CATEGORY 1 CME
Premiere Date: April 20, 2024
Expiration Date: October 20, 2025
This activity offers CE credits for:
1. Physicians (CME)
2. Other
All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
ACTIVITY GOAL
To discuss and describe the epidemiology, assessment, and evidence-based treatment of insomnia in older adults.
LEARNING OBJECTIVES
1. Discuss the epidemiology and assessment of insomnia in older adults.
2. Enumerate the evidence-based treatments for insomnia in older adults.
TARGET AUDIENCE
This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
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Physicians’ Education Resource, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.
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In humans, sleep is divided into nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.1 The non-REM sleep consists of 3 stages (N1-N3), with N1 and N2 being considered lighter stages of sleep, and N3 being considered as deep sleep. In healthy adults, sleep starts with NREM sleep and is then followed shortly by REM sleep.2 During a normal night’s sleep, there are 4 to 5 alterations between NREM and REM sleep.
Electroencephalogram (EEG) recordings show increasing voltage and decreasing frequency as NREM sleep progresses into deeper stages. The heart rate and blood pressure also decline during NREM sleep, whereas gastrointestinal motility and parasympathetic activities increase. In REM sleep, there are bursts of rapid eye movements, but there is significant loss of muscle tone.
Changes in sleep that are associated with normal aging include advances in sleep timing, a decrease in nocturnal sleep time, a decrease in sleep efficiency, an increase in the frequency of daytime naps, an increase in sleep latency, an increase in nocturnal awakenings, an increase in stages N1 and N2 of NREM sleep, a decrease in stage N3 of NREM sleep, a decrease in the percentage of REM sleep, and a decrease in total sleep time (TST).3,4 The TST decreases until about 60 years of age and then stabilizes in the later decades of life.3,5
Additionally, the circadian system and sleep homeostasis become less robust, and the pattern of sleep-related hormone secretions change with normal aging. Table 13,4 lists the sleep architectural changes associated with normal aging.
The sleep architectural changes associated with normal aging occur due to the decline in efficiency of the circadian internal clock.2,3 Additionally, there is reduction in the amplitude of circadian oscillation along with a decline in levels of melatonin. Aging also results in the reduction of the efficiency of the suprachiasmatic nucleus in the hypothalamus (main central clock), which negatively affects the day/night synchronization of the peripheral cellular clocks, causing significant changes in endocrine and metabolic pathways, the sleep-wake cycle, body temperature, motor activity, and behaviors. Furthermore, the decrease in the delta power and associated increase in beta wave power noted on EEGs that are caused by age-associated atrophy of the brain and cortical thinning also contribute to the sleep architectural changes associated with normal aging.
The word insomnia is derived from the French word insomnie, which refers to difficulties with sleep.6,7 According to the DSM-5-TR, insomnia becomes a disorder when the individual presents with a predominant complaint of dissatisfaction with sleep quantity or quality and it is associated with (≥ 1) of the following symptoms: (1) difficulty initiating sleep, (2) difficulty maintaining sleep that is characterized by frequent awakenings or problems with returning to sleep after awakenings, and (3) early-morning awakening and inability to return to sleep.8 The sleep disturbance also causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
Furthermore, the sleep difficulties occur for at least 3 nights per week and last for at least 3 months. These sleep difficulties also occur despite adequate opportunities for sleeping, and they are not better explained by, and do not occur exclusively due to, another sleep-wake disorder. The insomnia is also not attributable to the physiological effects of a medication or substance abuse and is not adequately explained by the presence of mental or medical conditions.
The DSM-5-TR specifies that insomnia can occur with non-sleep disorder mental comorbidity, including substance use disorders; with other medical comorbidity; or with other sleep disorders. Insomnia can be episodic if symptoms last at least 1 month, but less than 3 months; persistent, if symptoms last ≥ 3 months; and recurrent if there are ≥ 2 episodes within a 1-year period.
Epidemiology
Among older adults, the prevalence of insomnia symptoms ranges from 30% to 48%.9 Most of these individuals present with sleep maintenance symptoms (50%-70%), followed by difficulty initiating sleep (35%-60%), and nonrestorative sleep (20%-25%). The annual incidence of insomnia among older adults is approximately 5%, with approximately half of these individuals reporting a remission in symptoms at 3-year follow-up.10 The prevalence of insomnia disorder among older adults ranges from 12% to 20%.
Evidence indicates that insomnia is more common among older adults with lower education levels, those at lower income levels, those who are in low-ranking positions, those with limited social contact with children and friends, those who are less spiritual, those who have less financial support, those who lack close family and friends, and those with less desirable living situations.
One study found that African American women had a greater incidence of insomnia compared with African American men (19% vs 12%, P < 0.01) and compared with White men and women (both 14%, P <0 .01).10 Women were also less likely than men to report a remission in symptoms of insomnia at follow-up (42% vs 64%, P < 0.01). Among both races, the presence of depressed mood was a risk factor for the incidence of insomnia, and the absence of depressed mood was a predictor of remission of symptoms.
A retrospective database review found that female sex and the presence of dementia, depression, anxiety, chronic pain disorders, or atrial fibrillation are associated with thdevelopment of insomnia in older adults. Insomnia is also more common among older adults who have heart disease, stroke, and diabetes. Additional risk factors for the development of insomnia are the presence of chronic diseases, the use of prescribed sedatives, widowhood, depressed mood, physical disability, and poor perceived health. The use of stimulants, nasal decongestants, steroids, antidepressants, antihypertensives, and analgesics also increase the risk of developing insomnia in older adults.
Environmental risk factors for insomnia among older adults include excess noise, hot or cold temperatures, moving to a new place of living, and institutionalization. Social and behavioral factors include irregular sleep schedule, caregiving, retirement and other lifestyle changes, and bereavement.
A systematic review found that among older adults, factors that were most consistently identified as risks for future sleep disturbances were female gender, depressed mood, and physical illness. The investigators found less robust evidence for the following as risks for future sleep disturbances: lower physical activity levels, African American race, lower economic status, previous manual occupation, widowhood, marital quality, loneliness, perceived stress, preclinical dementia, long-term benzodiazepine and sedative use, low testosterone levels, and inflammatory markers.
Consequences
Insomnia among older adults is associated with the development of depressive symptoms, especially poor sleep quality and difficulty initiating and maintaining sleep.15 Insomnia is also associated with the development of suicidal ideation.
The risks for developing hypertension, myocardial infarction, and cerebrovascular events are greater among individuals with insomnia. Insomnia also increases the risk for metabolic syndrome and diabetes. Older men with insomnia are at greater risk of developing prostate cancer.
One meta-analysis indicated that insomnia among older adults increases the risk for dementia (relative risk [RR]= 1.53). Insomnia also worsens quality of life and adds to the direct and indirect cost of caring for these individuals.
Assessment
When evaluating symptoms of insomnia among older adults, it is essential to obtain a thorough clinical history from the individual and their family members who are aware of the person’s sleep habits.13 This history should assess the nature, the frequency, the progression, and the total duration of symptoms of insomnia. Conditions prior to sleep; sleep-wake patterns; symptoms of other sleep disorders, such as sleep apnea and restless leg syndrome; and the daytime consequences of insomnia should also be evaluated.
Furthermore, the predisposing, precipitating, and perpetuating factors for insomnia including behavioral and environmental factors, comorbid psychiatric disorders, substance use disorders, medical conditions, and intake of medications that can cause or worsen insomnia should be also be assessed. A thorough history should also assess the prior treatments for insomnia and the individual’s response to these treatments.
Sleep dairies that follow an individual’s sleeping and wakefulness patterns, and sleep questionnaires like the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity.
Index (ISI), can assist with the identification and a diagnosis of insomnia in older adults.
Polysomnography (PSG) is not indicated for the routine assessment of insomnia in older adults.19 PSG should only be considered when sleep apnea or a movement disorder is suspected, or when the individual has failed behavioral or pharmacologic treatments for insomnia. Figure 1 discusses the pathway for assessing insomnia in older adults.
Management
Available evidence indicates that both nonpharmacological and pharmacological strategies have shown benefit in the management of insomnia among older adults. The choice of treatment often depends on multiple factors including the duration and severity of symptoms, comorbidities, the individual’s motivation for accepting nonpharmacological (behavioral) treatments, and the individual’s risk for developing adverse effects from medications.
Irrespective of the type of treatment that is chosen, the main goals of treatment are to improve the quality and quantity of sleep and to minimize daytime impairments due to insomnia. Additionally, the treatment should improve any psychological distress caused by insomnia. In most cases, nonpharmacological interventions should be considered as first-line treatments for insomnia in older adults.9 Nonpharmacological and pharmacological treatments should be combined when either of the treatments has not produced the desired results.
Nonpharmacological Treatments
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is a highly effective nonpharmacological treatment for insomnia.22 CBT-I appears to have the equivalent efficacy to hypnotic agents and has no known adverse effects. The long-term improvements from CBT-I are thought to occur due to the individual with insomnia learning how to engage and promote their body’s natural sleep mechanisms.
Sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques are the 5 key components of CBT-I. The treatment can be delivered by a trained therapist via a self-guided method, or via fully automated online programs including SHUTi and Sleepio, among others.23 One meta-analysis of 20 studies that included individuals with a mean age of 56 years found that CBT-I improved sleep-onset latency (SOL) by 19.3 minutes, wake-after-sleep onset (WASO) by 26 minutes, TST by 7.61 minutes, and sleep efficiency (SE) by 9.91%. The investigators also noted sustained improvements at later time points.
The American College of Physicians (ACP) recommends that all adults with chronic insomnia should receive CBT-I as the initial treatment.15 One recent meta-analysis that included data from 14 studies found that CBT-I improved SE (8.36%, P < 0.00001), SOL (-9.29 minutes, P <0 .0001), WASO (-23.44 minutes, P <0 .00001), and TST (-12.35, P = 0.007) in older adults. When CBT-I alone is not successful in managing insomnia, the ACP recommends using a shared decision-making approach by clinicians that includes a discussion of the benefits, harms, and costs of short-term use of medications in order to decide whether to add pharmacotherapy.
Brief Behavioral Treatment for Insomnia (BBTI)
BBTI emphasizes the behavioral elements of insomnia treatment in lieu of the cognitive components of CBT-I.23 BBTI includes 4 main interventions: reduced time in bed to match the actual sleep duration; getting up at the same time every day, irrespective of the duration of sleep; going to bed only when sleepy; and only staying in bed when asleep. BBTI is delivered in a single initial session that is then followed by 2 to 3 brief follow-up visits either in person or via telephone.
BBTI has been found to be beneficial among older adults (mean age 71.7 years) with chronic insomnia (remission or response vs partial response or nonresponse rates, P < 0.001), when compared with controls.27 BBTI also produced better results in self-reported sleep and health assessments (P< 0.001), sleep diaries (P < 0.001), and actigraphy (P < 0.001), with improvements being maintained at 6 months. The number needed to treat (NNT) was 2.4. There were no differential effects noted based on hypnotic or antidepressant use, sleep apnea diagnosis, or the source of recruitment.
Sleep Restriction Therapy (SRT)
SRT improves sleep drive and consolidates sleep by making the individual’s time in bed equivalent to their total sleep duration.28 The total sleep duration is assessed with daily sleep diaries. In a randomized controlled trial (RCT) of older adults (mean age 68.9 years), individuals receiving SRT had significantly lower SOL (effect size = 1.11, P ≤ 0.003) and WASO (effect size = 1.19, P ≤ 0.031), and higher SE (effect size = 1.74, P ≤ 0.007) than controls.
Results post treatment at 3 months and 1 year showed that TST for the SRT increased from post treatment to 3 months (P = 0.04). Time in bed also changed over time (P < 0.0001). Additionally, insomnia severity improved post treatment among the SRT group (effect size = 1.18, P ≤ 0.0001). Treatment response was achieved in 50% of SRT participants (P = 0.001), with remission observed in 22.73% of the participants (P = 0.0001).
Stimulus Control Therapy (SCT)
SCT consists of a set of instructions designed to restore the association between bed/bedroom and sleep.28 SCT also establishes a consistent wake time. The instructions for SCT are to go to bed only when sleepy, to get out of bed when unable to sleep, to use the bed/bedroom for sleep and sex only, to wake up at the same time every morning, and to refrain from daytime napping.
In an RCT of older adults (mean age 68.9 years), Epstein, et al, found that individuals who received SCT had significantly lower SOL (effect size = 1.44, P ≤ 0.01), WASO (effect size = 1.04, P ≤ 0.01), and TST (effect size = 1.08, P ≤ 0.01) than controls.29 Treatment response was achieved in 56.6% of SCT participants (P = 0.001), with remission observed in 29.55% of the participants (P = 0.0001).
Relaxation Therapy (RT)
RT includes structured techniques that are designed to reduce somatic tension (abdominal breathing, progressive muscle relaxation, etc) and cognitive arousal (guided imagery training and meditation) that may perpetuate sleep difficulties.28 In an RCT, Lichstein, et al, found that among older adults (mean age 68.11 years), RT improved SOL (effect size = 0.18 and 0.40, respectively), WASO (effect size = 0.26 and 16, respectively), TST (effect size = 0.28 and 0.43, respectively), and SE (effect size = 0.16 and 0.29, respectively), when compared with placebo both post treatment and at follow-up.
Summary of Cognitive and Behavioral Interventions
The American Academy of Sleep Medicine (AASM) systematic review, meta-analysis, and GRADE assessment found that there is a significant amount of evidence to support the use of behavioral and psychological treatments—especially CBT-I—among adults with insomnia.28 However, this report also concluded that there are challenges for the delivery of these interventions—hence, there is a need to identify means for the optimal delivery of these treatments. One RCT also found that SCT, SRT, and multicomponent intervention (MCI) are equally efficacious and produce sustainable treatment gains among older adults with chronic primary insomnia.
A recent systematic review that evaluated the effectiveness of the behavioral components of CBT for insomnia in older adults included data from 15 studies.31 Among these, 3 studies focused on stimulus control (SC), 4 evaluated sleep restriction (SR), and 8 used MCI that contained both SC and SR. The investigators concluded that both SC and SR were effective in improving subjectively measured aspects of sleep, which was maintained at 3-month follow-up. Additionally, no significant differences were noted between these 2 treatments.
However, effect sizes in studies that solely used SC or SR were smaller and more heterogenous than studies that included multicomponent interventions (effect size = 0.55). Hence, in clinical populations where CBT-I may be cognitively difficult, treatments with MCI that combine both SC and SR can be used successfully.
Pharmacotherapy
Although CBT-I is the recommended as first-line treatment for insomnia, many individuals will be offered and/or want pharmacotherapy for the management of their insomnia.32 The reasons for offering pharmacotherapy for insomnia include the lack of availability of clinicians who can provide CBT-I, the ease of availability of pharmacotherapy, and the reduced time commitment that is required for pharmacotherapy, when compared with behavioral interventions. Pharmacotherapy is also used when there is the need for a faster treatment response.
There are some general considerations that should be followed when prescribing medications for insomnia in older adults. Multimorbidity and polypharmacy are major concerns when prescribing any medications for older adults, as 51% of older adults have multimorbidity, and 32% have encountered polypharmacy. These issues result in greater risk for new hospitalizations, falls, decline in both physical and cognitive functions, and death among older adults.
Additionally, there are significant pharmacokinetic and pharmacodynamic changes that occur with age that should be taken into account when prescribing medications to any older adult. These changes result in reduced metabolism and excretion of medications, which can cause toxic accumulation of drugs, even at approved dosage ranges. Furthermore, polypharmacy can result in dangerous drug-drug interactions that can result in catastrophic outcomes among older individuals.
As per the American Geriatrics Society (AGS) 2023 updated AGS Beers Criteria,® most of the medications used in treating insomnia are considered potentially inappropriate for use in older adults and should either be avoided or be used with extreme caution.38 Hence, medications for insomnia should only be used following a careful risk/benefit analysis and as short-term treatments.
Additionally, medications should be considered as adjunct to nonpharmacological interventions.33 When medications are prescribed to older adults with insomnia, they should be carefully monitored for both efficacy and adverse effects. Once the insomnia is under better control, a taper and discontinuation of the medication should be attempted. Intermittent use of medications is acceptable, as long as the individual is also pursuing CBT-I.
Four medication classes are approved by the FDA for the treatment of insomnia among adults. These include the benzodiazepine receptor agonists (benzodiazepines and nonbenzodiazepines, or Z-drugs), dual orexin receptor agonists (DORAs), selective histamine antagonists, and selective melatonin receptor agonists.
Tricyclic antidepressants like amitriptyline and nortriptyline have also been used to treat insomnia among older adults, but they should be either avoided or used cautiously due to their serious adverse effects, including anticholinergic effects and cardiotoxicity. 34,39-41 In addition, these medications should only be used by individuals who have insomnia and comorbid depression, fibromyalgia, or neuropathic pain.
The use of anticonvulsants like gabapentin or pregabalin should be restricted to individuals with insomnia and comorbid seizure disorder, fibromyalgia, restless leg syndrome, or neuropathic pain. Similarly, the use of antipsychotic medications like olanzapine and quetiapine should be restricted to only individuals who have insomnia and comorbid schizophrenia spectrum disorders or mood disorders.
Antihistamines like diphenhydramine and hydroxyzine have also been used for the treatment of insomnia in older adults, but their routine use is not recommended due to their severe adverse effect profile, which includes anticholinergic effects. Tryptophan and valerian have also been used to treat insomnia in older adults, but the evidence for their efficacy is lacking at this time.
In a meta-analysis published in The Lancet, the investigators included data from 154 RCTs in adults.42 They found that for the acute treatment of insomnia, benzodiazepines, eszopiclone, lemborexant, zolpidem, and zopiclone were more efficacious than placebo (effect size = 0.36 to 0.83). Additionally, benzodiazepines, eszopiclone, zolpidem, and zopiclone were more efficacious than melatonin, ramelteon, and zaleplon (effect size = 0.27 to 0.71).
The investigators also found that intermediate-acting benzodiazepines [odds ratio (OR) = 0.72], long-acting benzodiazepines (OR = 0.70), and eszopiclone (OR = 0.71) had fewer discontinuations due to any cause than did ramelteon. Zopiclone (OR = 2.00) and zolpidem (OR = 1.79) caused more dropouts due to adverse events than did placebo. Zopiclone caused more dropouts than eszopiclone (OR = 1.82) and suvorexant (OR = 3.13).
For the long-term treatment of insomnia, eszopiclone (effect size = 0.63) and lemborexant (effect size = 0.41) were more effective than placebo. Eszopiclone was more effective than ramelteon (effect size = 0.63) and zolpidem (effect size = 0.60). When compared with ramelteon, eszopiclone (OR = 0.43) and zolpidem (OR = 0.43) had lower rates of all-cause discontinuations. When compared with placebo, zolpidem was associated with a higher number of dropouts due to adverse effects (OR = 2.00).
Concluding Thoughts
Insomnia is not uncommon among older adults. It is associated with significant negative outcomes in these individuals including a decline in physical, mental, and cognitive health. The etiologies for insomnia in older adults are often multifactorial due to the complex interactions between various biological, psychological, social, and environmental factors.
Assessment of insomnia in older adults should involve a thorough history including an evaluation of all possible risk factors. Sleep diaries and sleep questionnaires can assist with the identification and diagnosis of insomnia in older adults. PSG is only indicated when sleep apnea or movement disorders are suspected, or when the individual has failed behavioral or pharmacologic treatments for insomnia.
CBT-I is the recommended as first-line treatment for insomnia in older adults. However, BBTI, SRT, SCT, and RT have also been found to be effective in the treatment of insomnia in this patient population. Pharmacotherapy is used in situations where there is a lack of availability of clinicians who can provide CBT-I and in situations where there is the need for a faster treatment response.
The 4 medication classes that are approved by the FDA for the treatment of insomnia among adults are the benzodiazepine receptor agonists (including the Z-drugs), DORAs, selective histamine antagonists, and selective melatonin receptor agonists. Although not FDA approved, certain anxiolytics, anticonvulsants, antidepressants, antipsychotics, nutritional products, and herbs are also used to treat insomnia in older adults.
Medications should be used cautiously in older adults with insomnia due to their risk for serious adverse effects and drug-drug interactions. Additionally, medications should be used at the lowest effective doses and for the shortest possible duration and as adjuncts to nonpharmacological treatments.
Note: This article originally appeared on Psychiatric Times
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