Insomnia

Changes in sleep architecture for older adults

More time in stage 1-2

Less time in stage 3-4 (deep sleep)

Consequences for poor sleep

decreased QOL

Impaired cognition

more depressive symptoms

increased mortality

Insomnia diagnosis

difficulty falling asleep or staying asleep for at least one month (>3 months for chronic insomnia)

impairment of daytime functioning results from difficulty sleeping

Medications that can cause insomnia

alcohol, duloxetine, beta agonists, corticosteroids, decongestants, diurects, nicotine, xanthines

1st line treatment for insomnia

CBT - cognitive behavioral therapy

Ex: improve sleep hygiene M

Meds for sleep onset insomnia

need shorter acting agents

Eszoplicone, ramelton, temazepam, triazolam, zaleplon, zolpidem

Meds for sleep maintenance insomnia

longer duration

doxepin, eszoplicone, temazepam, suvorexant, zolpidem

Insomnia meds with some efficacy in older adults per ACP

eszoplicone, zolpidem, ramelteon, doxepin

Insomnia - benzos

temazepam - preferred for geriatrics

Not hepatically metabolized (lorazepam, temazepam, quazepam)

helps fall asleep but not stay asleep

Non benzo benzos for insomnia

zolpidem, zaleplon, eszoplicone

can cause sleep related behaviors

Melatonin for insomnia

safe for short term use < 3 months

Ramelteon for insomnia

melatonin receptor agonist

do not use with fluvoxamine

better tolerated than BZDs

Orexin Receptor Antagonist for insomnia

suvorexant, lemborexant, daridorexant

MOA - blocks wake promoting compounds

give within 30 mins of sleep and must sleep at least 7 hours

This is for sleep maintenance.

Avoid CYP3A4 inhibitors/inducers

Doxepin for insomnia

low dose 3-6 mg effective in increasing total sleep time, decrease nocturnal awakening, improving sleep quality

Monitor anticholinergic side effects

Depressed + insomnia

mirtazapine or trazodone

antipsychotic + insomnia

antipsychotics with sedating effects

antihistamines for insomnia

not recommended