying asleep.¹ As people age, sleep cycle changes, chronic medical conditions, and medications decrease total sleep time, increase awakenings, and decrease time in deep sleep.¹ Insomnia increases the risk of depression, cognitive impairment, hypertension, heart disease, chronic fatigue, diabetes, and falls.  Non-pharmacological treatments are recommended first including cognitive behavioral therapy for insomnia (CBT-I) with sleep hygiene and controlling stimuli that make sleeping difficult.  CBT-I has shown long-term improvements in insomnia over pharmacological options.^1,3,4

Information on the most common medications used for insomnia in elderly patients is listed in Table 1.  Although low cost, benzodiazepines, non-benzodiazepines sedatives, and diphenhydramine are not recommended for treatment of insomnia in the elderly due to their minimal effectiveness and numerous side effects.^1,4-7 Preferred agents based upon efficacy and safety include doxepin at doses of 6 mg or less, ramelteon and suvorexant.  However, these agents are higher cost, making affordability an issue. Suvorexant, like benzodiazepines and non-benzodiazepines, is a schedule IV controlled substance, which indicates a potential for abuse and affects accessibility to the drug when prescriptions expire or need refills. The higher doses of doxepin, while low cost, are not recommended as side effects increase significantly. Trazodone has pronounced side effects and benefits are short term. Mirtazapine showed significant benefit with insomnia treatment, but data is limited to patients with depression.^1,3-7 Melatonin has shown minor benefits for insomnia treatment, decreasing sleep onset by 5-7 minutes. However, melatonin has become a favorite option for insomnia treatment in elderly individuals due to its benign side effect profile, accessibility, and low cost.

Insomnia is a major problem in the elderly population, with many negative effects if left untreated. Pharmacological options provide some benefit for insomnia, but a majority of products have major side effects. Non-pharmacological treatments like CBT-I are recommended for insomnia treatment in elderly people over pharmacologic options due to the long-term efficacy and lack of negative effects.^1-7

 

Table 1: Medications for Insomnia Treatment ^1,3-8

Medication Class and Examples	Advantages	Disadvantages	Cost
Benzodiazepines Temazepam Triazolam		Side effects: Drowsiness, falls, fractures, cognitive impairment, delirium, increased accidents, tolerance, rebound insomnia   Minimal effectiveness Not for long-term use Schedule IV controlled substance – potential for abuse	$ – $$
Non – Benzodiazepine Sedatives Zolpidem Zaleplon Eszopiclone	Short half-life-less hangover   Fewer side effects at low doses	Side effects: same as benzodiazepines, plus sleep -walking, -eating, -driving, rebound insomnia   Not for long-term use Schedule IV controlled substance – potential for abuse	$
Antidepressants Doxepin Trazodone Mirtazapine	Improvement significant   Doxepin: Minimal side effects at doses ≤ 6 mg	Side effects: drowsiness, dizziness, constipation   Doxepin: Pronounced side effects at doses >6 mg including dry mouth, rebound insomnia, orthostatic hypotension, cognitive impairment   Trazodone: Beneficial effects subside after 1 week; Other side effects: arrhythmias, orthostatic hypotension, falls   Mirtazapine: Indicated for insomnia if also treating depression; Other side effects: hyponatremia, weight gain, dry mouth	$   Except: Doxepin 3-6 mg $$$
Antihistamines Diphenhydramine	Available over-the-counter	Side effects: drowsiness, dizziness, cognitive impairment, falls, constipation, tolerance	$
Melatonin Receptor Agonists Ramelteon, Melatonin	Minimal side effects   No rebound insomnia   Ramelteon: Significant improvement   Melatonin: Available over-the-counter	Side effects: Headache, nausea, vomiting, upper respiratory infection, runny nose, dizziness   Melatonin: Dietary supplement with lack of standardization	Ramelteon $$$   Melatonin $
Orexin Receptor Antagonist Suvorexant	Well-tolerated	Side effects: drowsiness Schedule IV controlled substance – potential for abuse	$$$

$ = cost <$1/day; $$ = Cost $1-2/day; $$$ = cost $3-10/day

References:

1. Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med 2018;14:1017-24.
2. Vaz Fragoso C, Gill TM. Sleep complaints in the community – living older adults: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007;55:1853-66.
3. Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med 2006;119:463-69.
4. McCall WV. Sleep in the elderly: burden, diagnosis and treatment. Prim Care Companion J Clin Psychiatry 2004;6:9 – 20.
5. Reynolds AC, Adams RJ. Treatment of sleep disturbance in older adults. J Pharm Pract Res 2019;49:296-304.
6. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guidelines for pharmacological treatment of chronic insomnia in adults: an American academy of sleep medicine clinical practice guidelines. J Clin Sleep Med 2017l;13:307-49.
7. 2019 American geriatrics society beers criteria update expert panel. American geriatric society 2019 updated AGS beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-94.
8. Good Rx Inc. Available at: https://www.goodrx.com/ .