INSOMNIA IN THE ELDERLY
Insomnia in the Elderly: Assessment and
Management in a Primary Care Setting
Case Study and Commentary, Rhonda Wroble, PharmD, Becky A. Nagle, PharmD, Lisa A. Cataldi, MPH, and
Mark Monane, MD, MS
INTRODUCTION
I
nsomnia is a common problem in the elderly [1–3]. Pop-
ulation-based surveys reveal that up to 40% of people
aged 65 years and older are dissatisfied with their sleep or
report trouble sleeping. Twelve percent to 25% of these
patients complain of persistent insomnia [4]. Overall, it is esti-
mated that up to one third of patients seen in the primary care
setting experience occasional difficulties with sleep.
In the United States, the elderly make up 13% of the total
population but receive 35% to 40% of the prescriptions writ-
ten for sedative hypnotics [5]. Hypnotic medications are the
primary agents used in the short-term management of
insomnia. Older persons are prescribed hypnotics at twice
the rate of younger persons and are more likely to be long-
term (> 1 year) users of hypnotic agents [5].
Insomnia and the chronic use of sedating medications
cause accidents, loss of productivity, increased morbidity
and mortality, greater utilization of health care, alcohol
abuse, and depression [6,7]. The National Highway Traffic
Safety Administration estimates that 56,000 crashes per year
are the result of persons falling asleep at the wheel [8,9]. In
persons with dementia, sleep disruption can lead to nursing
home placement [8]. The use of certain hypnotics (long-
acting benzodiazepines), cyclic antidepressants, and anti-
psychotics have been shown to increase the rate of hip frac-
ture in the elderly [10–12].
Direct costs (eg, doctors visits, medication) as well as in-
direct costs (eg, injury due to hip fracture, lost productivity)
contribute to the economic burden associated with insom-
nia. The annual cost of insomnia in the United States has
been conservatively estimated at $92.5 to $107.5 billion [7].
When compared with the direct and indirect costs of heart
disease and stroke ($259 billion) [13]or asthma ($11.3 billion)
[14], the costs of insomnia are extraordinary.
Insomnia is rarely the primary reason patients schedule
office visits [6]; only 5% of the estimated 65 million
Americans who have insomnia present to their physicians
with an insomnia complaint [15,16]. In light of the multiple
adverse clinical, economic, and quality-of-life outcomes seen
with this disorder, it is important for primary care physicians
50 JCOM March 2000
to be able to detect and effectively manage insomnia in their
elderly patients.
CASE STUDY
Initial Presentation
A 77-year-old woman presents to her primary care
physician complaining of an inability to sleep and
requests a “sleeping pill.”
History
The patient’s chief complaint centers on her inability to stay
asleep. She states that she usually falls asleep within a half-
hour after going to bed but wakes up 2 hours later and can-
not fall back to sleep. She makes frequent trips to the bath-
room during the night. In the morning, she feels as if she “has
not slept at all.” She has had this problem for at least
2 months. She self-medicates with diphenhydramine 25 mg
as needed at bedtime for the management of her sleep com-
plaints. The patient has a history of hypertension, and her
current medications are furosemide 40 mg/day and atenolol
50 mg/day. She considers her diet “normal” but drinks 1 to
2 cups of coffee in the morning and 1 to 2 cups of herbal tea
“for relaxation” in the evening. Her husband says that the tea
provokes irritation rather than relaxation. She quit smoking
25 years ago and denies any substance use. She lives at home
with her spouse of 50 years.
Physical Examination
Physical examination is essentially unremarkable. Blood pres-
sure is 140/85 mm Hg and pulse is 70 bpm. There is no evi-
dence of pulmonary congestion, but pedal edema is noted.
Rhonda Wroble, PharmD, Managed Care Resident, Departments of
Medical Affairs and Pharmacy Relations, Merck-Medco Managed
Care, L.L.C., Franklin Lakes, NJ; Becky A. Nagle, PharmD, Director,
Clinical Pharmacy and Education, Merck-Medco Managed Care,
L.L.C.; Lisa A. Cataldi, MPH, Research Program Manager, Depart-
ment of Medical Affairs, Merck-Medco Managed Care, L.L.C.; and
Mark Monane, MD, MS, Senior Director, Geriatrics, Department of
Medical Affairs, Merck-Medco Managed Care, L.L.C.
Vol. 7, No. 3
 CASE-BASED REVIEW

Table 1. Conditions Associated with Chronic Insomnia

• How is insomnia defined and classified? Psychiatric disorders
Anxiety
Mood disorders
Insomnia is defined by the National Institutes of Health as an
Medical/neurologic disorders
experience of inadequate or poor quality of sleep character-
Osteoarthritis
ized by difficulty falling asleep, difficulty maintaining sleep,
Medication or substance use
waking up too early in the morning, or nonrefreshing sleep.
Certain hypertensives
The daytime consequences of insomnia include tiredness,
Decongestants
lack of energy, difficulty concentrating, and irritability [6].
Diuretics
Insomnia can be either acute or chronic. Acute insomnia
Caffeine (eg, coffee, tea, soft drinks, chocolate)
is characterized by periods of sleep difficulty lasting be-
Nicotine
tween 1 night and a few weeks. Emotional or physical dis-
Stimulants
comfort, disruptions in daily biological rhythms, or acute ill-
Specific sleep disorders
ness are causative factors. Chronic insomnia refers to sleep
Circadian rhythm sleep disorders
difficulty at least 3 nights per week lasting longer than
Obstructive sleep apnea
1 month. Chronic insomnia can be caused by multiple fac-
Periodic limb movement disorder
tors acting singly or in combination and often occurs in con-
Restless legs syndrome
junction with other health problems.
Primary insomnia

Adapted from Insomnia: assessment and management in primary care.

National Heart, Lung, and Blood Institute Working Group on Insomnia.
• What factors may be contributing to this patient’s
Am Fam Physician 1999;59:3029–38.
insomnia?

Insomnia can be associated with a number of psychiatric,
medical, and neurologic disorders (Table 1). Mood and anx-
iety disorders are the most common psychiatric diagnoses
associated with insomnia [17,18]. Medication and substance
use may contribute to difficulty sleeping. In addition, sleep
disorders such as restless legs syndrome, periodic limb
movement disorder, and sleep apnea can interfere with
sleep. Management strategies should be directed toward
identifying and treating the underlying condition. When
other causes of insomnia are ruled out or treated, primary
insomnia may account for difficulty with sleep. Chronic
stress, hyperarousal, poor sleep hygiene, and behavioral
conditioning may be factors contributing to primary insom-
nia [6]. Napping during the day can exacerbate insomnia by
reducing the ability to fall asleep at the “usual” bedtime [9].
Insomnia is not a normal consequence of aging; however,
sleep patterns do change over a person’s lifetime. In older
individuals, the sleep-wake cycle may be fragmented and
the deepest stages of non-REM (rapid eye movement) sleep
are reduced or nonexistent, resulting in more frequent night-
time arousals and awakenings. REM sleep seems to be pre-
served. In elderly persons, there is a shift in circadian rhythm
that may cause disruptions in the desired sleep-wake cycle.
Older people tend to fall asleep earlier in the evening and
awaken earlier in the morning (advanced sleep phase syn-
drome). This may or may not be a source of patient com-
plaint. Although sleep efficiency (the ratio of time spent
sleeping to total time spent in bed) is lower in elderly com-
pared with younger persons, it should not be assumed the
elderly require less sleep.
• What questions can help identify and characterize
sleep problems?
Following a complaint of insomnia, patients should be asked
about specific sleep/wake habits and activities. Some exam-
ple questions that can be asked during a sleep history are
shown in Table 2. Information may also be gleaned from
questioning family members. Patients should further be
instructed to keep a sleep diary for 1 to 2 weeks. In addition
to providing a useful account of the patient’s symptoms and
activities, the diary may serve as a baseline for assessment of
treatment effects [6]. A sample sleep diary form is shown in
the Figure.
Often, patients underestimate their own degree of sleep
difficulty. Therefore, incorporating a question about sleep
into the review of systems (eg, “Do you have any difficulty
initiating or maintaining sleep?”) may be helpful in identify-
ing older patients with insomnia.
Sleep studies are not used routinely in the evaluation of
insomnia but may be indicated in the elderly patient if
the patient has excessive daytime sleepiness or to rule out

Vol. 7, No. 3 JCOM March 2000 51

 INSOMNIA IN THE ELDERLY
Table 2. Sample Questions to Identify Problem Sleepiness in
Patients
Ask the patient about signs of excessive sleepiness:
Does the patient report dozing off or having difficulty staying awake
during routine tasks, especially while driving?
Does the patient complain of having difficulties or accidents at work,
school, social activities, or home because of poor attention span?
Does the patient complain of sleepiness or of getting nonrefreshing
sleep, or is the patient’s sleepiness frequently noted by others?
Does the patient nap on most days or more often than once a day?
Ask the patient about signs of sleep disorders:
Does it take the patient more than 30 minutes to fall asleep at night?
Are there awakenings during the night? Is there unwanted early
morning waking? (insomnia)
Does the bed partner report that the patient’s legs or arms jerk during
sleep? (periodic limb movement disorder)
Does the patient report “creeping, crawling feelings” in the legs?
(restless legs syndrome)
Does the patient (or bed partner) complain of loud snoring, gasping,
choking, or stopping breathing during sleep? (obstructive sleep
apnea)
Does the patient (or family) describe cataplexy (sudden muscle weak-
ness in response to emotional reactions), hypnagogic hallucinations
(vivid, dreamlike experiences while falling asleep or dozing) or
sleep paralysis (temporary inability to talk or move when falling
asleep or awakening)? (narcolepsy)
Ask the patient about the quantity and quality of sleep:
What are the work hours? Is the patient a shift worker?
At what time does the patient get up and go to bed on weekdays and
weekends?
Does the patient use caffeine, tobacco, alcohol, or over-the-counter
and prescription medications?
Is the sleep environment conducive to sleep in terms of noise, interrup-
tions, temperature, and light?
Does the patient have a medical condition, chronic pain, or other
such cause of sleep difficulties?
Adapted from Recognizing problem sleepiness in your patients.
National Center on Sleep Disorders Research Working Group. Am Fam
Physician 1999;54:941.
breathing-related sleep disorders, periodic limb movement
disorder, or narcolepsy [19].
Additional History
The physician inquires about symptoms of depres-
sion, anxiety, and specific sleep disorders. No
underlying psychiatric or sleep disorders are identified.
• What are management strategies for patients with
insomnia?
52 JCOM March 2000
The need for treatment is usually determined by the severity
of daytime symptoms, duration of insomnia, and predictabil-
ity of the episodes. Chronic insomnia often has a multifactor-
ial etiology and therefore may require more than one treat-
ment modality. Pharmacologic therapy usually predominates;
however, nonpharmacologic therapy has also been shown to
improve symptoms. A meta-analysis by Morin et al [4] exam-
ined the effect and durability of nonpharmacologic treatments
for the clinical management of chronic insomnia. The non-
pharmacologic interventions produced reliable and durable
changes in sleep patterns, and results were maintained at
follow-up averaging 6 months in duration. In a 1999 random-
ized controlled trial [20], a combination of behavioral therapy
and pharmacotherapy was effective for short-term manage-
ment of insomnia late in life. However, sleep improvements
were better sustained over time with behavioral therapy
alone. Furthermore, behavioral treatment, either alone or
combined, was rated more effective than pharmacotherapy
by subjects, their significant others, and clinicians.
Nonpharmacologic Therapy
Sleep Hygiene Education
Sleep hygiene education primarily focuses on identifying and
modifying lifestyle behaviors and environmental factors that
affect sleep. Sleep hygiene education should be incorporated
into all treatment modalities when treating an elderly patient
[4]. Good sleep hygiene measures are listed in Table 3.
Stimulus Control Therapy
Stimulus control therapy is based on the premise that insom-
nia is a conditioned response to temporal and environmen-
tal cues usually associated with sleep. The main objective of
stimulus control therapy is to reassociate the bed and bed-
room with rapid sleep onset. Stimulus control therapy in-
cludes:
• Going to bed only when sleepy
• Leaving the bed and going into another room when
unable to fall asleep and returning only when sleep is
imminent
• Arising at the same time every morning regardless of
the amount of sleep obtained
• Reserving the bed and bedroom for sleep and sexual
activities
• Minimizing daytime napping
Elderly patients may be reluctant to follow all the instruc-
tions involved in stimulus control therapy. For example, a
patient may worry about falling when getting out of bed.
Participating in an activity after they get out of bed (eg, read-
ing) will help patients take their mind off their sleep problem.
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 CASE-BASED REVIEW

SLEEP DIARY

Name

EXAMPLE

Date Monday
4/10

Bed time (previous night) 10:45 P.M.

Rise time 7:00 A.M.

Complete in AM

Estimated time to fall asleep 30 minutes

(previous night)

Estimated number of awakenings 5 times

and total time awake (previous night) 2 hours

Estimated amount of sleep obtained 4 hours

(previous night)

Naps 3:30
(time and duration) 45 minutes

Alcoholic drinks 1 drink

(number and time) at 8:00 P.M.

List stresses experienced today Flat tire

Complete in PM

Argued w/son

Rate how you felt today

1. Very tired/sleepy
2. Somewhat tired/sleepy 2
3. Fairly alert
4. Wide awake

Irritability
1 = not at all; 5 = very 5

Medications

Figure. Sample sleep diary. Adapted from Insomnia: assessment and management in primary care. National Heart, Lung, and Blood
Institute Working Group on Insomnia. Am Fam Physician 1999;59:3029–38.

Vol. 7, No. 3 JCOM March 2000 53

 INSOMNIA IN THE ELDERLY
Table 3. Sleep Hygiene Measures
Refrain from using caffeine or nicotine 4 to 6 hours prior to bedtime
Abstain from alcohol around bedtime (produces a lighter and more
fragmented sleep)
Avoid large meals or liquids in the evening to decrease nocturia
Avoid strenuous exercise close to bedtime
Minimize noise, light, and excessive temperature in the sleeping area
Sleep Restriction Therapy
Sleep restriction therapy may help insomniacs by consoli-
dating sleep and creating sleep efficiency. Individuals are
instructed to decrease the amount of time they spend in bed.
Initially, the time allowed sleeping is obtained by averaging
the amount of time spent sleeping for 1 week. Weekly adjust-
ments are made in 15- to 20-minute increments depending
on the sleep efficiency for that week. If the patient exceeds
90% efficiency, the time spent in bed is increased. If the
patient falls below 80% efficiency, the time spent in bed is
decreased. One study demonstrated that sleep restriction
therapy improved sleep efficiency in as little as 1 week in
some patients [21]. Fatigue and sleepiness is likely seen in
early treatment; however, changes in sleep are well main-
tained in the future.
Relaxation Therapy
Relaxation therapy is an approach to treating insomnia
based on the observation that hyperarousal interferes with
sleep. It is the most common nonpharmacologic treatment
for insomnia. Progressive muscle relaxation, autogenic train-
ing, and imagery training or meditation are examples of
methods used. Stimulus control and sleep restriction thera-
py may be more effective than relaxation therapy [22]. Older
adults may find relaxation therapy difficult. Although not a
good candidate for first-line therapy in this population, it
may serve as a useful adjunct.
Exercise
Regular aerobic exercise has been shown to deepen sleep [6].
In a study of older adults with moderate sleep complaints,
regular moderate-intensity exercise was beneficial for im-
proving subjective quality of sleep [23]. More controlled
studies are needed to determine whether or not exercise
improves insomnia in the elderly.
Light Therapy
Many practitioners are beginning to use or recommend light
therapy for their elderly patients with insomnia. Various
studies indicate light therapy may improve sleep efficacy,
sleep quality, insomnia due to delayed sleep phase syn-
drome (difficulty falling asleep and difficulty waking at
54 JCOM March 2000
desired times), and insomnia due to advanced sleep phase
syndrome (difficult staying awake and waking too early)
[24–26]. However, specific recommendations on light thera-
py are rapidly changing, and current literature should be
consulted for specific treatment guidelines for elderly pa-
tients with insomnia.
Pharmacotherapy
Hypnotic Agents
The primary indication for hypnotic medication use is for
the short-term treatment of insomnia, alone or as an adjunct
agent. The most common hypnotics used in the treatment of
insomnia are benzodiazepines. In general, benzodiazepines
shorten sleep latency (time it takes to fall asleep), reduce the
number and duration of nighttime awakenings, and increase
total sleep time. Benzodiazepines also prolong latency to
REM sleep, decrease REM sleep, and disrupt deep sleep
stages. Estimates indicate that 15% of patients using benzo-
diazepines take them for longer than 1 year. No studies have
shown the benefit of long-term benzodiazepine use, and few
studies have evaluated the safety and efficacy of use longer
than a few months [6].
Benzodiazepines are classified according to their half-life
and duration of action [5,27,28]. The prototypical short-acting
benzodiazepine, triazolam, has rapid therapeutic effects and
a decreased adverse effect profile versus the longer-acting
agents. Triazolam has a half-life of approximately 2 to 6 hours,
has clinically significant metabolites, and is rapidly absorbed.
However, this medication has been associated with severe
rebound insomnia [5], and its short action may not be optimal
for treating early morning awakenings seen in the elderly
population. Temazepam is the prototypical intermediate-
acting benzodiazepine, with a half-life of approximately 10 to
17 hours. It is absorbed quickly and reaches a peak plasma
concentration in 2 hours. It is metabolized by the conjugation
(phase II metabolism) pathway and has no clinically signifi-
cant active metabolites [5,29,30]. Because the intermediate-
acting benzodiazepines (temazepam, estazolam, alprazolam,
oxazepam, lorazepam, halazepam, chlordiazepoxide) have a
slower onset of action and a longer elimination half-life than
the shorter-acting agents, caution is necessary when prescrib-
ing these agents. Long-acting benzodiazepines (diazepam,
flurazepam, clonazepam, quazepam) have a slower onset
than both the short- and intermediate-acting agents. They
have high lipid solubility, a large volume of distribution,
active metabolites, and a long half-life (> 24 hours) that caus-
es accumulation resulting in daytime somnolence, confusion,
and an increased risk of hip fractures [10,11]. These agents
should be avoided in the elderly.
The most common adverse effects associated with the use
of benzodiazepines in the elderly include residual daytime
sedation, decreased mental acuity, coordination impairment,
Vol. 7, No. 3

decreases in occupational efficiency, and increased risk of
accidents. Rebound insomnia and anterograde amnesia are
also seen [29–31]. Residual daytime sedation (the most com-
mon adverse effect associated with benzodiazepine use) is
related to the agent’s half-life and duration of action and is
also associated with impaired daytime functioning. The long-
acting benzodiazepines cause the most residual daytime
sedation, and the short-acting agents are more likely to result
in rebound insomnia, daytime anxiety, and withdrawal
symptoms upon abrupt discontinuation with long-term use.
Very short-acting agents such as triazolam cause anterograde
amnesia and withdrawal symptoms more often than longer-
acting agents [5]. The withdrawal symptoms seen upon
abrupt discontinuation of moderate doses include anxiety or
agitation, an increased sensitivity to light and sound, pares-
thesias, muscle cramps, myoclonic jerks, sleep disturbances,
or dizziness. Seizures may be seen following discontinuation
of high-dose regimens [32]. To minimize symptoms, benzo-
diazepine should be tapered gradually over a period of time
depending on the agent and its duration of use.
The benzodiazepines cause respiratory depression and
should be avoided in suspected or established sleep apnea or
chronic obstructive pulmonary disease [27]. Concomitant
use of itraconazole, ketoconazole, nefazodone, or any agent
that impairs the oxidative metabolism of the benzodi-
azepines mediated by cytochrome P-450 3A4 (ie, fluoxetine,
fluvoxamine, ranitidine, cimetidine, and isoniazid) should
be avoided. Furthermore, when administered with mono-
amine oxidase inhibitors, the sedating effects of benzodi-
azepines may be potentiated or life-threatening. Their use
should be separated by at least 2 weeks. The consumption of
alcohol should also be avoided while using the benzodi-
azepines [29,30].
Nonbenzodiazepine Hypnotics
Zolpidem. Zolpidem is a nonbenzodiazepine imidazopyri-
dine hypnotic lacking any muscle relaxant, anxiolytic, and
anticonvulsant properties. The half-life of this short-acting
agent is 1.5 to 2.4 hours, with a rapid onset of action of
2 hours following oral ingestion, and is without active
metabolites. In the elderly, the half-life is prolonged to
2.5 hours, requiring a decrease in dosage when used in this
population [33]. Zolpidem is absent of tolerance or with-
drawal symptoms, and it lacks respiratory suppressant
activity in patients with pulmonary disease. Furthermore, it
induces a sleep pattern similar to physiologic sleep [33].
Zolpidem also appears to lack any associated daytime
sleepiness (study results may be inconsistent) or effects on
memory. It is well tolerated, but adverse reactions such as
dizziness or lightheadedness, somnolence, gastrointestinal
upset, and pain have been observed [21]. Confusion and falls
also have been reported while using zolpidem. The extent of
Vol. 7, No. 3
CASE-BASED REVIEW
adverse effects is dose-related and occurs at a higher fre-
quency in patients older than 65 years using nightly doses
more than 5 mg. Its use should be cautioned in patients with
hepatic or renal disease. Alcohol potentiates the effects of
zolpidem but lacks any other significant drug-drug interac-
tions. When switching a patient to zolpidem from a benzo-
diazepine, it is advisable to taper the benzodiazepine over
1 to 2 weeks and include a washout period of 2 to 3 days
before beginning zolpidem [5,31].
Zaleplon. Zaleplon belongs to a novel new class of sedatives
unrelated to any other hypnotic agent on the market, the
pyrazolopyrimidines. It was approved by the U.S. Food and
Drug Administration (FDA) in August 1999 and is indicated
for short-term treatment of insomnia in adults, including
elderly patients. Studies show that it binds selectively to
the GABAA receptor complex and potentiates t-butyl-
bicylophosphorothionate binding. Zaleplon is rapidly ab-
sorbed, with a terminal half-life of approximately 1 hour,
and does not accumulate with once-daily dosing. After oral
administration, zaleplon is extensively metabolized without
any active metabolites. In the elderly, the pharmacokinetics
are not significantly different; however, the dose should be
reduced in patients with mild to moderate hepatic impair-
ment and avoided in those with severe impairment [34].
Memory impairment, sedative/psychomotor effects,
withdrawal-emergent anxiety and insomnia, and other
withdrawal-emergent phenomena while using zaleplon
have been studied during clinical trials. In normal subjects,
memory impairment and sedative/psychomotor effects
were not present at 2 hours in one study and in none of the
studies at 3 to 4 hours. No increase in withdrawal-emergent
daytime anxiety was detected. When using 5- or 10-mg
doses, zaleplon had minimal subjective and no objective evi-
dence of rebound insomnia after the first night following dis-
continuation. But when using the 20-mg doses, both subjec-
tive and objective rebound insomnia occurred on the first
night following discontinuation. Furthermore, rebound in-
somnia apparently resolved by the second night following
withdrawal [34].
Antidepressants
The National Heart, Lung, and Blood Institute Working
Group on Insomnia concluded that little data are available to
recommend the use of antidepressants for insomnia in non-
depressed patients [6]. But when prescribed for patients with
major depression, sedating antidepressants (eg, amitripty-
line, doxepin, imipramine) improved subjective and objec-
tive measures of insomnia, and the sleep symptoms of
depression improved more quickly than other symptoms
[35]. Antidepressants cause anticholinergic side effects (ie,
constipation, blurred vision, nausea, dryness of the mouth,
JCOM March 2000 55
 INSOMNIA IN THE ELDERLY
TECHNOLOGY IN THE TREATMENT
OF INSOMNIA: PARTNERS FOR
HEALTHY AGING ®
S ystematic, computerized approaches to improv-
ing pharmacy care may be an effective way to
reduce potentially inappropriate medication use, in-
cluding medication use for the treatment of insomnia.
The Partners for Healthy Aging® program developed
by Merck-Medco Managed Care, L.L.C., for example,
uses a computerized drug utilization review database
linked to a telepharmacy intervention to improve
medication use in the elderly. An independent med-
ical advisory board consisting of geriatric specialists in
pharmacy, medicine, and nursing developed a set of
criteria addressing age-related, drug-related, and
disease-related recommendations. When a prescrip-
tion is written, a concurrent review applies the criteria
to the patient’s prescription and medical history. The
physician and pharmacist are alerted if there is any
potentially inappropriate prescribing, and recommen-
dations for appropriate agents are made [37]. The pro-
gram has helped to improve prescribing patterns and
quality of care in the community-based geriatric pop-
ulation [38].
confusion), cardiac toxicity, orthostatic hypertension, and
sexual dysfunction (selective serotonin reuptake inhibitors
[SSRIs]). In some individuals, tricyclic antidepressants (eg,
amitriptyline, desipramine) and SSRIs can exacerbate rest-
less leg syndrome and periodic limb movement disorder [6].
The use of antidepressants in the treatment of insomnia
should be reserved for individuals with concomitant depres-
sion or other psychiatric disorders.
Antihistamines
Antihistamines are known to have sedative effects, but they
also cause daytime sedation, cognitive impairment, and anti-
cholinergic side effects. The elderly are especially susceptible
to these undesirable effects; therefore, the use of antihista-
mines in this population should be avoided.
Melatonin
Melatonin plays an important role in the regulation of the
sleep/wake cycle in humans [36]. It is released by the pineal
gland in a higher concentration at night, and changes in its
secretion cycle are associated with sleep disturbances in
older individuals [36]. Elderly patients with insomnia who
56 JCOM March 2000
are deficient in melatonin and have been administered a
sustained-release or fast-release formulation generally have
improved initiation and maintenance of sleep. Sustained-
release products are indicated for the individual who has dif-
ficulties maintaining sleep, while the fast-release formula-
tions improve sleep initiation. Melatonin therapy decreased
sleep latency and/or increased sleep efficiency and wake
time after sleep onset. In one study, pruritus was reported
but resolved spontaneously. Tolerance may not develop, but
sleep quality may diminish when melatonin therapy is dis-
continued. Melatonin may also play a role in assisting chron-
ic benzodiazepine users discontinue their use [36]. The FDA
has not approved melatonin; therefore, the safety and purity
can not be ensured. Furthermore, the use of melatonin to
treat insomnia is still under investigation and for now its use
should be cautioned.
Other Agents
Older drugs such as chloral hydrate, methyprylon, and
meprobamate are not recommended for treatment of insom-
nia because of their narrow therapeutic ratio, rapid develop-
ment of tolerance, high potential for abuse, and complica-
tions associated with withdrawal [6]. One review article
concluded that valerian (Valeriana officinalis), a popular
herbal product, may be useful in alleviating mild, short-term
insomnia [31]. However, further clinical trials are required to
evaluate the safety and efficacy of this over-the-counter
agent, and its use should be cautioned until more evidence
is available on its role in insomnia in the elderly.
• What are caveats in selecting therapy for elderly pa-
tients with insomnia?
Prescribing in the Elderly
The physiologic changes of aging include increased adipose
tissue and reduced total body water, lean body mass, con-
centration of plasma proteins, number of functioning hepa-
tocytes, liver mass, renal function, and renal plasma flow.
The clinical effect of these changes varies according to the
physical properties of the drug prescribed. When an elderly
person is using an agent that is metabolized through
processes in the liver, the half-life of the agent may be
increased. It is also important to recognize that the lipophilic-
ity and active metabolites of these agents greatly contribute
to their effects in the elderly (ie, prolonged duration of activ-
ity, accumulation, and/or increases in adverse effects).
Therefore, it is important for practitioners to review the
pharmacokinetic and pharmacodynamic changes that occur
Vol. 7, No. 3

in the elderly when choosing therapy. For example, the risk
of hip fracture increases substantially when using benzodi-
azepines with a longer half-life compared with short-
acting agents and when using doses too large for this popu-
lation [11,39].
Treatment
The physician tells the patient that several factors
may be contributing to her insomnia. The patient
has been self-medicating with an over-the-counter sleeping
agent, drinks 2 cups of herbal tea in the evening, and has
been taking her diuretic at dinnertime. The patient is advised
to check to see whether the tea contains caffeine and, if it
does, to switch to a caffeine-free variety. She is advised to
take her diuretic early in the morning to reduce the number
of nighttime bathroom trips. In addition, the patient is edu-
cated about sleep hygiene measures and is told to stop tak-
ing over-the-counter products for her sleeping difficulties.
No pharmacologic therapy is prescribed.
Six Months Later
At a follow-up visit 6 months later, the patient
reports that she is sleeping much better. She states
that she wakes much less frequently during the night, if at all,
and in the morning feels well-rested and ready for a new day.
Summary
Insomnia is a common problem in the elderly. Chronic insom-
nia is usually multifactorial in nature. First-line management
should be directed at identifying and treating the underlying
problem. The decision to treat an elderly patient with phar-
macologic therapy must be carefully evaluated. Dosing reduc-
tions are necessary to avoid any adverse drug or long-term
consequences and to minimize rebound insomnia in patients
who undergo drug tapering. When drug therapy is used,
short-term use is recommended. Many patients prefer and do
better on nonpharmacologic therapy; employing a non-drug
approach should initially be attempted.
Authors’ address: Merck-Medco Managed Care, L.L.C., 100
Parsons Pond Dr., Franklin Lakes, NJ 07417.
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