eMedicine Specialties > Psychiatry > Geriatric
Sleep Disorder, Geriatric: Treatment & Medication
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- The geriatric population is the largest group of people who use hypnotic drugs. People older than 60 years receive 33% of all hypnotic prescriptions, although they comprise only 14% of the population. The use of sedative-hypnotics by the elderly population has been associated with falls, hip fractures, and daytime carryover symptoms. When evaluating a patient, exclude primary sleep disorders and review medications and other contributory medical conditions.
- Patient education on age-related changes in sleep and good sleep hygiene may be adequate treatment for many older adults. If the initial history and physical examination findings do not reveal a serious underlying cause, a trial of improved sleep hygiene is the best initial approach. The common recommended measures include the following:
- Maintain a regular wake-up time.
- Maintain a regular sleeping time.
- Decrease or eliminate daytime naps.
- Exercise daily but not immediately before bedtime.
- Use the bed only for sleeping or sex.
- Do not read or watch television in bed.
- Do not use bedtime as worry time.
- Avoid heavy meals at bedtime.
- Limit or eliminate alcohol, caffeine, and nicotine before bedtime.
- Maintain a routine period of preparation for bed (eg, washing up, brushing).
- Control the nighttime environment with comfortable temperature, quietness, and darkness.
- Wear comfortable, loose-fitting clothes to bed.
- If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, such as listening to soft music or reading, but avoid exposure to bright light during these times.
- Get adequate exposure to bright light during the day.
- Avoid daytime naps. Explaining to the patient that daytime naps decrease nighttime sleep is helpful.
- People who are overweight and habitually snore loudly may be helped by weight loss. All people who snore loudly should abstain from alcohol or other sedatives before going to bed. They should also take measures to avoid supine sleeping (eg, by taping a tennis ball to the back of their bedclothes).
- In the absence of SA, contributing conditions, such as allergies, nasal pathology, or nasopharyngeal enlargement, should be sought and adequately managed by intranasal corticoid sprays or evaluated by an ear, nose, and throat specialist.
- If the sleep problem is secondary to some medical problem, then treat the primary problem rather than the sleep problem.
- Polysomnography is indicated when primary sleep disorders such as SA or PLMS are suspected.
Consultations
Consultation with appropriate specialists may be indicated, depending on the underlying causes of the sleep disorder, eg, psychiatric consultation for severe depression, pulmonary or surgical consultation for obstructive sleep apnea.
Medication
The first priority should be to determine the underlying cause of the sleep disorder, rather than just treat insomnia symptomatically. Usually, treatment on a short-term basis together with sleep hygiene is appropriate for transient insomnia, for example, second to bereavement or acute hospitalization. Insomnia in this population is treated with antidepressants, benzodiazepines, nonbenzodiazepines, melatonin agonist, and herbals. Medications, if used, should be started with low dose and monitored for side effects.16
In March of 2007, the FDA requested that the manufacturers of 13 sedative-hypnotic medications (such as, temazepam, flurazepam, triazolam, estazolam, zolpidem, zalepon, eszoplicone, quazepam, ramelton, butabarbitol, and secobarbitol) change their labeling to include stronger language about the risks of severe allergic reactions and complex sleep-related behaviors (eg, driving, making telephone calls, eating, having sex while not fully awake).
Hypnotics/benzodiazepines
According to the 1990 National Institutes of Health (NIH) consensus statement, hypnotics should be used on a limited short-term period and should only be used for older adults with transient insomnia because of increased hypnotic-related adverse effects. Avoid over-the-counter hypnotics (eg, diphenhydramine) because they have strong anticholinergic effects.
Barbiturates also are not indicated for insomnia, and psychiatric consultation may become necessary for patients receiving barbiturates for many years. The advantage of chloral hydrate is its rapid onset and rapid metabolism, although whether it is safe and well tolerated in the older population is unclear. Barbiturates are effective only for short-term use, losing much of their effectiveness after 2 weeks of administration. They are not used for insomnia in older patients.
Benzodiazepines remain the most commonly prescribed agents for sleep. The major advantages of the benzodiazepines (short and intermediate acting) are their relative safety in overdose, lower addiction risk, and weak interaction with other drugs. They should be used for a maximum of 2-3 weeks, or, if used longer, they should be used for only 2-3 nights per week. Because continued use results in increasing tolerance and increasing dose, care must be taken to avoid dependence. While the short- and intermediate-acting benzodiazepines are less likely to be associated with falls and hips fractures than the barbiturates and the longer-acting benzodiazepines, they are still a risk factor for falls in the older population.
Benzodiazepines are also more likely to produce the most pronounced rebound and withdrawal symptoms after discontinuation of the drug. Tapering the dosage can reduce rebound insomnia after discontinuation of these agents. Do not use long-acting agents (eg, flurazepam) in the older population because of the long half-life (2-8 d) and the tendency to accumulate over several days or weeks. These drugs are associated with daytime sedation, lethargy, ataxia, falls, and cognitive and psychomotor impairment.
Newer nonbenzodiazepines hypnotics like zolpidem, zaleplon, and eszoplicone do not cause rebound insomnia or withdrawal symptoms at discontinuation. Eszoplicone is approved for prolonged use.
Triazolam (Halcion)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Rapidly absorbed and eliminated and may cause rebound insomnia, anterograde amnesia, and confusion, especially in elderly individuals.
Adult
Older patient: 0.125 mg PO hs; use 0.25 mg only in patients who are exceptional and do not respond to a trial of lower dose; not to exceed 0.25 mg/d
Pediatric
Not established
Increased toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohol
Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive SA; history of substance abuse
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution and close monitoring needed in hepatic disease, low albumin levels, renal or pulmonary disease; causes residual daytime sedation, impairs cognition, and increases risk of falls, especially in older people; caution with other CNS depressants
Zolpidem (Ambien)
Structurally dissimilar to benzodiazepines but similar in activity with the exception of having reduced effects on skeletal muscle and seizure threshold. Advantage of no rebound insomnia or anxiety at discontinuation. At recommended doses, it is as effective as triazolam. Adverse CNS effects (eg, nightmares, agitation, drowsiness) noted in 10% of patients. As with benzodiazepine hypnotics, is approved only for short-term use (3-4 wk maximum) and, if used longer, for only 2-3 nights/wk.
Adult
5 mg PO hs; not to exceed 10 mg
Pediatric
Not established
Increases toxicity of alcohol and CNS depressants
Documented hypersensitivity; breastfeeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor elderly people for impaired cognitive or motor performance
Zaleplon (Sonata)
Short-acting pyrazolopyrimidine hypnotic with full agonistic activity on central benzodiazepine receptors (B21 type). At small doses, it is an affective sleep inducer with limited risk of disturbance in morning performance. Like zolpidem, zaleplon is particularly suitable for treatment of initial insomnia and does not cause rebound insomnia and withdrawal symptoms at discontinuation. Approved only for short-term use (3-4 wk maximum), and, if used longer, limit use to only 2-3 nights/wk.
Adult
5 mg PO hs
Pediatric
Not established
Cimetidine significantly increases levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Failure of insomnia to remit after 7-10 d of treatment may indicate need for evaluation of a primary psychiatric or medical illness; reevaluate patient if needs to be taken for >2-3 wk (not to prescribe in quantities exceeding a 1-mo supply); caution in patients exhibiting signs or symptoms of depression
Eszopiclone (Lunesta)
Nonbenzodiazepine hypnotic pyrrolopyrazine derivative of the cyclopyrrolone class. The precise mechanism of action is unknown but is believed to interact with GABA-receptor at binding domains close to or allosterically coupled to benzodiazepine receptors. Indicated for insomnia to decrease sleep latency and improve sleep maintenance. Short half-life of 6 h. Higher doses (ie, 2 mg for elderly adults and 3 mg for nonelderly adults) are more effective for sleep maintenance, whereas lower doses (ie, 1 mg for elderly adults and 2 mg for nonelderly adults) are suitable for difficulty in falling asleep.
Adult
Nonelderly adults: 2 mg PO hs; may increase to 3 mg PO hs prn
Elderly adults: 1 mg PO hs initially; not to exceed 2 mg PO hs
Severe hepatic impairment: Do not exceed 2 mg PO hs
Pediatric
<18 years: Not established
>18 years: Administer as in adults
CYP3A4 and CYP2E1 substrate; potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, nelfinavir) increase AUC, Cmax, and t1/2 and therefore potential toxicity (decrease dose); potent CYP3A4 inducers (eg, rifampicin) increase clearance; coadministration with alcohol or other CNS depressants may increase effect and toxicity (decrease dose); coadministration with olanzapine may decrease DSST scores; sleep onset may be delayed if taken with or immediately after a high-fat or heavy meal
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause dyspepsia, headache, or coldlike symptoms; rare adverse effects associated with hypnotics include short-term amnesia, confusion, agitation, hallucinations, worsened depression, or suicidal thoughts; high doses (ie, 6-12 mg) produce euphoric effects similar to those of diazepam 20 mg; anxiety, abnormal dreams, nausea, and upset stomach may occur within 48 h after discontinuing; alertness may be affected the following day; use caution while operating machinery or driving a car
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Helpful for sleep maintenance insomnia and should be taken 30 min before bedtime. Causes less withdrawal and rebound than short-acting benzodiazepines but may cause more daytime sedation.
Adult
0.5-1 mg PO hs
Pediatric
Not established
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates
Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease;
like all benzodiazepines, danger of abuse and physical dependence; avoid abrupt cessation
Temazepam (Restoril)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Intermediate-acting agent that is helpful for sleep-maintenance insomnia. If patients also have difficulty falling asleep, agent should be taken 30 min before bedtime. Causes less withdrawal and rebound than short-acting benzodiazepines but may cause more daytime sedation.
Adult
15 mg PO hs
Pediatric
Not established
Increased toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohol
Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive SA; history of substance abuse; severe uncontrolled pain
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity);
like all benzodiazepines, danger of abuse, addiction, and physical dependence; avoid abrupt cessation
Antidepressants
Sedating antidepressants (eg, trazodone, nefazodone), in low doses, can also be prescribed at bedtime for insomnia. Indicated for use when patient has a previous history of substance abuse. As with other antidepressants, little scientific evidence supports efficacy in the treatment of insomnia without associated depression and their use in patients with insomnia but without depression is not FDA approved and should be considered off label use.
Doxepin (Adapin, Sinequan)
Increases concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by presynaptic neuronal membrane. These effects are associated with a decrease in symptoms of depression.
Adult
30-150 mg/d PO hs or 2-3 divided doses; gradually increase dose to 300 mg/d prn
Pediatric
<12 years: Not recommended
>12 years: 25-50 mg/d PO hs or bid/tid and increase gradually to 100 mg/d
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates
Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism and patients receiving thyroid replacement
Mirtazapine (Remeron)
Exhibits both noradrenergic and serotonergic activity. In cases of depression associated with severe insomnia and anxiety, shown to be superior to other SSRI drugs.
Adult
15 mg PO hs initially; may increase by 15 mg increments q1-2wk, not to exceed 45 mg hs
Pediatric
Not established
May increase effect of CNS depressants; concurrent administration with MAOI may trigger hypertensive crisis
Documented hypersensitivity; MAOI within 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause drowsiness; discontinue use if patient develops sore throat, fever, or other signs of infection; suicide ideation is inherent in depression and may persist until significant remission occurs; severe neutropenia reported in clinical trials
Trazodone (Desyrel)
Antagonist at the 5-HT2 receptor and minimally inhibits the reuptake of 5-HT. Has negligible affinity for cholinergic and histaminergic receptors. Not associated with tolerance or withdrawal effects. Associated orthostatic hypotension can be minimized by administration with food. Limited data exist regarding efficacy in patients who are not depressed, and the FDA does not approve it as a hypnotic.
Adult
50 mg PO hs
Pediatric
Not established
May enhance response to alcohol, barbiturates, and other CNS depressants; cimetidine significantly increases levels of trazodone; serotonin syndrome may occur when used with other serotonergic agents, such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, nefazodone, SSRIs, but especially with MAOIs
Documented hypersensitivity; MAOIs use within 14 d of initiating treatment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypotension has occurred, including orthostatic hypotension and syncope; may produce drowsiness, dizziness, or blurred vision; patients taking this medication should be cautious while driving or performing other tasks requiring alertness, coordination, or dexterity; caution in cardiac disease, cerebrovascular disease, or seizures; discontinue therapy and reevaluate if priapism occurs
Nefazodone (Serzone)
Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Has negligible affinity for cholinergic and histaminergic receptors.
Adult
50 mg PO hs
Pediatric
Not established
Increases effects of digoxin, carbamazepine, triazolam, alprazolam, and protease inhibitors through its effect of inhibiting CYP450 3A4 enzyme; serotonin syndrome may occur when used with other serotonergic agents, such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, SSRIs, but especially with MAOIs
Documented hypersensitivity; MAOIs use within 14 d of initiating treatment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac disease, cerebrovascular disease, or seizures
Melatonin agonists
These agents may promote sleep. Ramelteon does not cause rebound insomnia or withdrawal symptoms at discontinuation. It is approved for prolonged use.
Ramelteon (Rozerem)
Melatonin receptor agonist with high selectivity for human melatonin MT1 and MT2 receptors. MT1 and MT2 are thought to promote sleep and be involved in maintaining circadian rhythm and normal sleep-wake cycle. Indicated for insomnia characterized by difficulty with sleep onset.
Adult
8 mg PO 30 min before bedtime on empty stomach
Pediatric
Not established
Major substrate of cytochrome P450 CYP1A2 and minor substrate of CYP2C and CYP3A4; strong CYP1A2 inhibitors (eg, fluvoxamine) increase AUC up to 190-fold and Cmax 70-fold; strong CYP inducers (eg, rifampin) decrease total exposure by mean of 80%; strong CYP3A4 inhibitors (eg, ketoconazole) and strong CYP2C9 inhibitors (eg, fluconazole) may increase serum levels
Documented hypersensitivity; strong cytochrome P450 CYP1A2 inhibitors (eg, fluvoxamine); severe hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May affect reproductive hormones in adults (eg, decreased testosterone levels, increased prolactin levels), further study required to determine safety in prepubescent and pubescent children; caution with mild hepatic impairment; adverse effects leading to discontinuation in clinical trials included: dizziness, nausea, fatigue, headache, and worsening insomnia
More on Sleep Disorder, Geriatric |
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| Differential Diagnoses & Workup: Sleep Disorder, Geriatric |
 Treatment & Medication: Sleep Disorder, Geriatric |
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Further Reading
Keywords
sleep disturbances, sleep problems, sleep changes, sleep disorders, insomnia, sleep apnea, SA, hypersomnolence, sleep latency, sleep efficiency, periodic limb-movement disorder, PLMD, periodic limb-movement syndrome, periodic limb movement syndrome, periodic limb movements in sleep, PLMS, nocturnal myoclonus, rapid eye movement, REM, non-REM, paradoxical desynchronized sleep, slow-wave sleep, SWS, conjugate gaze, dreams, dreaming, nocturnal penile tumescence, NPT, electrooculography, EOG, circadian rhythms
