Treatment of sleep disturbance in older adults

Abstract

Sleep and circadian rhythm disturbances are prevalent in older populations. Numerous factors can affect sleep, including medications, living environment and physical, mental and psychosocial factors (e.g. loneliness and stress). Sleep architecture changes with aging, with less deep sleep (slow wave sleep) and an increased frequency of awakenings after sleep onset. Benzodiazepines, Z-drugs and low doses of the tricyclic antidepressant doxepin have modest positive benefits for sleep complaints, but side effects are a concern in older people because they include an increased risk of falls, fractures and cognitive impairment. Somnolence can be prolonged in older adults. Melatonin has very modest effects on sleep initiation in older adults, although appears safe. Overall, the effects of pharmacological treatments are modest and there are concerns about the efficacy and safety of their ongoing use. There is strong evidence for non-pharmacological interventions, including cognitive and behavioural strategies, to improve sleep. These have at least comparable efficacy to pharmacological interventions, fewer adverse effects and are more likely to have longer-term, sustained benefits. Sleep complaints in older adults need to be approached on a patient-by-patient basis, and medication should be reviewed frequently, with preference to limit pharmacological intervention as far as practicable.

Reducing risk of harm from sedative–hypnotic medications in older people

“…In this issue of the Journal , Amy Reynolds and Robert Adams summarise the literature on pharmacological management of sleep disturbance in older people . They highlight that medications used to treat insomnia have limited effectiveness and are associated with significant side effects in older people, including falls and cognitive decline . Despite the risks, sedative–hypnotic medications are commonly prescribed …”

“…Commonly used sedative–hypnotic medications are all listed by the American Geriatrics Society's Beers Criteria as medications that should usually be avoided in older people . Melatonin has become a popular alternative because it is thought to be safe, but its effectiveness is limited and it has been linked to increased fracture risk …”

“…It is not surprising that older people often seek help for sleep complaints, because sleep quality and duration decline with age and some of the chronic diseases that commonly affect older people can cause or worsen insomnia . It is important that sleep disorders are managed because they can contribute to adverse health outcomes and reduced quality of life …”

“…depression, pain) and remove medications that may cause or worsen sleep disturbance (e.g. stimulants, beta‐blockers), where possible . At the same time, non‐pharmacological sleep management approaches should be introduced, including ensuring an optimal sleep environment, sleep hygiene and relaxation training.…”

“…Explaining the limited effectiveness of sedative–hypnotic medications and the risks associated with their use (before they are started) may help with motivating the person to try non‐pharmacological approaches. Cognitive behavioural treatment for insomnia (CBT‐I), to address beliefs and behaviours that may hinder sleep, is a proven strategy for the treatment of chronic insomnia in older people . CBT‐I produces similar or greater benefits compared with sedative–hypnotic medications, with fewer side effects and more sustained benefits .…”