Therapy Update for Insomnia in the Elderly

OBJECTIVE: To offer an update on insomnia in older adults and treatment options. DATA SOURCES: A search of PubMed using the terms "insomnia" and "older adults" was performed. Current guidelines, review articles, and drug database and manufacturer package inserts were utilized to provide relevant information. STUDY SELECTION: All English-language articles from 2012 to February 2017 and their bibliographies were reviewed for relevance. Current guidelines from the American College of Physicians, the American Academy of Sleep Medicine, and the American Geriatrics Society's Beers criteria were reviewed. DATA SYNTHESIS: Insomnia is a frequent complaint in the elderly. Treatment guidelines for this specific population are lacking. Anticholinergics, doxepin > 6 mg, benzodiazepines (BZDs), and non BZD receptor agonists (BzDRAs) are potentially inappropriate drugs for older adults. For adults with chronic insomnia, sleep hygiene practices and cognitive behavioral therapy should be considered as the initial treatments. If drug therapy is required or desired, the guidelines recommend short-term uses of BZDs (triazolam or temazepam), BzDRAs, low-dose doxepin (≤ 6 mg), ramelteon, or suvorexant. Risks and benefits of pharmacotherapy should be discussed with patients and caregivers prior to treatment initiation. Frequent and regular monitoring for adverse events is warranted to prevent detrimental outcomes. CONCLUSION: Nonpharmacologic interventions are the first-line therapy for adults with chronic insomnia. Short-term drug therapy may be considered as an alternative or add-on treatment. Hypnotic use is associated with harm and requires close monitoring, especially in older adults.