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insomnia in the elderly

- also see insomnia & sleep disorders in the elderly Clinical manifestations: 1) difficulty falling asleep, staying asleep, or waking up too early [6] 2) daytime sleepiness, fatigue or poor concentration 3) sleep difficulty must occur at least 3 nights per week & be present for at least 3 months Differential diagnsosis: - age-associated changes in sleep Management: - cognitive behavioral therapy (CBT) & sleep hygiene first-line treatment - more effective than medications for long-term management of insomnia - CBT & sleep hygiene in combination with medication - the choice of a hypnotic agent in the elderly is based on symptoms - sleep-onset insomnia: ramelteon or short-acting Z-drugs - sleep maintenance: suvorexant or low-dose doxepin - both sleep onset & sleep maintenance: eszopiclone or zolpidem extended release - zolpidem not advised due to cognitive & balance problems & risk for fractures [8] - middle-of-the-night awakenings: Low-dose zolpidem sublingual tablets or zaleplon - other - benzodiazepines not for routine use - melatonin slightly improves sleep onset & sleep duration - product quality & efficacy may vary - extended-release melatonin first line in post menopausal women [5] - the American Academy of Sleep Medicine recommends against use of melatonin due to lack of evidence of effectiveness [6] - melatonin should be tried first while awaiting sleep study [6] - low dose doxepin (only FDA-approved antidepressant) [8] - may be small improvement in sleep quality with short-term use [9] - doxepin at lower doses than needed for antidepressant effects is only antidepressant FDA approved for treatment of insomnia [8] - mirtazapine 7.5 mg reduces chronic insomnia symptoms in elderly people [7] - use may be limited by mild but clinically relevant adverse effects - causes daytime sleepiness & reduces sustained attention - cases of REM behavioral sleep disorder have been reported [6] - ramelteon is FDA-approved for treatment of sleep-onset & sleep-maintenance insomnia - American College of Physicians found weak evidence in support of use elderly [6] - trazodone improves sleep quality & sleep continuity, risk considered significant - tryptophan diminishes sleep onset in adults - data in the elderly are not available - valerian is safe but benefits on sleep quality are equivocal - dual orexin receptor antagonist lemborexant may improve sleep maintenance & sleep continuity - oral magnesium < 1 g up to 3 times/day may be of benefit [3] - tiagabine is not effective

General

insomnia sleep disorders in the elderly

References

  1. Patel D, Steinberg J, Patel P. Insomnia in the Elderly: A Review. J Clin Sleep Med. 2018 Jun 15;14(6):1017-1024. PMID: 29852897 PMCID: PMC5991956 Free PMC article. Review.
  2. Abad VC, Guilleminault C. Insomnia in Elderly Patients: Recommendations for Pharmacological Management. Drugs Aging. 2018 Sep;35(9):791-817. doi: 10.1007/s40266-018-0569-8. PMID: 30058034 Review.
  3. Mah J, Pitre T Oral magnesium supplementation for insomnia in older adults: a Systematic Review & Meta-Analysis. BMC Complement Med Ther. 2021 Apr 17;21(1):125. PMID: 33865376 PMCID: PMC8053283 Free PMC article.
  4. Brewster GS, Riegel B, Gehrman PR. Insomnia in the Older Adult. Sleep Med Clin. 2022 Jun;17(2):233-239. PMID: 35659076 Review. - Brewster GS, Riegel B, Gehrman PR. Insomnia in the Older Adult. Sleep Med Clin. 2018 Mar;13(1):13-19. PMID: 29412980 PMCID: PMC5847293 Free PMC article. Review.
  5. Proserpio P, Marra S, Campana C Insomnia and menopause: a narrative review on mechanisms and treatments. Climacteric. 2020 Dec;23(6):539-549. PMID: 32880197 Review.
  6. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - Geriatric Review Syllabus (GRS12) Colburn JL, Westcott AM, Potter JF (eds) American Geriatrics Society. 2025
  7. Nguyen PV, Dang-Vu TT, Forest G, et al. Mirtazapine for chronic insomnia in older adults: a randomised double-blind placebo-controlled trial-the MIRAGE study. Age Ageing. 2025 Mar 3;54(3):afaf050. PMID: 40135470
  8. Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  9. Everitt H. Baldwin DS, Stuart B et al Antidepressants for insomnia in adults. Cochrane Database Syst Rev. 2018 May 14;5:CD010753 PMID: 29761479 http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD010753.pub2/abstract