INSOMNIA IN THE ELDERLY: EVALUATION AND MANAGEMENT

ABSTRACT

@#Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75 percent of adults >65 years of age has sleep disturbance and 30 percent of themhas insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significantoverlap and usually treatment of the underlying disorder doesnot solve the problem or cure it. The elderly has multiplecomorbidities and poly pharmacy with a myriad of cause forinsomnia. A comprehensive medical and psychiatric historytogether with a complete physical examination and mentalstate examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene educationshould be the initial treatment together with the treatmentof the contributing physical and psychiatric conditions.Referral to an expert for cognitive behavioural therapy ormulticomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are neededit can be combined with behavioural therapy. Medication usedshould be the lowest effective dose and prescribed for short-term use of not more than four weeks. Medications used needto be discontinued gradually and one needs to be mindfulof rebound insomnia upon withdrawal. Whenever possible,it will be ideal to avoid benzodiazepines and other sedativehypnotics as first choice for insomnia. Over the counter sleepaids which usually contain antihistamines may not be goodchoices as they carry significant risk of adverse events and druginteractions. Currently the safest medications for use in theelderly includes the Z-drugs (zolpidem, zopiclone), melatoninand low dose tricyclic antidepressant Doxepin.