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Sleep in the Elderly: Burden, Diagnosis, and Treatment
W. Vaughn McCall, M.D., M.S.
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Abstract
Insomnia is commonly seen in elderly populations and is associated with numerous individual and socioeconomic consequences. Elderly patients are more likely to suffer from chronic insomnia characterized by difficulty maintaining sleep than difficulty initiating sleep. Management of insomnia in these patients requires very careful evaluation and exclusion of an underlying medical or psychiatric condition. Nonpharmacologic interventions in elderly patients, especially use of behavioral therapy, have demonstrated some success. Commonly prescribed medications have also been effective, though they have limitations. Newer agents currently under investigation for insomnia hold promise for good efficacy and safety in the elderly population. The following review presents clinical studies, survey results, and guidelines retrieved from peer-reviewed journals in the PubMed database using the search terms elderly, temazepam, trazodone, zolpidem, zaleplon, insomnia, and prevalence and the dates 1980 to 2003. In addition, newer research with emerging agents has been included for completeness.
Insomnia is a condition that is underrecognized, underdiagnosed, and undertreated in the general population.1 Despite being a common complaint among elderly people (aged 65 years and older), sleep disorders are rarely systematically diagnosed and treated, even by geriatric specialists.2 Insomnia is a serious problem among older individuals because of its widespread prevalence and because poor sleep can have detrimental consequences for many of the aspects of vitality and resilience required for successful aging.3 Sleep disturbances among the elderly are associated with significant morbidity and mortality and increase the risk for nursing home placement.4,5 Insomnia is also correlated with risk for falls.6 Sleep maintenance, rather than sleep initiation, is the most commonly reported problem among older people with sleep disturbance2,7,8 and can have serious consequences.8,9 However, while a range of treatment options exists, there is currently a lack of pharmacologic agents that provide an optimum combination of therapeutic benefits. Ideal pharmacologic outcomes would include improved sleep initiation, sleep maintenance without next-day residual effects, and, ideally, improved next-day functioning.
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EPIDEMIOLOGY OF INSOMNIA IN THE ELDERLY
In 1982, the National Institute on Aging conducted a multicenter, epidemiologic study to assess the prevalence of sleep complaints among more than 9000 non-institutionalized elderly persons aged 65 years and older. Over half (57%) of these elderly people reported some form of chronic disruption of sleep, while only 12% reported no sleep complaints.7 Among all participants (N = 9282; mean age = 74 years), the prevalence of chronic sleep complaints included difficulty in initiating or maintaining sleep (43%), nocturnal waking (30%), insomnia (29%), daytime napping (25%), trouble falling asleep (19%), waking too early (19%), and waking not rested (13%).7 A 3-year follow-up study reported an annual incidence rate of approximately 5%, with roughly 15% of elderly insomniacs resolving their symptoms each year.10 Chronic insomnia is also more common in this population. A 1991 National Sleep Foundation poll of a representative sample of 1000 Americans aged 18 years or older, who were divided by age into 6 groups (18–24, 25–34, 35–44, 45–54, 55–64, and ≥ 65), found that 9% of the sample reported chronic insomnia, while 20% in the group ≥ 65 years reported chronic insomnia, the highest among all age groups.11
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BURDEN OF INSOMNIA IN THE ELDERLY
Insomnia incurs a significant direct and indirect burden on society. Direct economic costs of insomnia were calculated to be $13.9 billion in 1995,12 and a 1996 review indicated that total direct, indirect, and related costs may run as high as $30 to $35 billion annually.13
While the overall economic costs of insomnia specifically in the elderly population have not been assessed to date, several studies14,15 have provided data on segmented direct and indirect costs and on adverse effects on quality-of-life parameters in the elderly. Insomnia may precipitate injuries, such as falls, and aggravate existing health conditions. In a survey of 1526 community-dwelling older adults aged 64 to 99 years, difficulties with “falling asleep at night,” “waking during the night,” and “waking up in the morning” were significantly related to the number of reported falls.6 Subsequent fall-related injuries are an important factor for nursing home placement.4 Estimates indicate that of the $158 billion of lifetime economic costs of injury in the United States, fall-related injuries will contribute a total of $10 billion.6
A 1995 assessment of health care service costs found that nursing home care related to insomnia in the elderly amounted to $10.9 billion (91% of all health care services related to insomnia, across all age groups).12 Sleep disturbances in the elderly, and the subsequent disruption of caregivers' sleep, exact a toll on family support. Insomnia has been cited as a primary factor in caregivers' decisions to institutionalize an elder, with 20.4%12 and 52%16 of admissions to long-term care directly attributable to elderly sleep disturbances. A survey of 1855 elderly urban residents found that insomnia was the strongest predictor among males for both mortality and nursing home placement.5 Insomnia may also contribute to cognitive decline,17 and insomnia-induced cognitive impairments can confound accurate dementia diagnoses and lead to suboptimal and delayed treatment.4
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FOCUS ON SLEEP MAINTENANCE
Insomnia is associated with difficulty in initiating sleep (i.e., is a problem of sleep onset), maintaining sleep, or obtaining restorative sleep18; however, the elderly spend more time awake after initially falling asleep than their younger counterparts < 65 years, and sleep maintenance problems are therefore the primary symptoms in this age group.2,8,19 Foley et al.7 reported that 49% of elderly patients experienced sleep maintenance symptoms (30% complained of waking during the night; 19% complained of waking too early), compared with only 19% who experienced the sleep-onset symptom—difficulty falling asleep.
These findings have been confirmed in a study that utilized objective measures. Webb2 compared electroencephalograph measures of 80 healthy older adults (aged 50–60 years) and a control group of 32 younger adults (aged 20–30 years). Sleep in the older group was characterized by more frequent and prolonged awakenings (Figure 1). Among older men, wake after sleep onset, a robust measure of poor sleep maintenance, defined in this study as time (in minutes) awake after sleep onset/time asleep and expressed as a percentage, was increased approximately 8-fold over that of younger men (8.1 vs. 1.2, respectively; p < .01). Number of awakenings lasting 5 minutes or longer were more frequent and of longer duration in the older groups (1.4 in men and 0.9 in women, aged 50–60 years; 0.1 in men and 0.3 in women, aged 20–30 years; p < .01 for comparison among older and younger groups in both genders).2
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As sleep disturbances among the elderly are often secondary to existing chronic disease, overall poor physical health, and psychosocial morbidity, it is important for practitioners to assess if insomnia is a primary or secondary condition.9 The principal medical or psychiatric condition, as well as medications used to treat it (e.g., cardiovascular medication), may cause sleep disruption and contribute to daytime sleepiness.4,10,26,27 Common causes of insomnia in the elderly are listed in Table 3.
Table 3
Common Causes of Insomnia:
Longitudinal data have consistently established depression as one of the strongest correlates of insomnia,10,28,29 and while the causal relationship between insomnia and depression remains unclear, it is important to exclude the possibility of a depressive episode in an elderly patient who presents with symptoms of insomnia. The Beck Depression Inventory30 is one of many useful, well-validated, self-administered scales to detect depression symptoms. A score above 10 suggests clinical depression might be present and warrants a more thorough investigation of whether it is, in fact, depression (Table 4).
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Pharmacologic Therapies
Pharmacologic therapy should take into consideration the pharmacokinetic and pharmacodynamic changes in drug metabolism that typically accompany the aging process. Caution should be exercised in selecting appropriate medication and medication dosages for treatment of insomnia in elderly patients.35 Medications that impair cognitive and psychomotor function can have serious consequences for elderly patients who are institutionalized and for those living in the community.
Use of benzodiazepines has been correlated with an increased risk of falling,40–43 and a higher serum concentration of benzodiazepines has been noted in those who fall compared with those who do not fall.44 Falls appear to be associated with the use of both short- and long-term benzodiazepines.45 Cumming and Klineberg46 found that use of the relatively short-acting temazepam, the most commonly used of all the benzodiazepines for insomnia treatment,47 increased risk of falls compared with nonusers.46 Diazepam was also found to be a risk factor for multiple falls in one study (odds ratio = 3.7, 95% CI = 1.5 to 9.3).41
More recent studies have indicated that excessive benzodiazepine dosage may be a more salient factor than drug half-life.48 According to Beers' 1997 criteria for determining potentially inappropriate medication use in the elderly, short- to intermediate-acting benzodiazepines (e.g., temazepam) and zolpidem are to be considered inappropriate if maximum recommended doses are exceeded.49 Although very little research has been conducted to evaluate the use of agents like temazepam and zolpidem in the naturalistic setting, a recent review50 of the pharmacy profiles of 2193 homebound people older than age 60 years was conducted. Of these people, 285 patients were prescribed excessive doses of temazepam and zolpidem. It was determined that 28% of short- to intermediate-acting benzodiazepine prescriptions and 60% of zolpidem prescriptions exceeded recommended dosing limitations,50 which suggests that excessive dosing does indeed occur.
Despite the increased risk for falls, benzodiazepines and generic antidepressants (such as trazodone) are among the most popular classes of medications prescribed for elderly patients.47,51 Benzodiazepines were second only to cardiac medications in frequency of prescription, and there was a high prevalence of antidepressant drugs.50 An analysis of inappropriate (risk > benefit) psychotropic prescribing, using data from the 1996 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, determined that antidepressant agents, antianxiety drugs, and sedative-hypnotics were the drug classes most frequently prescribed to ambulatory elderly patients.52
Consensus guidelines regarding the treatment of insomnia established in 198453 and now considered obsolete by the National Institutes of Health (NIH) appear to have influenced the U.S. Food and Drug Administration's (FDA) decision to restrict prescription of hypnotic medications to a maximum of 1 month.54 This restriction may have contributed to increased utilization of antidepressants for treating insomnia among physicians, as there is evidence that chronic insomnia frequently persists far beyond 1 month, especially in elderly patients.55 These guidelines were formulated, in part, on the basis of the dearth of research exploring longer-term safety and efficacy of these agents. Recently, however, longer-term double-blind56 and open-label57,58 studies have demonstrated the safety of nonbenzodiazepine agents in adults and elderly patients with chronic insomnia. In the future, such findings may contribute to increased confidence for longer-term usage of these medications. So, in the absence of widely accepted algorithms for the use of hypnotics, common sense dictates that hypnotics are justified for short-term, symptomatic relief of transient insomnia, and for short-term relief of chronic insomnia in patients who are frantic and in crisis about their condition. Anxious patients may not be willing to wait for the delayed onset of behavioral therapy for primary insomnia or the delayed onset of treatments for secondary insomnia (i.e., antidepressant treatment of major depression). Hypnotics may be avoided, at least initially, in patients with chronic insomnia who are not anxious and are willing to wait a few weeks to see if alternative treatments work. Hypnotics could be judiciously added later if the initial approach is not fruitful.
In terms of overall trends in insomnia treatment, a 10-year analysis of pharmaceutical data from the National Disease and Therapeutic Index (NDTI) indicated a dramatic decrease in overall pharmacologic treatment of insomnia from 1987 to 1996.51 The NDTI provides descriptive information on disease and treatment patterns in U.S. private medical practices and includes 2790 office-based physicians drawn from 24 medical specialties. Hypnotic drug mentions decreased 53.7%, while antidepressant mentions for insomnia treatment increased 146%. There was a substantial shift away from the use of benzodiazepines and toward the prescribing of antidepressants and nonbenzodiazepine hypnotics. In 1996, NDTI data indicated that trazodone and zolpidem were the 2 drugs prescribed most frequently for treatment of insomnia.51 Temazepam is the most commonly prescribed benzodiazepine for insomnia.47 Therefore, based on current utilization patterns, the following section will review pertinent data on temazepam, trazodone, zolpidem, and the newest nonbenzodiazepine—zaleplon—for the treatment of insomnia in elderly patients.
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