Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part VII: Insomnia

Abstract

OBJECTIVE : To present the seventh in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on insomnia and presents a treatment algorithm for managing insomnia in older adults, along with a representative clinical case. METHODS : A modified Delphi process was used to develop the algorithm and supportive materials. A multidisciplinary expert panel representing expertise in health psychology and sleep medicine developed the algorithm and supporting documents that were subsequently refined through an iterative process of input from a primary care provider panel. RESULTS : We present an illustrative clinical case and an algorithm to help guide the care of older adults with insomnia, an important contributor to CLBP and disability. Multicomponent cognitive behavioral therapy for insomnia (CBTI) and similar treatments (e.g., brief behavioral treatment for insomnia [BBTI]) are the recommended first-line treatment. Medications should be considered only if BBTI/CBTI is suboptimal or not effective and should be prescribed at the lowest effective dose for short periods of time (< 90 days). CONCLUSIONS : Insomnia is commonly comorbid with CLBP in older adults and should be routinely evaluated and treated because it is an important contributor to pain and disability. The algorithm presented was structured to assist primary care providers in planning treatment for older adults with CLBP and insomnia.

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

“…Treating sleep disturbances and sleep and circadian disorders in patients with PTSD can improve not only sleep but also as daytime PTSD symptoms and mood disturbances. 6,16,88,[162][163][164] In TBI samples, preliminary evidence also suggests that sleep-focused treatments targeting insomnia can alleviate cognitive and mood symptoms, as well as fatigue. 14,15,165 There are promising early reports that prazosin, a noradrenergic alpha-1 antagonist used in the treatment of PTSD-related nightmares, may improve both sleep quality and cognitive performance in adults with mTBI.…”

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults

“…Nine medical conditions used in calculating the Charlson Comorbidity Index (CCI) score [30] were defined from diagnosis codes in the health care claims: chronic obstructive pulmonary disease (COPD), dementia, diabetes (mild, moderate, or with chronic complications), heart problems (myocardial infarction, heart failure, peripheral vascular disease), liver disease (mild, moderate, or severe), peptic ulcer disease, renal disease, rheumatologic disease, or stroke. The CCI is a measure of the risk of one-year all-cause mortality attributable to selected comorbidities that has also been shown to be highly predictive of morbidity and health care expenditures [44].…”

“…Persistent back pain has also been associated with increased falls, whether a result of the increased pain or associated medications [11,26–28]. Insomnia and other sleep problems associated with back pain further compromise quality of life among older adults [1,29,30]. Although active, high-dose, and early physical therapy has been associated with increased function and decreased pain intensity and/or duration, the delivery and effectiveness of physical therapy is not consistent [20,24].…”

Treating Insomnia in Older Adult Patients: Limiting Benzodiazepine Use

“…For treating insomnia, clinicians should first consider the possibility of organic disorders that may necessitate specific treatment, such as narcolepsy or sleep apnea [45]. chronic use of such medication should be avoided, but a short course might be appropriate [46]. New drugs for treating insomnia that do not target the GABA A -R system are emerging [47]- [56].…”