#040 Treatment of Insomnia in the Geriatrics Population
Fast Facts and Concepts #040 PDF
AUTHORS: Gretchen Wagner, Kathryn Denson
OBJECTIVES: Identify strategies for treating insomnia in a geriatric patient.
ACGME COMPETENCIES: Patient Care; Medical Knowledge
Insomnia: Difficulty with sleep due to prolonged sleep onset latency, frequent nocturnal awakenings, prolonged periods of wakefulness during the sleep period, or frequent transient arousals .
CONTEXT: Management of sleep disturbances in a geriatric patient
ACTION: List treatment strategies for insomnia and choose an appropriate strategy for an individual patient.
Geriatric patients commonly experience sleeping disturbances. Although sources differ, up to 60% of geriatric patients report problems with sleeping at least a few nights per week, with 6-15% meeting diagnostic criteria for insomnia1. Higher rates of insomnia are seen in women, especially after the onset of menopause1. Despite the increased prevalence of insomnia in geriatric patients, insomnia is not normal aging. Sleep disturbances in geriatric patients are associated with decreased quality of life, daytime fatigue or low energy, cognitive decline, and mood dysphoria1.
The increased prevalence of insomnia in the geriatrics population is likely multifactorial in etiology. Patients are more susceptible to sleep disturbances if they have comorbid medical, psychiatric, or neurologic illnesses, due to the nature of the illness, as well as due to the use of medications to treat the illness. Depression and anxiety are common psychiatric contributors to insomnia.
Polysomnography (PSG), a type of diagnostic sleep test, has shown that older patients experience less total nighttime sleep, spend more time in bed, have more nighttime awakenings, and take longer to fall asleep4. Physiologically, patients show increased activation of the autonomic nervous system, as indicated by increases in heart rate, blood pressure, metabolic rate, body temperature, activity of the hypothalamic-pituitary-adrenal axis, and norepinephrine secretion . This activation may explain why patients with insomnia typically have higher frequency brain waves while sleeping, a factor which may predispose them to awaking during sleep. Additionally, with age, the circadian rhythm becomes less synchronized; possibly affected by variation in bedtime, medications and dosing administration times, mealtimes and other changes in routine (timing of “lights-out/on” in long-term care facilities).4
There are three general treatment strategies for insomnia:
#3 Combination treatments (pharmacotherapy with behavioral therapy) – “improves sleep continuity and efficiency” initially relative to pharmacotherapy or behavioral therapy alone, however long-term maintenance may be better with pharmacotherapy alone8
Roth T. Insomnia: definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine. 2007; 3(5):S7-S10.
Kierlin L, Olmstead R, Yokomizo M, Nicassio P, Irwin MR. Diagnostic and Statistic Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults. Sleep Medicine. 2012; 13:958-960.
McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. American Journal of Managed Care. 2009; 15(1):S14-S23.
Galimi R. Insomnia in the elderly: an update and future challenges. Gerontology. 2010; 58:231-247.
Morin CM, Benca R. Chronic Insomnia. Lancet. 2012; 379:1129-1141.
Durso SM, Sullivan GM. Geriatrics Review Syllabus (8th edition). American Geriatrics Society, 2013.
Setiati S, Laksmi PW. Insomnia in Geriatrics. Indonesian Journal of Internal Medicine. 2005; 37(4):224-229.
Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and Pharmacological Therapies for Late-Life Insomnia. Journal of the American Medical Association. 1999; 281: 991-999.
Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD.
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.