Treatment of Chronic Insomnia, Specifically in Elderly Patients

BACKGROUND

Definition – difficulty with the initiation, maintenance, duration or quality of sleep that results in impairment of daytime functioning, despite adequate opportunity and circumstances for sleep; chronic is >1 month

Prevalence – 10-15% of patients in the US

Increased risk in – women, older pts, pts with chronic medical conditions or psych disorders

Consequences – fatigue, mood disturbances, problems in interpersonal relationships, occupational difficulties, reduced QOL

Classification

- primary insomnia – diagnosis of exclusion, state of hyperarousal while awake and asleep

- secondary insomnia – more common; due to psychosocial stressors, lifestyle habits, psych disorders, medical condition, or drug/substance use

TREATMENT

Cognitive behavioral therapy (CBT)

Types:

- stimulus control therapy – maladaptive response to bedtime or bedroom environment, learning process to reassociate the bed with sleep

- sleep-restriction therapy – teach pts to increase sleep time by inducing sleep deprivation by reducing time in bed

- relaxation therapy – based on primary insomnia associated with hyperarousal

- cognitive therapy – teach pt about sleep needs, correction of unrealistic expectations, discussions about anxiety and catastrophic thinking

- sleep-hygiene education – addresses extrinsic factors (caffeine, noise in bedroom)

Results:

- meta-analyses show 50% of pts show meaningful clinical improvement with CBT

- combined therapies more effective than individual techniques, individual tx more effective than group tx

- studied well in primary insomnia but not secondary (esp due to psych disorders)

- efficacy of PCP driven CBT in shorter sessions still needs to be studied

Pharmacologic therapy

(1) Benzodiazepines (BDZ)

- temazepam (Restoril) – for sleep-maintenance, SE: drowsiness, dizziness, incoordination

- estazolam (ProSom) – for sleep-maintenance, SE: drowsiness, dizziness, incoordination

- triazolam (Halcion) – for sleep-onset, SE: anterograde amnesia, drowsiness, dizziness, incoord, rebound insomnia

(2) Benzodiazepine-receptor agonists

- eszopiclone (Lunesta) – for sleep-maintenance, SE: unpleasant taste, dry mouth, drowsiness, dizziness

- zolpidem (Ambien) – for sleep-onset, SE: drowsiness, dizziness, occ amnesia

- zaleplon (Sonata) - for sleep-onset or sleep-maintenance, SE: drowsiness; can be administered on waking in the latter part of the night

(BDZ and BDZ-receptor agonists have only been studied for use up to 6-months)

(3) Others

- sedating antidepressants (trazadone, doxepin, mirtazapine) – lack of data from RCTs

- sedating histamine-1-receptor antagonists (diphenhydramine, dozylamine) – limited RCTs show these improve sleep subjectively but not objectively, side effect of morning sedation

- melatonin – limited studies with small numbers of pts treated for short periods with various doses/formulations show conflicting results

CBT vs. Pharmacologic therapy

- CBT leads to better long term improvements compared to pharmacological therapy

- CBT alone leads to better long term improvements compared to combination therapy

- CBT while tapering doses of BDZ lead to a higher percentage of pts who were drug-free

CHRONIC INSOMNIA IN THE ELDERLY

- prevalence of 30-60% - increased risk in pts with lower income, lower education, widows

- causes: different sleep architecture (difficult sleep initiation, reduced total sleep time, less delta wave sleep, more sleep fragmentation, changes in circadian rhythm, increased napping freq and duration), increased meds & medical conditions

Pharmacologic therapy

- decrease in lean body mass, reduction in plasma protein, and increase in body fat leads to an increased concentration of unbound drug and increased drug-elimination half-life  start low, go slow

- side effects are more frequent, dose reductions are needed

- long acting BDZ – increased risk of falls and hip fx

- Ramelteon (MT1/MT2 receptor agonist) – approved tx of chronic insomnia in elderly

References:

1. Silber MH. “Chronic Insomnia.” NEJM 353(8):803-810, 2005.

2. Kamel NS & Gammack JK. “Insomnia in the Elderly: Cause, Approach, & Treatment.” Am J Med 119:463-469, 2006.

Category: Medicine Notes , Pharmacology Notes