An article by Javier Olivera Pueyo,
Psychiatrist – Spanish Society of Psychogeriatrics ()
In general, the Aging brings a series of changes in sleep. These changes produce a subjective impression of unsatisfactory sleep that can be described as insomnia and affects more than half of older adults.
Over the years the overall sleep tends to be reduced due to increased time to fall asleep, increased nocturnal awakenings, and earlier awakening. Increases the lightest sleep, decreasing the percentage of deep sleep. REM sleep is reduced, increasing its latency and decreasing its percentage in the global pattern. Daytime naps increase and eventually sleep quality and efficiency is reduced. For all these reasons, in the elderly, there is also, on occasions, what could be called “pseudoinsomnia” due to this feeling of not having slept or not having rested enough, without it really being something objective and concrete.
Causes and consequences of insomnia in the elderly
This feeling of insufficient and unrefreshing sleep can lead to important consequences in the elderly. It affects memory and concentration, worsens cognitive functioning, favors the risk of falls and even increases overall mortality, according to the results of different studies.
He primary insomnia It is defined as either difficulty initiating or maintaining sleep, or lack of restful sleep. This symptom lasts for at least a month and also causes significant personal and/or social discomfort.
In addition to insomnia, the most frequent sleep disorders in the elderly are: dyssomnias (restless legs syndrome, nocturnal myoclonus, etc.), the syndrome of Sleep apnea or parasomnias, such as REM sleep behavior disorder, or rhythmic movement disorder (boastful capitis nocturnal), very typical, also, in the elderly.
Secondary insomnia may be due to:
- Other mental disorders. Insomnia can appear in practically all of them, but it is especially notable in affective disorders (depression and bipolar disorder), anxiety disorders, adjustment disorders and grief, as well as delirium (disorders of the sleep-wake rhythm and nocturnal confusional pictures are fundamental for its diagnosis) or dementia (in all types and, with special relevance, in Lewy body dementia, even preceding other types of symptoms).
- physical illnesses. Above all, pathologies that cause pain (such as osteoarticular ones), but also those associated with respiratory distress (heart failure, chronic obstructive pulmonary disease…), cerebrovascular accidents, Parkinson’s disease, thyroid diseases, associated nocturia to prostatism…
- To the use of stimulants and alcohol. Caffeine, nicotine or alcohol abuse favor insomnia and the worst quality of sleep.
- Environmental and behavioral factors. Noise, lack of comfort, temperature, eating or drinking immediately before going to bed also influence the difficulty in falling asleep.
- To the use of drugs with a stimulating effect. Bronchodilators, dopaminergics, corticosteroids, most antidepressants, the paradoxical effect of benzodiazepines, some diuretics, thyroxine… have an impact on sleep.
Subjective and objective insomnia is a highly prevalent syndrome in the elderly. Half of this population suffers from some sleep disturbance
Evaluation and treatment of a person elderly with insomnia
For the correct diagnosis of insomnia should assess a 24-hour sleep pattern. The duration of the symptoms, the total time spent in bed, the time until falling asleep (falling asleep), the usual time of waking up, the number of nocturnal awakenings, the moments of sleep during the day (naps) will be taken into account. , etc.) and the total amount of daily sleep. There will be a detailed analysis of organic pathologies and painas well as drugs that can interrupt sleep and favor the worst quality of it.
Given the special sensitivity of the elderly to the use of psychoactive drugs and, especially, those with a sedative and hypnotic profile, initial treatment should be non-pharmacological treatment. In this sense, some measures are included to improve sleep hygiene:
- Try to keep a regular schedule for going to bed and getting up.
- Avoid strenuous exercise just before going to bed and favor moderate regular exercise during the day (for example, walks in the fresh air).
- Stay exposed to light during the day.
- Avoid copious meals and prioritize light dinners.
- Relaxing environment, with little noise, in the place of night rest.
- Reduce the time spent in bed without sleep. Avoid being in bed during the day.
- To avoid the use of tobacco. Nicotine acts as a stimulant.
- Avoid alcohol consumption, since, although it may help to fall asleep, then the resulting sleep is fragmented and of poorer quality.
- If sleeping drugs are used, sporadic intake may be used, depending on the evolution of insomnia.
And, if it is finally necessary Pharmacotherapydue to the discomfort generated by the sensation of scarce or unrefreshing sleep, we must assess that the sedative effects in the elderly may be associated with complications as important as falls, impaired memory, attention and concentration, as well as episodes of confusion. For this reason, it is important to limit its use, monitor it over time and reduce the dose, whenever possible. between the different psychopharmacological possibilities for insomnia in the elderly we highlight:
- Benzodiazepines. Due to their side effects, the non-prolonged use of benzodiazepines with a shorter half-life is preferable, especially lorazapam at a dose of 0.5 to 1 mg/night. Low doses of clonazepam (0.25-0.5 mg/night) may be useful in insomnia associated with restless leg movements.
- Non-benzodiazepine hypnotics. Among them, perhaps the most widely used is zolpidem at a dose of 5 mg at night. The possibility of associated gait instability and, therefore, the risk of falls when walking at night should be evaluated.
- antidepressants such as mianserin or mirtazapine which, due to their antihistaminergic action, also associate a hypnotic effect. Dose between 15 and 30 mg/night. Also, trazodone, particularly effective in improving sleep quality, with few side effects (except nocturnal hypotension), at doses of 50 to 150 mg/night. This drug is especially indicated in patients with dementia, polymedicated, with respiratory disease to avoid benzodiazepines, etc.
- Melatonin. Especially recommended for its physiological reduction in the elderly with few side effects. For its hypnotic action, doses close to or greater than 2 mg are recommended.
- other drugs. Antihistamines such as doxylamine and diphenhydramine may promote sleep, but their anticholinergic side effects initially discourage their use in the elderly. Clomethiazole, a hypnotic derived from thiamines, has also shown efficacy and rapidity of action, at doses of 192 and 384 mg/night. It is useful as an alternative to benzodiazepines, with some side effects, such as nasal congestion or excessive sedation. In recent years, the use of sedative antipsychotics such as quetiapine, at doses of 25–50 mg/night, has also increased, especially in patients with insomnia associated with confusional or behavioral disturbances at night.
Definitely, subjective and objective insomnia is a highly prevalent syndrome in the elderly (About 50% of them have some type of sleep disturbance). Primary insomnia is frequent, due to the physiological changes associated with age, but also insomnia secondary to multiple pathologies, other drugs, environmental factors… The consequences of insomnia in the elderly can be especially serious (falls, impaired concentration and memory, daytime discomfort…). The correct diagnosis includes the elaboration of a daily pattern of 24 hours. Regarding treatment, it is always preferable to start with a behavioral approach and sleep hygiene, and, if this is not effective, some psychotropic drugs of different profiles can be used, with adequate monitoring and periodic reassessment of results and side effects, seeking low doses for the shortest possible time.