Managing Insomnia

Contributed by: Lesley Charles, MBChB, CCFP - View bio

Case

Mrs. Janson is a 96-year-old woman, recently widowed, with a history of hypertension, dyslipidemia and GERD. Her medications include ramipril 5 mg daily, rosuvastatin 10 mg daily and pantoprazole 40 mg daily. She presents to clinic with a two-week history of not sleeping well.

Issue

Insomnia is a common issue for many older adults. It involves difficulty getting to sleep, staying asleep, waking too early or sleep that is poor quality or not restorative.¹  

Background

Sleep changes as people age, tending to become lighter and shorter. After age 50, total sleep time decreases by about 30 minutes per decade. Seniors wake more after falling asleep and often experience daytime sleepiness.^2,3 These frequent disruptions make it harder for older adults to get restorative sleep, and this has a direct impact on how well they recover from illness, cope with chronic diseases and function during the day.

Sleep problems in older adults are not solely a result of aging; they are often linked to underlying medical conditions, especially when multiple conditions are present.

Evidence

Research shows that insomnia affects one third of seniors^4,5 and can be difficult to diagnose because many conditions influence sleep (see table).

The relationship between insomnia and health problems is bidirectional: health problems often cause insomnia, and insomnia can worsen health. For example, in older adults, insomnia can lead to increased anxiety and depression, cognitive decline, increased falls and difficulty balancing and walking.^6-9 It also raises the risk of developing high blood pressure, diabetes, cancer, chronic pain, heart disease, stroke, and problems affecting breathing, urinary and gastrointestinal systems.^6-9 Collectively, these issues contribute to a poorer quality of life.

Given the complex interplay between insomnia and comorbidities in older adults, a thorough evaluation is essential to identify contributing factors and guide effective management.

Assessment

A structured approach begins with a comprehensive sleep history. Assess disturbed sleep symptoms such as daytime sleepiness, fatigue and duration of sleep difficulties. Document the sleep environment and sleep schedule, including bedtime, time to sleep onset, final awakening time and any nap times and their length. Explore specific sleep issues like number and duration of awakenings, snoring, gasping for air, pauses in breathing, urges to move legs and nocturia.

Next, broaden the assessment to include symptoms that may point to underlying conditions such as wheezing, shortness of breath, edema or pain. Screen for psychiatric concerns like depressed mood, anxiety or suicidal ideation. Ask about sleep disorders (e.g., snoring, restless leg syndrome), neurological symptoms (e.g., memory loss), medications (especially stimulants) and substance use (alcohol, caffeine, illicit drugs).

Once the history is complete, proceed to a focused physical examination. This helps to identify physical signs that may contribute to insomnia or reveal comorbid conditions. Pay attention to excessive oropharyngeal tissue (which may indicate obstructive sleep apnea [OSA]); lower extremity swelling (suggestive of heart failure); extremity deformities (linked to rheumatologic disease); and any abnormal findings on the Mental Status Examination (MSE), such as signs of dementia.

If the physical exam raises questions, consider further investigations. These may include a sleep diary, actigraphy, polysomnography if OSA is suspected, and a multiple sleep latency test if narcolepsy is a concern.

Once contributing factors are identified, a structured management approach can be implemented.

Management

Management begins by addressing any medical condition, psychiatric illness, substance use or sleep disorder identified during evaluation. The three pillars of management are:

1. Treat any underlying condition first.
2. Implement sleep hygiene strategies.
3. If these measures fail, consider behavioural therapy, medication or a combination thereof.

Sleep Hygiene: 10 Good Sleep Habits¹⁰

1. Follow a regular sleeping schedule.
2. No napping.
3. Calculate the average number of hours you spent in bed each night over the past week, and then aim to keep that same amount of time in bed every night going forward.
4. Exercise, but not in the evening.
5. Limit caffeine, alcohol and nicotine.
6. Avoid eating a large meal before bed.
7. Allow for quiet time before bed.
8. Only use the bed to sleep.
9. Make sure the room is dark and quiet.
10. Turn the clock face away from view.

Behaviour therapies

Progressive muscle relaxation

Relax one muscle at a time. Focus first on the face, followed by the jaw and neck, upper then lower arms, fingers, chest, abdomen, buttocks, thighs, calves and finally the feet. Contract these muscles gently for one or two seconds, then relax them.  

The relaxation response

Close eyes and allow relaxation to spread throughout body. Concentrate on breathing into abdomen, while focusing on a peaceful word or image.

Sleep restriction therapy

Limit total time in bed to the average time actually spent sleeping. Use a sleep diary for a week to work out the average amount.

Cognitive behavioural therapy (CBT)

Can be a good approach to manage anxiety and catastrophic thinking around not getting a good night’s sleep. CBT combines the behaviour therapies listed above with cognitive strategies in a series of sessions.¹²

Medication

If non-pharmacologic measures fail, medications may be considered. These fall broadly into four categories:

Benzodiazepines

Reduce the time to the start of sleep by 10 minutes, prolong stage two sleep and increase total sleep time by 30 to 60 minutes. Medications include lorazepam, clonazepam and temazepam.^13,14

Non-benzodiazepine sedatives

Reduce the time it takes to fall asleep and the number of awakenings, while also improving sleep duration and quality. Zopiclone shortens the time to sleep onset, although it is less effective than benzodiazepines at increasing total sleep time. Other options include trazodone, mirtazapine, tricyclic antidepressants like amitriptyline and nortriptyline.

Melatonin and melatonin receptor agonists

Most useful for people who have trouble falling asleep. It can be bought over the counter. In the U.S., ramelteon is also available and works in a similar way to melatonin. Both have fewer side effects than benzodiazepines and non-benzodiazepines.¹⁵  

Dual orexin receptor antagonists (DORAs)*

DORAs block the effects of orexins which are neuropeptides that stimulate wakefulness. Examples include daridorexant and lemborexant. Both medications are used for the treatment of insomnia and show consistent improvements in sleep onset, sleep maintenance and total sleep time across randomized controlled trials. Most studies rely on subjective sleep measures and include extensive exclusion criteria, and are manufacturer-funded, which limits generalizability to real-world patients.

Safety issues include somnolence, dizziness, fatigue, sleep paralysis, possible adverse effects on mood (e.g., worsening of depression/suicidal ideation) and potential next-day impairment, with added fall risk in older adults (65 years and older).

Neither daridorexant nor lemborexant shows evidence of physical dependence, but both carry measurable misuse and diversion potential, supported by small abuse-liability studies in recreational sedative users. Both medications are difficult to detect on standard urine drug screens, requiring specialized toxicology methods.

Overall the current evidence appears to support that DORAs are effective for sleep improvement in older adults and generally well tolerated, but caution and ongoing monitoring will be important due to risk of falls, psychoactive effects and the lack of controlled trials with older patients, especially those with comorbidities.^16-36

Recommendations

Throughout the assessment and management of insomnia in older adults, individualized care and ongoing monitoring are essential for safe and effective prescribing. In Mrs. Janson’s case, her insomnia was linked to an acute grief reaction following the recent loss of her spouse. After discussing non-pharmacologic strategies and ensuring no underlying medical or psychiatric conditions required immediate intervention, a short-term pharmacologic option was considered.

She was prescribed trazodone 12.5 mg at bedtime, titrated in 12.5 mg intervals as needed, with plans for short-term use. Follow-up was arranged to monitor for depression and taper trazodone as her grief reaction resolved.

Acknowledgement

*The section on dual orexin receptor antagonists (DORAs) was informed by input from Dr. Monica Wickland-Weller, CCFP — Senior Medical Advisor, CPSA.

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