Research has shown that the prevalence of insomnia increases with age. The appropriate treatment of insomnia in older patients can be challenging for several reasons, including the prevalence of comorbid conditions, increased use of a variety of medications (especially central nervous system active compounds), and a compromised ability to metabolize and/or excrete these medications. This compromised function has typically resulted in lower recommended doses for many therapies, especially for hypnotic agents for which starting doses for the elderly are often half or less than those for adults. The purpose of using lower doses is to minimize adverse events (eg, amnestic effects or residual sedation) and thereby maximize daytime functioning and patient safety.
“Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly.”
An important consideration for safety in the elderly population is the risk for falls and fall-related injuries. A recent article by Frey et al in the Journal of the American Geriatrics Society evaluated the effect of sleep inertia on balance and cognition during nighttime awakenings in both adults and the elderly. The authors found that zolpidem produced clinically significant balance and cognitive impairments upon awakening from sleep. However, the study did not directly evaluate the incidence of falls; instead, it used the results of performance on tandem walking as a predictor of falls. These tandem walks occurred 120 minutes after a scheduled sleep opportunity and, thus, were designed to test the effects of zolpidem and sleep inertia in the first half of the night when those effects would be greatest. While the study is methodologically sound, it should be noted that the study did not involve insomniacs, nor did it model the typical behavior of patients taking zolpidem for insomnia.
Considerations for Insomnia Treatment
Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly. Medication-related impairments in the elderly may be longer lasting than those of other adults. They may also be dose-dependent. Furthermore, the degree of impairment can correlate strongly with plasma concentrations and is likely to be greatest at peak concentrations. There may also be a synergistic effect with co-administration of hypnotics and alcohol or psychoactive drugs.
We have considerable evidence that hypnotic drugs can impair balance and contribute to falls, but untreated sleep problems are also an independent risk factor for falls. Research indicates that patients with untreated or inadequately treated insomnia have a higher risk for falls than those who use hypnotics but do not have insomnia. Clinicians should keep these considerations in mind when managing older patients with insomnia.
Therapeutic Options Emerging for Insomnia
With the advent of non-benzodiazepine sedative hypnotics, several effective treatment options have become available for the treatment of insomnia in the elderly. Data support the efficacy and safety of zaleplon, zolpidem, eszopiclone, and ramelteon in elderly populations. Recently, low-dose (3 mg and 6 mg) doxepin was approved by the FDA for the treatment of sleep maintenance insomnia. A difference from other insomnia medications is that low-dose doxepin does not appear to inhibit arousal systems or have significant anticholinergic effects, memory effects, or next-day residual effects. Phase III trials on elderly populations have not found significant effects on falls or cognition, and there is hope that this might translate into a reduced risk of falls in elderly patients with insomnia.
Walsh JK, Roth T. Pharmacologic treatment of insomnia: benzodiazepine receptor agonists, in Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Elsevier, St. Louis, MO. 2011:905-915.
Frey DJ, Ortega JD, Wiseman C, et al. Influence of zolpidem and sleep inertia on balance and cognition during nighttime awakening: a randomized placebo-controlled trial. J Amer Ger Soc. 2011;59:73-81.
Mets MAJ, Volkerts ER, Olivier J, et al. Effect of hypnotic drugs on body balance and standing steadiness. Sleep Med Rev. 2010;14:259-267.
Lankford A. Low-dose doxepin (3 and 6 mg) for the treatment of insomnia. Future Neuro. 2011; in press.
Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry. 1997;154:1417-1423.
Avidan AY, Fries BE, James ML, et al. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc. 2005;53:955-962.