Dr. Vivien C Abad and colleagues have very vividly outlined Pharmacological Management of Chronic insomnia in Elderly. The article has appeared in the Journal of Drugs & Aging.
Chronic insomnia affects 57% of the elderly in the United States, with impairment of quality of life, function, and health. Elderly patients are more likely to face difficulty maintaining sleep than difficulty initiating sleep. The disease has financial implications as well as billions of dollars in direct and indirect costs of care.
Management of insomnia in these patients requires very careful evaluation and exclusion of an underlying medical or psychiatric condition. The main modalities of its treatment in the elderly are psychological/ behavioural therapies, pharmacological treatment, or a combination of both.
The Key Points are-
- Various speciality societies view psychological/ behavioural therapies as the initial treatment intervention.
- Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioural therapies.
- Current drugs for insomnia fall into different classes:
2)Histamine receptor antagonists
3)Non-benzodiazepine gamma-aminobutyric acid receptor agonists,
The Food and Drug Administration (FDA)-approved drugs for insomnia mainly include suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon.
- The choice of a hypnotic agent in the elderly is symptom-based. Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia. Suvorexant or low-dose doxepin can improve sleep maintenance.
- Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance.
- Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings.
- Benzodiazepines should not be used routinely.
- Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks.
- Tiagabine, sometimes used off-label for insomnia, is not effective and should not be utilized.
Non-FDA-approved hypnotic agents that are commonly used include melatonin, diphenhydramine, tryptophan, and valerian, despite limited data on benefits and harms.
- Melatonin slightly improves sleep onset and sleep duration, but product quality and efficacy may vary.
- Tryptophan decreases sleep onset in adults, but data in the elderly are not available.
- Valerian is relatively safe but has equivocal benefits on sleep quality.
- Phase II studies of dual orexin receptor antagonists (almorexant, lemborexant, and filorexant) have shown some improvement in sleep maintenance and sleep continuity.
- Piromelatine may improve sleep maintenance.
- Histamine receptor inverse agonists (APD-125, eplivanserin, and LY2624803) improve slow-wave sleep but, for various reasons, the drug companies withdrew their products.
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