Insomnia treatment should aim to improve a patient’s 24-hour quality of life, by improving sleep and consequently daytime functioning and health.
Treatment may delay institutionalization, as well as improve the quality of life for the patient’s family. Furthermore, a proper treatment for insomnia has the potential to reverse insomnia-related morbidities, including risk of cardiovascular diseases, depression, falls and accidents1. It may also improve patient productivity, concentration and memory2.
Insomnia Diagnosis The first step in treating insomnia is to identify the underlying causes of it. Sleep disturbances in the elderly may not only be a result of the aging process per se, but can be caused by many other factors, such as medical and psychiatric problems or medications, that are amenable to treatment. Diagnosing insomnia requires keeping a sleep diary for a couple of weeks3 which would indicate the patient’s usual bedtime, time of arising, duration and quantity of sleep each day, use of alcohol, exercise and medications3.
Non-pharmacological Treatment The first line treatment should include the use of behavioural techniques that broadly consist of sleep hygiene, stimulus control, and sleep restriction. These non-pharmacologic interventions4 are simple, low cost and may be effective, while they can be used solely or in combination with medications to improve sleep5. Some treatments may include physiologic interventions such as a daytime walk with correctly timed daylight exposure6, or appropriate temperature control and dark sleep environment.
Pharmacological Treatment Current medications used for insomnia include benzodiazepine- BZD, Z-drugs, melatonin and variants, antidepressants, antipsychotics and antihistamines.
BZD and Z-drugs The most widely prescribed drugs for the treatment of insomnia. Some of these agents are effective for shortening the time of falling asleep and a small portion of them are indicated for both sleep onset and sleep maintenance7 8. Main concerns with these drugs are risks of dependence, daytime residual disturbances, cognitive and psychomotor impairments, falls and accidents9, memory disturbances and dementia10. Thus, the efficacy versus safety profiles of BZD and Z-drug hypnotics has a negative risk-benefit ratio in elderly patients8.
Antipsychotics, antidepressants and antihistamines Sedating antidepressants, antipsychotics and antihistamines are commonly used off label as sleep medications, despite insufficient evidence11. Many clinicians prefer prescribing these medications over hypnotics, because they perceive them as having less risk of dependence and tolerance than traditional hypnotics. Moreover, it was found that these over–the-counter agents may increase the risk of developing dementia and even lead to Alzheimer disease12.
Melatonin and Melatonin receptor agonists Endogenous melatonin levels decrease with age13. This decline may contribute to the common complaint of sleep disturbances including poor sleep quality and difficulties in sleep initiation and maintenance in elderly people14. Therefore, melatonin products are widely used for the treatment of insomnia. Nowadays, there are several food supplements melatonin products available mainly in the US. It is important to differentiate these food supplements from registered prescription melatonin based medicinal drugs.
It is important to recognize that insomnia is not merely a problem with sleep, but rather a 24-hour-a-day problem. As such, it is necessary to choose a treatment that will not only improve sleep parameters, but also enhance daytime functioning.
