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Chronic insomnia: a practical review.

V Rajput¹, S M Bromley

¹Robert Wood Johnson Medical School, Camden, New Jersey, USA.

American Family Physician

|October 19, 1999

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Insomnia in older adults is complex due to age-related sleep changes. Behavioral strategies and addressing potential causes like depression or medications are key management approaches.

Area of Science:

Gerontology
Sleep Medicine
Pharmacology

Background:

Insomnia presents with diverse, often overlapping causes, including medical issues, medications, psychiatric conditions, and poor sleep hygiene.
Sleep disturbances in the elderly are particularly complex due to age-related physiological changes, complicating treatment.
Common contributing factors in older adults include depression, medication side effects, and sleep apnea.

Purpose of the Study:

To outline a practical management strategy for insomnia, especially in the elderly population.
To highlight the importance of behavioral interventions and identifying underlying causes.
To discuss appropriate pharmacologic options and contraindications for insomnia treatment.

Main Methods:

Review of current literature on insomnia etiologies and management strategies.

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Emphasis on differential diagnosis, including depression, medication review, and sleep apnea.

Discussion of behavioral therapies such as sleep hygiene and light therapy.

Evaluation of pharmacologic interventions, including sedating antidepressants, anxiolytics, and melatonin, with a focus on avoiding long-term benzodiazepine use.

Main Results:

Behavioral approaches focusing on good sleep habits are beneficial for most insomnia patients.
Bright light therapy can help reset circadian rhythms when sleep-wake cycles are misaligned.
Periodic limb movements during sleep are common in the elderly and may require treatment if causing arousals.
Low-dose sedating antidepressants or nonbenzodiazepine anxiolytics may be preferable to traditional hypnotics when medication is necessary.
Long-term use of long-acting benzodiazepines should be avoided.

Conclusions:

A systematic approach to insomnia management in the elderly should prioritize identifying and treating underlying conditions like depression or sleep apnea.
Behavioral interventions and optimizing sleep hygiene form the cornerstone of effective insomnia treatment.
Pharmacological treatments should be used judiciously, with careful consideration of risks and benefits, favoring agents with better long-term safety profiles over long-acting benzodiazepines.