Managing Insomnia in Elderly Care: Effective Strategies and Treatments

Chronic insomnia is a prevalent issue among residents in aged care facilities, negatively impacting their quality of life, health, and overall function. This condition is often associated with anxiety and depression and can lead to severe complications like falls and cognitive impairments. Given these challenges, it’s crucial to approach insomnia with effective and safe treatment strategies.

Understanding Sleep Changes in Older Adults

As people age, their sleep architecture undergoes significant changes that can contribute to sleep disturbances. Older adults often experience increased sleep onset latency, meaning it takes longer for them to fall asleep. There is also a shift in the structure of sleep, with an increase in light sleep (stages 1 and 2 of non-REM sleep) and a reduction in slow wave sleep (stage 3 non-REM sleep) and REM sleep. These changes result in shorter total sleep time and more frequent awakenings during the night, often exacerbated by sensitivity to environmental disturbances such as noise, light, and temperature changes.

Primary Treatment Approaches for Insomnia in Elderly Care

The main treatments for insomnia in older people include psychological/behavioural therapies and pharmacological treatments, often used in combination for best results. It is also crucial to address secondary causes of insomnia, such as pain or underlying medical conditions like dementia, to improve sleep outcomes.

Non-Pharmacological Treatments

Psychological and behavioural interventions are the cornerstone of managing insomnia in the elderly, with the following approaches widely recommended:

Stimulus Control: This involves conditioning the mind to associate the bed and bedroom with sleep, establishing consistent sleep and wake times to strengthen the body’s sleep-wake cycle.
Sleep Restriction: Limiting time in bed to actual sleep time helps increase sleep efficiency. Patients are advised to avoid staying in bed while awake.
Relaxation Techniques: Techniques such as progressive muscle relaxation, deep breathing exercises, and mindfulness can help mitigate anxiety and the physical symptoms of stress that interfere with sleep.
Cognitive Behavioral Therapy for Insomnia (CBT-I): This method addresses misconceptions about sleep and teaches strategies to alter sleep habits and behaviours effectively.
Mindfulness: Promoting a state of mind where one remains non-reactive to disruptive thoughts, helping to ease the transition to sleep.
Sleep Hygiene: Educating patients about good sleep habits, such as optimal sleep environment and appropriate pre-sleep activities.

Pharmacological Treatments

When behavioural and cognitive therapies are insufficient, the following medications may be considered:

Benzodiazepines: Such as temazepam, used primarily for short-term management due to their propensity for tolerance and dependence. These are generally not recommended for long-term use.
Z-drugs: Including zolpidem and zopiclone, which are similar to benzodiazepines in terms of efficacy and safety profile, intended only for short-term use.
Melatonin: This naturally occurring hormone can be used to decrease sleep onset latency and improve overall sleep quality, though individual responses may vary.
Suvorexant: This medication acts on the orexin receptor system to help regulate the sleep-wake cycle, beneficial from the first night of use, although its long-term safety profile remains under review.

Specific Medications and Their Effects

Benzodiazepines and Z-drugs

Benzodiazepines, such as temazepam, are commonly prescribed for the short-term management of insomnia in adults. They may improve sleep onset and maintenance, but their efficacy diminishes after about two weeks of continuous use due to the development of tolerance. The sleep provided by benzodiazepines tends to be of lower quality and less restorative. Adverse effects include increased risk of falls, cognitive decline, and potential dependency, necessitating careful monitoring and management.

Z-drugs, like zolpidem and zopiclone, offer similar efficacy to benzodiazepines for treating insomnia. Zolpidem’s dosage for older adults typically starts at 5mg or 6.25mg of the controlled release form to prolong sleep duration. Zopiclone should be initiated at a dose of 3.75mg for older individuals. Despite their utility, these drugs share benzodiazepines’ risks of dependence, tolerance, and withdrawal symptoms and are therefore recommended only for short-term use. Both types of medication should be prescribed cautiously, particularly in populations at risk of adverse effects.

Alternative Medications

Melatonin, a hormone that regulates the sleep-wake cycle, may help reduce sleep onset latency and is generally well-tolerated. While the effectiveness of melatonin can vary significantly between individuals, it is typically free from serious side effects, making it a viable option for those who respond well to it. Controlled-release formulations are taken 1 to 2 hours before bed, although there is insufficient evidence to recommend treatment beyond three weeks.

Suvorexant, an orexin receptor antagonist, is another alternative that may benefit sleep architecture, offering improvements from the first night of use. However, its long-term safety profile is still under review, and caution is advised in individuals with respiratory conditions. Common side effects include somnolence, dizziness, and headache.

Low-dose tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline can be used off-label for insomnia management. These medications primarily increase time spent in stage 2 sleep, with minimal impact on other sleep stages. While their anticholinergic side effects are typically less pronounced at lower doses, the potential for significant drug interactions exists.

Sedating antihistamines like doxylamine are approved for treating insomnia and sleeplessness, although they may cause confusion or paradoxical excitation in older adults. Antihistamines may interfere with REM sleep and are not generally recommended for long-term management of insomnia due to their side effect profiles.

Each of these medications offers potential benefits for managing insomnia, but also carries risks, particularly in the elderly, where the incidence of adverse effects can be higher.

Complementary Treatments and Safety Considerations

Complementary medicines, such as valerian, passion flower, hops, chamomile, and catnip, are promoted for managing sleep problems. These herbal products are considered relatively safe for use in older adults, though the evidence supporting their effectiveness in treating insomnia is limited. These treatments are generally well-tolerated and may provide some benefit without the risks associated with pharmacological therapies.

Insomnia FAQs

What non-pharmacological treatments are recommended for managing insomnia in older adults?

Recommended non-pharmacological treatments include cognitive behavioural therapy, stimulus control, sleep restriction, relaxation techniques, and sleep hygiene education. These approaches aim to improve sleep patterns without the side effects associated with medications.

Can melatonin be used long-term for managing insomnia in the elderly?

Melatonin can help reduce sleep onset latency and improve sleep quality in some elderly individuals, but there is insufficient evidence to support its use beyond three weeks. Controlled-release melatonin is typically taken 1 to 2 hours before bed, and its long-term safety and efficacy remain under review.

What are the risks associated with using benzodiazepines for insomnia in older adults?

Benzodiazepines can increase the risk of falls, cognitive decline, and dependency. Their efficacy is lost after about two weeks of use, and they should be prescribed cautiously, especially given the heightened risk of adverse effects in the elderly.

Key Takeaways

Insomnia is a common issue among older adults in aged care facilities, characterised by difficulty initiating and maintaining sleep, and it significantly impacts their quality of life and health.
Effective management of insomnia in the elderly includes both psychological/behavioural therapies and pharmacological treatments. Cognitive Behavioral Therapy, stimulus control, sleep restriction, and sleep hygiene are critical non-drug approaches.
While medications like benzodiazepines, Z-drugs, melatonin, and newer options like suvorexant are available, they should be used cautiously due to the potential for adverse effects such as dependency and cognitive decline.
Herbal remedies like valerian and chamomile are considered safe but have limited evidence supporting their effectiveness. They may be useful for some individuals without the risks associated with traditional sleep medications.
It is crucial to balance the benefits of improved sleep against the potential for adverse outcomes, especially in the elderly, who are more susceptible to side effects and complications from sleep medications. Regular monitoring and adjustment of treatment strategies are essential to ensure safety and efficacy.

Summary

Managing insomnia in elderly care requires a comprehensive approach that prioritises safe and effective treatment modalities. Psychological and behavioural therapies like Cognitive Behavioral Therapy and sleep hygiene are the cornerstone of non-pharmacological management.

When medications are necessary, benzodiazepines, Z-drugs, melatonin, and suvorexant should be used with caution due to the potential for adverse effects and dependency. Herbal and complementary medicines may offer additional support without the risks associated with pharmacological treatments.

To effectively address insomnia in the elderly, it is important to balance treatment strategies to enhance sleep quality while minimising potential side effects. Regular medication reviews and adjustments are crucial for optimising outcomes and ensuring the health and well-being of elderly patients in care settings.

If you’re experiencing challenges with managing insomnia in an aged care facility, contact us today to see how we can help.