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Insomnia affects many older adults, needs to be treated

Tuesday, May 08 2007 | Comments
Evidence Grade 0 What's This?
Insomnia is a significant problem in older adults and should be treated to avoid the harmful consequences of the disorder.

According to Dr. Daniel Buysse, professor of psychiatry at the University of Pittsburgh School of Medicine, it is only recently that insomnia has become recognized as its own disorder rather than as a symptom of another disease. When physicians thought of insomnia as merely a symptom of a chronic disease, they focused on treating the other illness, and the insomnia never actually went away. In the new model of thinking, insomnia is seen as its own comorbid disorder.

"The best part to viewing it this way is that it gives us both permission and almost the imperative to address the insomnia as well as the other conditions," Dr. Buysse said.

Untreated insomnia is associated with everything from memory problems and difficulty concentrating to an increased risk of falls and fractures, Dr. Buysse noted; the risk of falls and fractures, he added, is particularly important in an older population.

Sonia Ancoli-Israel, professor of psychiatry at the University of California San Diego School of Medicine, noted that many of the consequences of insomnia could be misinterpreted as dementia in older patients. Although disturbed sleep causes difficulty in sustaining attention, slowed response times, and difficulty with memory in adults of all ages, physicians sometimes assume these are symptoms of dementia when they are dealing with older adults. Ancoli-Israel pointed out that insomnia and dementia can be comorbid conditions as well; if this is the case, both disorders should be treated.

Treating insomnia can be done behaviorally or pharmacologically, but either way, it should be done, the presenters agreed. Dr. Buysse said he likes to start his patients with a set of behavioral prescriptions designed to improve the quality of nocturnal sleep. He noted, however, that patients must be involved in this process and willing to change  their behaviors for this method to work.

For the brief behavioral treatment of insomnia (BBTI), Dr. Buysse suggested that physicians restrict patients' time in bed, establish a regular wake-up time, tell patients to go to bed only when they are tired, and tell them to stay in bed only when they are asleep. For a typical BBTI prescription, Dr. Buysse asks patients about their current bedtime, wake-up time, total time spent in bed, sleep latency, and wake after sleep onset. He then establishes how much time is spent sleeping and how much time is spent awake in bed.

Dr. Buysse then gives patients a bedtime and wake-up time that will allow them to be in bed for only the number of hours they are actually sleeping plus an additional 30 minutes. By going to bed later and waking up earlier, they are more likely to be tired when they are in bed and to spend that time actually sleeping. Dr. Buysse noted that older patients often do not know what to do with themselves with the extra hours they gain by not spending them in bed, so much of his time with patients is used to come up with hobbies and ways for them to spend their time awake.

Exercise and physical activity could be incorporated in an older patient's life, both as a way to fill this extra time and as a possible treatment for insomnia. Ancoli-Israel and Dr. Phyllis Zee, a professor of neurology at Northwestern University's Feinberg School of Medicine, both advocated increased physical activity as a possible treatment for older adults with insomnia.

Dr. Zee cited a study by Naylor et al. of community-dwelling, healthy, older adults who had increased social and physical activity twice a day for 2 weeks. After 2 weeks, the participants had increased slow-wave (deep) sleep and improved daytime neuropsychological performance.

Ancoli-Israel noted that patients with dementia who reside in nursing homes could also benefit from increased physical activity during the day to improve their sleep. Increased light during the day and decreased light and noise levels at night could further improve the sleep quality for these patients, she said, citing a study by Alessi et al. that supported these suggestions. After 5 days of efforts to decrease in-bed time during the day, increase daytime light exposure, increase physical activity, increase structured bedtime routines, and decrease nighttime noise and light, researchers observed a significant decrease in daytime sleeping in the intervention group.

If behavioral and other nonpharmacologic therapies (eg, light therapy to adjust circadian rhythms) are not sufficient to treat insomnia, pharmacologic therapy should be used, Dr. Buysse said. He suggested starting treatment in an older patient with a benzodiazepine receptor agonist (eg, temazepam, eszopiclone) or a melatonin receptor agonist (eg, ramelteon). If the response to treatment is insufficient, he suggested using trazodone or doxepin, followed by a combination of a benzodiazepine receptor agonist or a melatonin receptor agonist plus either trazodone or doxepin. He noted that if the patient's complaint is that it takes too long to fall asleep, a short-acting agent should be used, and if the complaint is that a patient has trouble staying asleep, a longer-acting agent should be used.

Dr. Buysse acknowledged that pharmacologic sleep therapies have been associated with tolerance, abuse, and dependence, but added that these are not inevitable consequences of treatment. Long-term studies have shown that the drugs maintain their effects with time, so the problem of tolerance may not be as prevalent as people fear. Neither is the problem of abuse, he said, because, although it is possible, it is "an uncommon phenomenon in clinical practice." Dependence, however, is a fairly common occurrence associated with these drugs, he said, noting that he does not believe newer drugs fare much better than their older counterparts in terms of rebound insomnia.

No matter what the approach, insomnia needs to be treated and addressed as a real health problem in older patients, the presenters concluded.

"When you talk to older adults [who] have sleep problems, you can be assured that there are other things going along with that," Dr. Buysse said. "So, it's kind of a screening question. 'How are you sleeping?' is not a bad way to start."

This information concerns uses that are not approved by the Food and Drug Administration.

By Laura Iadevaia

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