The American Journal of Medicine
Volume 119, Issue 6 , Pages 463-469, June 2006

Insomnia in the Elderly: Cause, Approach, and Treatment

  • Nabil S. Kamel, MD

      Affiliations

    • Division of Geriatric Medicine, Saint Louis University Health Sciences Center
    • GRECC, St. Louis VA Medical Center, St. Louis, Mo.
    • Corresponding Author InformationRequests for reprints should be addressed to Nabil S. Kamel, MD, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104.
    • ,
  • Julie K. Gammack, MD

      Affiliations

    • Division of Geriatric Medicine, Saint Louis University Health Sciences Center
    • GRECC, St. Louis VA Medical Center, St. Louis, Mo.

Received 14 June 2005; accepted 14 October 2005.

Article Outline

Abstract 

Insomnia is a prevalent problem in late life. Sleep problems in the elderly are often mistakenly considered a normal part of aging. Insomnia, the most common sleep disorder, is a subjective report of insufficient or nonrestorative sleep despite adequate opportunity to sleep. Despite the fact that more than 50% of elderly people have insomnia, it is typically undertreated, and nonpharmacologic interventions are underused by health care practitioners. This article will review the causes of insomnia in the elderly, the approach to patient evaluation, and the nonpharmacologic and pharmacologic treatment of insomnia.

Keywords:  Sleep , Elderly , Insomnia

 

Insomnia is a subjective report of insufficient or nonrestorative sleep despite adequate opportunity to sleep.1 Foley et al2 reported the annual incidence of insomnia at approximately 5% in older adults. The overall incidence of insomnia was similar in men and women but was higher among men 85 years and older.2 Lower income, lower education, and being a widow were associated with increased risk for insomnia.2 The prevalence of insomnia reported within regions of the United States3, 4, 5 and in other countries6, 7, 8 is similar and ranges between 30% and 60%.

Back to Article Outline

Physiology 

Two primary factors control the physiologic need for sleep: the total quantity of sleep (average of ∼8 hours of sleep each 24-hour period) and the daily circadian rhythm of sleepiness and alertness.9 Sleep requirements and patterns change throughout life, but sleep problems in the elderly are not a normal part of aging.10

Whether older people need less sleep or cannot get the sleep they need, requires ongoing research.11 There is currently no gold standard for how much sleep is normal in the older adult but is based on patient perceptions and the impact on functional status.12 A National Institutes of Health consensus statement recently addressed the diagnosis, risks, consequences, and treatment of chronic insomnia in adults.13 The American Academy of Sleep Medicine also has published several practice guidelines for insomnia evaluation and management. In general, there is little high-quality evidence to guide practitioners in the care of older adults with insomnia.

Back to Article Outline

Sleep architecture 

The progression of sleep across the night is called sleep architecture, and it is displayed as a sleep histogram or hypnogram.14 Sleep architecture is composed of 3 segments. The first segment includes light sleep (stages 1 and 2), and the second segment includes deep sleep (stages 3 and 4). Taken together, stages 3 and 4 are referred to as delta sleep or slow wave sleep (SWS). SWS is believed to be the most restorative part of sleep. Stages 1 to 4 constitute nonrapid eye movement (non-REM). The third sleep segment includes the period of REM sleep. Stages 3 and 4 are generally observed during the first half of the sleep period, and REM sleep occurs most frequently during the second half. Typically, subjects cycle through non-REM and REM sleep stages with a periodicity of 90 to 120 minutes.

Clinical Significance

 

•Physiologic changes of aging, environmental conditions, and chronic medical illnesses contribute to insomnia in the elderly.

•Sleep disturbance in the elderly is associated with decreased memory, impaired concentration, and impaired functional performance. It contributes to an increased risk of accidents, falls, and chronic fatigue.

•Most traditional medications for treating insomnia are associated with worrisome side effects in the elderly population. Sleep hygiene measures should be considered as first line therapy.

Sleep Architecture in the Elderly 

The sleep architecture changes significantly in the healthy elderly individual (Figure 1).9, 15 Sleep initiation is more difficult; total sleep time and sleep efficiency are reduced; delta wave or SWS decreases; sleep fragmentation increases; and more time is spent in bed awake after retiring. Natural physiologic changes in circadian rhythm influence many older people to go to bed earlier and to wake up earlier.9 These factors can contribute to deterioration in sleep quality and less total sleep.9, 14, 15 With aging, the duration of REM sleep tends to be more preserved,9 but sleep latency is significantly decreased, suggesting the elderly are more somnolent than the younger population.14

  • View full-size image.
  • Figure 1. 

    Sleep changes in the elderly compared with the young adult. Reproduced with permission from the 1999 issue of American Family Physician. Copyright © 1999 American Academy of Family Physicians. All rights reserved.

Older adults find it more difficult to stay awake during the day. Both the frequency and duration of daytime naps increase, although the increase in duration is fairly small relative to a substantial increase in napping frequency. Excessive daytime napping can eventually lead to reversal of the sleep–wake cycle.1 Patients may report day–night reversal, in which sleep does not began until dawn and then continues until mid-afternoon.9 Daytime sleepiness can be evaluated using the Multiple Sleep Latency Test, which measures the ability of a subject to fall asleep during 4 to 5 20-minute periods throughout the day.14 The Epworth sleepiness scale is another helpful screening tool.16

Back to Article Outline

Cause 

Insomnia is classified as transient (no more than a few nights), acute (less than 3-4 weeks), and chronic (more than 3-4 weeks). Transient or acute insomnia usually occurs in people with no history of sleep disturbances and is often related to an identifiable cause.10 Precipitants of acute insomnia include acute medical illness, hospitalization, changes in the sleeping environment, medications, jet lag, and acute or recurring psychosocial stressors.10 Chronic or long-term insomnia may be associated with a variety of underlying medical, behavioral, and environmental conditions,1, 9, 10, 17 and a variety of medications1, 9, 17, 18 listed in Table 1.

Table 1. Causes of Chronic Insomnia
1)Primary specific sleep disorders:
Circadian rhythm disorders:
1) Advanced sleep-phase syndrome
2) Delayed sleep-phase syndrome
Sleep apnea (obstructive, central, or mixed)
Restless leg syndrome
Periodic limb movement disorders (nocturnal myoclonus)
REM, behavior disorder
2)Physical illness:
Pain: arthritis, musculoskeletal pain, other painful conditions
Cardiovascular: heart failure, nocturnal breathlessness, nocturnal angina
Pulmonary: chronic obstructive pulmonary disease, allergic rhinitis (nasal obstruction)
Gastrointestinal: gastroesophageal reflux disease, peptic ulcer disease, constipation, diarrhea, pruritus ani
Urinary: nocturia and urinary retention, incomplete bladder emptying, incontinence
Central nervous system: stroke, Parkinson disease, Alzheimer disease, seizure disorder
Psychiatric illness: anxiety, depression, psychosis, dementia, delirium
Pruritus
Menopause (hot flushes)
3)Behavioral: daytime nap, early retirement to bed, use of bed for other activities (eg, reading and watching television), heavy meals, lack of exercise, and sedentary lifestyle
4)Environmental: noise, light and other disturbances, extreme temperatures, uncomfortable bedding, and lack of exposure to sunlight
5)Medications:
Central nervous system stimulants: sympathomimetics, caffeine, nicotine, antidepressant, amphetamines, ephedrine, phenylpropanolamine Phenytoin
Antidepressants: bupropion, selective serotonin reuptake inhibitors, venlafaxine
Anti-Parkinsonian agents: levodopa
Decongestants: pseudoephedrine
Bronchodilators: theophylline
Cardiovascular: B-blockers, diuretics
Antihypertensives: clonidine, methyldopa, corticosteroids
Histamines, H2 blockers: cimetidine
Anticholinergics
Alcohol
Herbal remedies
Stimulant laxative

REM = rapid eye movement.

Back to Article Outline

The impact of sleep impairment 

Typical symptoms of sleep impairment in the elderly include difficulty falling asleep and maintaining sleep, early morning awakening, and excessive daytime sleepiness.9

Insomniacs may become physically and mentally fatigued, anxious, and irritable. As bedtime approaches, insomniacs become more tense, anxious, and worried about health, death, work, and personal problems.19

Sleep problems may have a negative impact on health-related quality of life by increasing the risk of accidents, malaise, and chronic fatigue.3, 5 Poor sleep quality is associated with decreased memory and concentration, and impaired performance on psychomotor tests.20 Sleep disturbance also is associated with an increased risk of falls,21 cognitive decline,22 and higher rate of mortality.23

Studies showed that sleep deprivation in young, healthy men is associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite.24 It leads to elevation of blood pressure25 and high-sensitivity C-reactive protein concentrations, which is predictive of cardiovascular mortality.26 Sleep duration of 6 hours or less (even after exclusion of patients with insomnia) is associated with increased prevalence of diabetes and impaired glucose tolerance test results.27

Back to Article Outline

Approach to insomnia 

The first step in evaluating sleep problems in the elderly (Table 2) is to establish that the person truly has insomnia.1 The next step is to define the dominant sleep disturbance.28 When considering a patient’s sleep pattern it is helpful to think about the quality, duration, number of awakenings, and timing.11 It is often useful to have the patient complete a 1-week1 or 2-week28 sleep diary. This record should indicate the patient’s usual bedtime, time of arising, timing and quantity of meals, use of alcohol, exercise, medications (prescribed and over the counter), and descriptions of the duration and quantity of sleep each day.28

Table 2. Approach to the Elderly Patient with Insomnia
Sleep history:
Confirm that the patient had insomnia
Identify the symptom (onset, duration, pattern, and severity)
Evaluate 24-h sleep/wakefulness patterns
Review 1 to 2-wk sleep diary
Interview the bed partner
Review the family history of sleep disorders
Identify the cause
Primary sleep disorders
Medical illness
Psychiatric illness
Behavioral
Environmental
Medications
Evaluate the personal and societal impact of the sleep disorder
Management:
Comprehensive physical examination
Appropriate laboratory investigations
Treatment
Discuss the expectation with the patient
Effective treatment of the primary problem
Sleep hygiene measures
Nonpharmacologic measures
Pharmacologic intervention
Referral to sleep specialist if necessary

In taking the general medical and medication history, the physician should identify conditions and medications known to be associated with disturbed sleep.19 The potential confounding effects of medications, alcohol, and substance abuse should be assessed in all patients presenting with sleep problems.29 Insomnia coinciding with the introduction of a new medication should be attributed to that medication until proven otherwise.1

Further evaluation should include a detailed mental state and psychiatric examination, laboratory investigations including thyroid function, serum chemistry panel, cardiopulmonary studies if indicated, and assessment of the sleep environment. Referring a patient to a sleep specialist for evaluation may be needed.1

Back to Article Outline

Treatment 

The goal of therapy is to reduce morbidity and improve the quality of life for the patient and family. Proper treatment of insomnia has the potential to reverse insomnia-related morbidities, including risk of depression, disability, and impaired quality of life.30 Furthermore, optimal management of insomnia may improve patient productivity and cognition, and decrease health care use and risk of accidents.30

Nonpharmacologic 

Insomnia is typically undertreated, and nonpharmacologic interventions are underused by health care practitioners. Management of insomnia that is secondary to medical illness, such as pain or shortness of breath, should start with treatment of the primary disease process. Adjusting the dose and the timing of medication administration31 also can have significant impact on sleep quality. In counseling the insomniac, it is helpful to set reasonable expectations and explain how anxiety participates in the vicious circle that exacerbates and maintains the condition.19 If minimal or no impairment in daytime function is reported, the patient may simply need reassuring that the symptoms are not pathologic or damaging.12

Nonpharmacologic “sleep hygiene” interventions that target the source of the problem can still be implemented first in this situation, and should be continued even when a medication is required.1 Physiologic interventions such as a daytime walk with correctly timed daylight exposure is useful for insomnia.1, 9, 11 Appropriate temperature control, adequate ventilation, and dark sleep environment may also lead to dramatic improvement in sleep quality.

Sleep hygiene measures1, 10, 17, 19 (Table 3) should be tailored and applied to every patient being evaluated for sleep disturbances.

Table 3. Sleep-Hygiene Measures
Avoid and minimize use of caffeine, cigarettes, stimulants, alcohol, and other medications
If medically able, increase activity level in the afternoon or early evening (not close to bedtime) by walking or exercising outdoors
Increase exposure to natural light and bright light during day and early evening
Avoid napping, particularly after 2:00 pm; limit naps to 1 nap of less than 30 minutes
Check the effect of medications on sleep
Go to bed only when sleepy
Maintain comfortable temperature in bedroom
Minimize light and noise exposure as much as possible
Eat a light snack if hungry
Avoid heavy meals at bedtime
Limit liquids in the evening
Keep a regular schedule
Rest and retire at the same time each day
Eat and exercise on a regular schedule
Stress-management measures:
Tolerance of occasional sleeplessness
Discuss worries and stressful events enough time before bedtime
Use relaxation techniques

Behavioral Therapy 

Behavioral therapy aims to change maladaptive sleep habits, reduce autonomic arousal, and alter dysfunctional belief and attitudes that can perpetuate insomnia.20 Behavioral interventions include relaxation therapy, sleep restriction, stimulus control, and cognitive therapies. Progressive muscle relaxation aims to reduce somatic arousal, whereas attention-focusing techniques (imagery training, mediation) are intended to lower pre-sleep cognitive arousal. Relaxation procedures are particularly suited for individuals with tension and anxiety.20 Sleep-restriction therapy is used when excessive time is spent in bed. Therapy requires 4 to 6 weeks to induce a mild sleep loss that increases the ability to fall asleep and stay asleep.20

Stimulus-control therapy consists of limiting the use of the bedroom to sleeping and sexual activity so that bedtime will be perceived as a time to sleep.30 This technique is indicated for patients who have irregular sleep–wake schedules or who engaged in sleep-incompatible activities.20 The goal of cognitive therapy is to provide reassurance to patients that sleeping less than 8 hours a night is not necessarily unhealthy and does not always lead to dramatic consequences the next day.20 Patients should understand that if they cannot sleep, it is acceptable to rise, take a bath, or read and then return to bed for another attempt at sleep.30

Morin et al32 conducted a randomized, placebo-controlled clinical trial of 78 adults (mean age, 65 years) with chronic and primary insomnia. Cognitive-behavior therapy was compared with temazepam and placebo. Reductions in time awake after sleep onset was greater in cognitive-behavior therapy (55%) compared with temazepam (46.5%) (P<.01 for both). Follow-up showed that sleep improvements are better sustained over time with cognitive-behavior therapy.32 A comparative meta-analysis of pharmacotherapy and behavior therapy showed similar short-term treatment outcomes in primary insomnia.33

It is now well established that a person’s circadian rhythm is strongly influenced by exposure to light.9 Bright-light therapy is an effective way to establish a healthy sleep–wake cycle.31 The timing of the light therapy depends on the pattern of the sleep–wake cycle disturbance. Several studies have demonstrated the benefit of 60 to 120 minutes of artificial light treatment, with an appropriate intensity of 6000 to 8000 LUX, on nighttime sleep quality in both healthy and demented individuals.34, 35

Pharmacologic 

Five basic principles characterize rational pharmacotherapy for insomnia: use of the lowest effective dose, use of intermittent dosing (2 to 4 times weekly), short-term medication prescribing (regular use for not more than 3 to 4 weeks), and gradual medication discontinuation to reduce rebound insomnia.28 Medications with shorter elimination half-lives are generally preferred to minimize daytime sedation.28

The medication selection should be based on the presence and severity of daytime symptoms, particularly the impact on daytime functioning and on the patient’s quality of life. Expected pharmacologic outcomes include improved sleep initiation, sleep maintenance without hangover effects, and improved next-day functioning.12

Agreement should first be reached on the duration of medication treatment, usually a few days, because it may be difficult to cease treatment after long-term use.1 Appropriate administration is acute, short-term use (no longer than 2-3 weeks) in combination with behavioral therapy.18

With this approach there is less potential for misuse because fewer doses of medications are required. However, many patients may benefit from long-term use, a practice that does not necessarily require nightly dosing but medication administration in response to symptom occurrence.30

Benzodiazepines 

Benzodiazepines (BZDs) improve insomnia by reducing REM sleep, decreasing sleep latency, and decreasing nocturnal awakenings.17 The absorption of BZDs is not affected by aging, but the decrease in lean body mass, reduction in plasma proteins, and increase in body fat seen in older adults result in an increased concentration of unbound drug and increased drug-elimination half-life.17 Long-acting BZDs are thus best avoided.

Rebound insomnia can occur within 1 or 2 weeks of use, and it is characterized by a worsening of sleep relative to baseline.20 BZDs often give rise to hangover effects. Even short-acting BZDs may impair psychomotor performance and memory the next day.20 Tolerance to the hypnotic effects of BZDs is an important issue. BZDs are initially very effective in inducing and prolonging sleep; however, tolerance develops rapidly on repeated administration.20 BZDs are also associated with addiction, daytime sedation, dizziness falls, hip fractures, and car accidents. Accidents are more likely to occur with preparations having a long half-life or in patients with impaired sleep because of long-term use.11 Temazepam, a commonly used BZD, is used in sleep-maintenance insomnia, has a half-life of 8 to 25 hours, and can be given in doses of 15 to 30 mg at night.31

Non-Benzodiazepine Medications 

Zolpidem 

Zolpidem is a hypnotic that binds selectively to the omega-1 subclass of BZD receptors in the brain. It is the most commonly prescribed hypnotic in the United States and Europe.20 Zolpidem can be used in sleep-onset insomnia.31 It has a short half-life of only 2.5 to 2.9 hours and can be given in a dosage of 5 to 10 mg. It is contraindicated in sleep-related breathing disorders,31, 36 severe hepatic impairment, acute pulmonary impairment, and respiratory depression.36 Zolpidem is well tolerated in the elderly. The most common side effects include nausea, dizziness, and drowsiness.36

Zolpidem does not alter sleep architecture.20 This drug carries the same risks as BZDs, including dependence with use of more than 4 weeks.28 Zolpidem has not been associated with significant hangover effects or tolerance, but rebound insomnia has been reported.20, 37

Zaleplon 

Zaleplon is new hypnotic that binds selectively to the omega-1 subclass of BZD receptors in the brain. It can be used in sleep-onset insomnia and has a half-life of only 1 hour. Typical dosing is 5 to 10 mg. No major side effects have been reported.31 Ancoli-Israel et al37, 38 demonstrated the safety and efficacy of zaleplon in older adults during short and long-term treatment. No pharmacologic tolerance developed during treatment, and there were no indications of rebound insomnia or withdrawal symptoms after medication discontinuation.

Zopiclone 

Zopiclone, not available in the United States, is a cyclopyrrolone agent that acts at the GABA receptor. It is well absorbed orally and metabolized by the liver.17 This drug also exhibits some anticonvulsant, myorelaxant, and antianxiety activities in addition to being a potent sedative hypnotic agent.20 Zopiclone 7.5 mg at bedtime decreases the sleep latency when compared with placebo and decreases the number of nocturnal awakenings.20 Total sleep duration generally increases, but the drug does not change sleep architecture to any extent.20 Zopiclone seems to produce minimal impairment in daytime performance, short-term memory, and long-term memory in comparison with BZDs.17, 20

Eszopiclone 

Eszopiclone is a novel non-BZD, cyclopyrrolone, anti-insomnia agent. A randomized double-blinded study conducted by Scharf,39 including 231 elderly patients (mean age: 72.3 ± 4.9 years), showed that eszopiclone (2 mg) significantly improved subjective endpoints of sleep latency, quality, depth of sleep, increased total sleep time, and reduced wake time after sleep onset (P<.05). Eszopiclone also reduced the number and duration of naps. The most common side effect was headache (15% in placebo and active groups). A meta-analysis of 5 randomized-controlled trials demonstrated safety and efficacy in the elderly population.40

Indiplon 

Indiplon is a novel pyrazolopyrimidine, non-BZD, sedative-hypnotic agent, mediated by a GABA-A receptor agonist.41, 42 It is not yet approved by the Food and Drug Administration. A randomized double-blinded study of 60 subjects (mean age: 69.1 ± 3.1 years) showed that indiplon 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 study42 (42 patients; mean age 70 years) showed similar results with doses up to 20 mg. Next-day residual effects were similar to placebo.

Antidepressants 

Trazodone 

Trazodone is a nontricyclic antidepressant with sedating properties often used in low doses as a hypnotic. The true therapeutic efficacy of this drug in nondepressed insomniacs remains unknown. Trazodone is one of the most sedating antidepressant drugs and has been reported to increase SWS.29 It is often used to treat depressed patients with significant insomnia.29 Data presented by Walsh and Schweitzer43 showed that trazodone is used for insomnia more often than any other prescription drug. Preliminary evidence suggests that low-dose trazodone may be beneficial in patients with psychotropic-induced insomnia, monoamine oxidase inhibitor-induced insomnia, or contraindications for BZDs.44

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%).44 These side effects could be serious in the older patient. Compared with older tricyclic antidepressants, trazodone seems to have a more benign cardiovascular risk profile.44

MT1/MT2 Receptor Agonist 

Ramelteon is newly approved by the Food and Drug Administration for the treatment of chronic insomnia in the elderly. It is a highly selective melatonin MT1 and MT2 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 5 weeks. Patients reported significant reduction in sleep latency at week 1 (P = .009) and week 5 (P<.001), and increase in total sleep time at week 1. No withdrawal effect was noticed.45

Non-prescription Medications 

Alcohol 

Alcohol is frequently used to promote sleep but can be a major cause of sleep disruption. Alcohol causes decreased latency of sleep onset, increased SWS, and decreased REM sleep during the first part of night. As alcohol levels decline during the second half of the night, increased amount of REM sleep rebound, sleep fragmentation, and early morning awakening occur.29

Antihistaminics 

Antihistaminics, such as diphenhydramine, may be used for their sedating effects. They are associated with cognitive impairment, daytime drowsiness, and anticholinergic effects.9, 17, 20 There are no specific data to show that antihistamines either improve insomnia or prolong sleep,18 and in general, these medications are avoided in the elderly because of potential side effects.13

Melatonin 

Large-scale efficacy studies of melatonin are lacking, although small, short-term trials have reported encouraging results on sleep quality and latency.46 Caution is needed in advising patients about the potential lack of quality control in over-the-counter melatonin, the timing of ingestion, and the appropriate dosing.46

Herbal Preparations 

Other nonprescription herbal medications such as valerian, chamomile, hops, kava-kava, and passionflower are well-described sleep aids in the herbal medicine arena. Although randomized controlled trials have been most frequently performed on valerian, efficacy and safety data for most herbal preparations are mixed or lacking.47

Back to Article Outline

Conclusion 

Given the prevalence of insomnia in the elderly population and the availability of effective treatment, it is important to screen older individuals for the presence of sleep disorders. Patients must be educated on normal sleep-related changes but also made aware that sleep problems are not a part of normal aging. Sleep impairment may have a negative impact on health and health-related quality of life.

A comprehensive assessment for insomnia includes a complete history of medical illness, a review of medications, a comprehensive physical examination, and appropriate blood work. Referral to a specialist in sleep disorders may be indicated.

Appropriate treatment should include nonpharmacologic interventions and pharmacologic treatment if indicated. Behavioral interventions can be used to treat chronic insomnia and include relaxation therapy, stimulus control, sleep restriction, and cognitive therapies. Non-BZD medications such as zolpidem and zaleplon are most useful because they do not alter sleep architecture and have no hangover effect, tolerance, or rebound insomnia.

Trazodone is often used in low doses as a hypnotic. Eszopiclone was recently approved by the Food and Drug Administration for the treatment of insomnia. Its dose in the elderly is 1 to 2 mg. Ramelteon, a selective melatonin MT1 and MT2 receptor agonist, was newly approved by the Food and Drug Administration for the treatment of chronic insomnia in the elderly. Indiplon is currently under investigation with promising results in clinical studies.

Guidelines that direct the choice and use of pharmacologic and nonpharmacologic therapies are needed. More studies are needed to establish the appropriate role and use of medications, and their safety and efficacy in the treatment of insomnia in older adults.

Back to Article Outline

References 

  1. Woodward M . Insomnia in the elderly . Aust Fam Physician . 1999;28:653–658
  2. Foley DJ , Monjan A , Simonsick EM , et al.   Incidence and remission of insomnia among elderly adults (an epidemiologic study of 6,800 persons over three years) . Sleep . 1999;22(S2):S366–S372
  3. Schubert CR , Cruickshanks KJ , Dalton DS , et al.   Prevalence of sleep problems and quality of life in an older population . Sleep . 2002;25:889–893
  4. Baber SI , Enright PL , Boyle P , et al.   Sleep disturbances and their correlates in elderly Japanese American men residing in Hawaii . J Gerontology A Biol Sci Med Sci . 2000;55A:M406–M411
  5. Foley DJ , Monjan AA , Brown SL , et al.   Sleep complaints among elderly persons (an epidemiologic study of three communities) . Sleep . 1995;18:425–432
  6. Sukying C , Bhokakul V , Udomsubpayakul U . An epidemiological study on insomnia in an elderly Thai population . J Med Assoc Thai . 2003;86:316–324
  7. Chlu HFK , Leung T , Lam LCW , et al.   Sleep problems in Chinese elderly in Hong Kong . Sleep . 1999;22:717–726
  8. Maggi S , Langlois JA , Minicuci N , et al.   Sleep complaints in community-dwelling older persons (prevalence, associated factors and reported causes) . J Am Geriatr Soc . 1998;46:161–168
  9. Neubauer DN . Sleep problems in the elderly . Am Fam Physician . 1999;59:2551–2558
  10. Rajput V , Bromley SM . Chronic insomnia (a practical review) . Am Fam Physician . 1999;60:1431–1438
  11. Montgomery P . Treatments for sleep problems in elderly people . Br Med J . 2002;325:1049
  12. McCall WV . Sleep in the elderly (burden, diagnosis and treatment) . Prim Care Companion J Clin Psychiatry . 2004;6:9–20
  13. National Institutes of Health state-of-the-science conference statement on manifestations and management of chronic insomnia in adults. June 13-15, 2005; Final Statement August 18,1005. Available at: http://consensus.nih.gov/2005/2005insomniaS0S026html.htm. Accessed August 26, 2005.
  14. Feinsilver SH . Sleep in the elderly. What is normal? . Clin Geriatr Med . 2003;19:177–188
  15. Dement W , Richardson G , Prinz P . Changes of sleep and wakefulness with age . In:  Finch C ,  Schneider EL editor. Handbook of the Biology of Aging . 2nd edition. New York: Van Nostrand Reinhold; 1985;p. 692–717
  16. John MW . A new method for measuring daytime sleepiness (the Epworth sleepiness scale) . Sleep . 1991;14:540–545
  17. Woodward M . Hypnosedatives in the elderly. A guide to appropriate use . CNS Drugs . 1999;11:263–279
  18. Ancoli-Israel S . Sleep problems in older adults (putting myths to bed) . Geriatrics . 1997;52:20–30
  19. Vgontzas AN , Kales A . Sleep and its disorders . Annu Rev Med . 1999;50:387–400
  20. Grunstein R . Insomnia. Diagnosis and management . Aust Fam Physician . 2002;31:1–6
  21. Brassington GS , King AC , Bliwise DL . Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years . J Am Geriatr Soc . 2000;48:1234–1240
  22. Cricco M , Simonsick EM , Foley DJ . The impact of insomnia on cognitive functioning in older adults . J Am Geriatr Soc . 2001;49:1185–1189
  23. Manabe K , Matsui T , Yamaya M , et al.   Sleep patterns and mortality among elderly patients in a geriatric hospital . Gerontology . 2000;46:318–322
  24. Spiegel K , Tasali E , Penev P , et al.   Brief communication (sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite) . Ann Intern Med . 2004;141:846–850
  25. Ogawa Y , Kanbayashi T , Saito Y , et al.   Total sleep deprivation elevates blood pressure through arterial baroreflex resetting (a study with microneurographic technique) . Sleep . 2003;26:986–999
  26. Meier-Ewert HK , Ridker PM , Rifai N , et al.   Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk . J Am Coll Cardiol . 2004;43:678–683
  27. Gottlieb DJ , Punjabi NM , Newman AB , et al.   Association of sleep time with diabetes mellitus and impaired glucose tolerance . Arch Intern Med . 2005;165:863–867
  28. Kupfer DJ , Reynolds CF . Management of insomnia . N Engl J Med . 1997;336:341–346
  29. Obermeyer WH , Benca RM . Effects of drugs on sleep . Neurol Clin . 1996;14:827–840
  30. Roth T , Hajak G , Üstün TB . Consensus for the pharmacological management of insomnia in the new millennium . Int J Clin Pract . 2001;55:42–52
  31. Shochat T , Loredo J , Ancoli-Israel S . Sleep disorders in the elderly . Curr Treat Options Neurol . 2001;3:19–36
  32. Morin CM , Colecchi C , Stone J , et al.   Behavioral and pharmacological therapies for late-life insomnia. A randomized controlled trial . JAMA . 1999;281:991–999
  33. Smith MT , Perlis ML , Park A , et al.   Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia . Am J Psychiatry . 2002;159:5–11
  34. Kobayashi R , Kohsaka M , Fukuda N , et al.   Effects of morning bright light on sleep in healthy elderly women . Psychiatry Clin Neurosci . 1999;53:237–238
  35. Fetveit A , Skjerve A , Bjorvatn B . Bright light treatment improves sleep in institutionalized elderly—an open trial . Int J Geriatr Psychol . 2003;18:520–526
  36. Holm KJ , Goa KL . Zolpidem. An update of its pharmacology, therapeutic efficacy and tolerability in the treatment of insomnia . Drugs . 2000;59:865–889
  37. Ancoli-Israel S , Richardson GS , Mangano RM . Long-term use of sedative hypnotics in older patients with insomnia . Sleep Med . 2005;6:107–113
  38. Ancoli-Israel S , Walsh JK , Mangano RM , et al.   Zaleplon, a novel nonbenzodiazepine hypnotic, effectively treats insomnia in elderly patients without causing rebound effects . Prim Care Companion J Clin Psychiatry . 1999;1:114–120
  39. Scharf M , Seiden D , Erman M , et al.   Eszopiclone rapidly induced sleep and provided sleep maintenance in elderly patients with chronic insomnia . Chicago, Ill: 11th Congress of the International Psychogeriatric Association; 2003; August 17-22
  40. Melton ST, Wood JM, Kirkwood CK. Eszopiclone for insomnia. Ann Pharmacother. August 30, 2005; E-publication.
  41. Walsh JK , Lankford DD , Krystal A , et al.   Efficacy and tolerability of four doses of indiplon (NBI-34060) modified-release in elderly patients with sleep maintenance insomnia . Sleep . 2003;26:A78
  42. Scharf MB , Rosenberg R , Cohn M , et al.   Safety and efficacy of immediate release indiplon (NBI-34060) in elderly patients with insomnia . Sleep . 2003;26:A85
  43. Walsh JK , Schweitzer PK . Ten-year trends in the pharmacological treatment of insomnia . Sleep . 1999;22:371–375
  44. Haria M , Fitton A , McTavish D . Trazodone. A review of its pharmacology, therapeutic use in depression and therapeutic potential in other disorders . Drugs & Aging . 1994;4:331–355
  45. Roth T , Seiden D , Zee P , et al.   Phase III outpatient trial of Ramelteon for the treatment of chronic insomnia in elderly patients . J Am Geriatr Soc . 2005;53:S25
  46. Peck JS , LeGoff DB , Ahmed I , et al.   Cognitive effects of exogenous melatonin administration in elderly persons (a pilot study) . Am J Geriatr Psychiatry . 2004;12:432–436
  47. Stevinson C , Ernst E . Valerian for insomnia (a systematic review of randomized clinical trials) . Sleep Med . 2000;1:91–99

 This project is supported by funds from the Geriatric Academic Career Award, a grant through the Public Health, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services, or the US Government. There are no conflicts of interest reported by the authors.

PII: S0002-9343(05)01056-9

doi:10.1016/j.amjmed.2005.10.051

The American Journal of Medicine
Volume 119, Issue 6 , Pages 463-469, June 2006

Article Tools

* Image Usage & Resolution