|Year : 2014 | Volume
| Issue : 2 | Page : 71-78
Late life insomnia: A brief review
Priti Singh1, Nisha Mani Pandey2, Sarvada C Tiwari3
1 Consultant Psychiatrist, Vishal Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India
2 Department of Geriatric Mental Health (DGMH), KG Medical University, Lucknow, Uttar Pradesh, India
3 Professor and Head, KG Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||3-Mar-2015|
Dr. Priti Singh
Consultant Psychiatrist, 4/28, Vishal Khand, Gomti Nagar, Lucknow - 226003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Insomnia in life-life is a common clinical presentation and yet its appropriate assessment and management can be challenging. This is largely due to the complex interplay of various co-morbid factors like physical or mental disorders, poly-pharmacotherapy, primary sleep disorders, psycho-social and environmental factors. Despite several evidence-based effective treatments being available, inappropriate pharmacotherapy is common and frequently leads to poorer outcomes and considerable risks in this population group. Nonpharmacological treatments are effective, but remain largely under-funded and infrequently used. This paper reviews the important changes in classification of insomnia; normal age related changes of sleep; factors contributing to late-life insomnia and useful assessment tools and treatment strategies in the management of chronic insomnia.
Keywords: Aging, insomnia, late-life, management, sleep, treatment
|How to cite this article:|
Singh P, Pandey NM, Tiwari SC. Late life insomnia: A brief review. J Geriatr Ment Health 2014;1:71-8
| Introduction|| |
Insomnia is a relatively common complaint in clinical practice, more so with an aging population and co-morbid with physical or psychiatric disorders. The International Classification of Sleep Disorders third edition (ICSD-3) defines insomnia as "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of day-time impairment."  It is a highly prevalent disorder with an even higher rate of occurrence in older adults  with over 50% of older adults complain of insomnia.  It is also known to impact on attention deficits, delayed reaction, short-term memory difficulties, functional problems and increased risk of falls. ,
| Classification of Insomnia-Recent Developments|| |
Scientific understanding of "insomnia" has gradually but significantly changed over the last few decades. The earlier classifications of insomnia included "primary insomnia" or "secondary insomnia" with primary insomnia being defined as, "having difficulty initiating or maintaining sleep for a minimum of 1-month, producing clinically significant distress and associated with impaired social or occupational function."  It is independent of narcolepsy, other sleep and mental disorders, and is not directly related to medication side-effects or to a medical condition. 
"Secondary insomnia" occurs secondary to other conditions including medical disorders like physically disturbing condition such as pain, thyroid disease, acid reflux, coronary artery disease or pulmonary problems; psychiatric disorders like anxiety and depression; sleep related movement disturbance like nocturnal myoclonus, restless leg;  medication side-effects as with steroids, theophylline, anticancer drugs, beta-blockers, caffeine, alcohol and nicotine; , psycho-social factors associated with aging (e.g., retirement, inactivity, or care-giving) , and environmental and behavioral factors such as decreased exposure to bright light and a lack of exercise. 
Majority of the older adults present with secondary insomnia and primary insomnia is considered rare. , However, it is also known that insomnia that initially occurs secondary to a physical or psychiatric disorder may evolve into an independent problem that has a bidirectional relationship with the original primary disorder. 
Defining insomnia in "primary" and "secondary" terms in clinical practice is however challenging and hence to address this, the 2005 National Institute of Health (NIH) consensus statement on chronic insomnia recommended replacing "secondary insomnia" with "comorbid insomnia" to describe insomnia that co-occurs with other conditions. ,
The 5 th edition Diagnostic and Statistical Manual of Mental Disorders (DSM-5)  further suggests replacing the diagnostic terms of "primary insomnia" or "secondary insomnia" with "insomnia disorder" to establish diagnostic validity of insomnia in its own right with specification of comorbid mental and/or physical conditions, so that no causal attributions between insomnia and the physical/mental condition are made. Furthermore, extension of the duration criteria from 1-month to 3 months acknowledges that chronicity of symptoms distinguish "insomnia disorder" from insomnia symptoms alone.  Similarly, the recently published ICSD-3 have described insomnia in categories, including "chronic" and short-term insomnias. 
| Normal Sleep and Changes with Age|| |
Clinically it is important to distinguish abnormal sleep patterns from normal changes expected with age. A recommended normal sleep pattern for the older person includes a sleep latency (time until fall asleep) of up to 30 min, obtaining 5-10 (average 6) h of sleep at night, possessing a sleep efficiency of 85%, and not experiencing day-time impairment because of sleepiness.  Sleep patterns change with ageing and certain normal changes, including an increased amount of light sleep (stages 1 and 2 of the sleep cycle), a decreased amount of deep sleep (stages 3 and 4 of the sleep cycle) and less time spent in the rapid eye movement stage of sleep. A meta-analysis of 65 studies representing 3577 healthy subjects showed that the total amount of sleep decreases linearly with age with a loss of ~10 min/decade.  Overall, sleep quality and sleep efficiency (total sleep time/total bed time) seem to decrease with normal aging to 70-80% and patients may express this as an experience of lighter and more fragmented sleep. 
| Co-Morbid Factors to Consider in Older Adults Presenting with Insomnia|| |
Primary sleep disorders
Compared to younger people, older adults have higher rates of primary sleep disorders other than insomnia, such as obstructive sleep apnea (OSA), restless legs syndrome (RLS), and periodic limb movements (PLMs), which are risk factors for insomnia symptoms.  OSA affects 19-57% of older adults and is characterized by repeated cessation or attenuation of breathing ("apneas" and "hypopneas," respectively) during sleep.  The most common OSA symptoms are loud snoring or gasping during sleep and day-time sleepiness.  RLS is characterized by uncomfortable sensations in the legs, marked by the urge to move one's legs, which are relieved by movement of the legs; these symptoms have a distinct circadian pattern (minimal in the morning and worse at night) making it difficult to sleep.  PLMs are involuntary limb jerks experienced by up to 45% of older adults, are frequently observed among individuals with RLS, and can disrupt the sleep of both affected individuals and their bed partners. 
| Chronic Illness and Insomnia|| |
The bulk of insomnia symptoms in older adults may be attributable to the increased prevalence of chronic conditions in this population; only 1-7% of insomnia in later life occurs independently of chronic conditions. ,, Chronic pain is frequently accompanied by insomnia in older adults.  Pain and sleep are interrelated; pain has been shown to disrupt sleep, but sleep deprivation can also result in a decreased pain threshold.  Osteoarthritis (OA) is often a source of pain in older adults, affecting more than 50% of those aged 65 and older. , The chronic course of OA is associated with chronic insomnia in older adults. 
| Mental Illness|| |
Chronic insomnia is also prevalent in older adults with mood disorders, and insomnia is among the diagnostic criteria for several psychiatric disorders.  Insomnia is particularly associated with depression and generalized anxiety disorder (GAD)-between 40% and 60% of insomnia patients have depressive or GAD symptomatology.  Though insomnia can be a symptom of these disorders, it can also contribute to or exacerbate psychiatric disorders, and should be targeted for treatment when present.  Correlation between insomnia and mental illness is well established with evidence that, untreated insomnia may result in depression, and the presence of a depressed mood may predict insomnia. ,
| Sleep Disorders in Dementia|| |
Study by McCurry et al. suggest that 19-44% of community-dwelling patients with dementia complain about sleep disturbances.  These patients experience abnormal nighttime behavior that includes confusion, wandering and agitation along with day-time napping due to excessive day-time sleepiness. Although dementia could itself be responsible for the sleep disturbances, other potential causes should be evaluated. Primarily, insomnia in dementia has been treated with pharmacotherapy but adaptation of structured psychological therapies can also be effectively employed. This may include training for caregivers of dementia as they themselves commonly suffer from insomnia. ,
| Lifestyle Changes|| |
Lifestyle changes common in old age, such as retirement, reduced mobility, and reduced social interaction are additional sources of sleep disruption. , Elderly caregivers, particularly those caring for a family member with dementia, have sleep patterns similar to individuals with depression or insomnia. 
| Circadian Changes|| |
Circadian phase advance in older adults can lead to less total time in bed, greater day-time sleepiness, and more day-time napping, which can further contribute to complaints about night time sleep.  Further, age-related yellowing of the eye's lens may restrict light input to the supra chiasmatic nucleus (SCN), and reductions in input from this signal can disrupt the sleep-wake cycle. 
| Assessment of Insomnia in Older Adults|| |
Insomnia in the elderly can be difficult to adequately assess due to the presence of several co-morbid factors such as mental, physical and sleep disorders. These should be carefully assessed for as even partial, or subclinical, symptoms of insomnia can have a profound impact on the patient's health and often progress to chronic insomnia. Therefore, early detection and intervention of insomnia symptoms may prevent or mitigate these negative consequences. 
Several self-reporting questionnaires aimed at assessing sleep and day-time functions have been useful in identifying people with late-life insomnia, including sleep diaries, Pittsburg Sleep Quality Index (PSQI),  Insomnia Severity Index (ISI),  Epworth Sleepiness Scale (ESS),  and the Dysfunctional Beliefs and Attitudes about Sleep (DBAS).  It is important, however, to note that these measures depend heavily on the patient's memory over the past weeks and months and hence may be ineffective in older adults with memory problems.
Two most commonly used self-reporting methods for obtaining sleep data are sleep diaries and the PSQI. Sleep diaries may be simplified to solely include time in bed, sleep and wake time estimates with sleep efficiency calculations.  Sleep diaries should be filled out for a minimum of 2 weeks prior to therapy, as well as throughout and after any treatments. They easily show sleep changes occurring with treatment and assist the clinician in determining the individual level of compliance to treatment. Sleep diaries are subject to the same standardization difficulties as self-reports, although, they can provide reliable and valid estimates of sleep parameters.  They capture data on the time between sleep onset and the moment at which the electric encephalogram displays stage 2 sleep pattern.  Sleep diaries are the most valid tools for measuring insomnia in general practice. Standardized sleep diaries like "consensus sleep diary" are also available and can be useful as they include items for sleep onset latency, wake after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep satisfaction. 
The PSQI is a 19-item questionnaire with seven sub scales (subjective sleep quality, sleep latency, sleep duration, habitual sleep disturbances, use of sleep medication and day-time dysfunction).  Each sub-scale is rated from 0 to 3 with the higher scores reflecting more severe sleep com-plaints. The addition of all the scores permits an analysis of the patient's overall sleep experience. The lower the overall score, the better the person sleeps. The tool has an adequate internal reliability, validity and consistency for clinical and community samples of the elderly population. However, the questions are heavily based on the memory over the past month.
The 7-item ISI measures the subjective symptoms and negative outcomes of insomnia over the past 2 weeks, and the worries and distress caused by these.  A score >7 on the ISI indicates "sub-threshold" levels of insomnia; scores >14 indicate "clinical insomnia."  Compared with sleep diaries, the ISI has good validity and high internal consistency in middle-aged and older age insomnia patients and has been shown to be sensitive to detect changes over time. 
Polysomnography (PSG) is not indicated for the routine assessment of insomnia. This is due to the subjective nature of an insomnia complaint and the high expense and invasiveness of PSG.  It is, however, useful in the assessment of other sleep disorders like OSA, sleep-related breathing disorder, periodic leg movements in sleep and persistent circadian disorders.
| Treatment of Insomnia in Older Adults|| |
While medications are traditionally used to treat insomnia, recent studies have shown that behavioral treatments are more effective and thus, recommended as the first-line treatment option. In some instances, a combined approach is appropriate. 
| Pharmacologic Therapies|| |
Historically several different classes of drugs have been used to treat insomnia. The most common include benzodiazepine (BDZ) class of drugs, newer BDZ receptor agonists (BZRAs) or 'Z' drugs (Zopiclone, Zolpidem and Eszopiclone) and Melotonin receptor agonists (Melatonin and Ramelteon). Other classes of drugs with sedative properties (anti-histamines used for cold-cough over the counter medication, and psychotropic drugs) have also been traditionally used. There are, however, several concerns regarding prolonged treatment with most of the available sedative-hypnotics due to adverse side-effect profile, limited efficacy in long-term and or drug dependence.
| Benzodiazepines|| |
Benzodiazepine have been shown to be effective for the short-term treatment of insomnia complaints such as sleep onset latency, number of nighttime awakenings, total sleep time, and sleep quality, but there is no evidence of their effectiveness in the long-term. , Risks of long-term BDZ use include developing tolerance or dependence; rebound insomnia; the residual day-time sedation; cognitive impairment; and motor incoordination.  In 2005, a meta-analysis found the use of BDZs to be associated with cognitive decline in three of six eligible studies.  The number needed to treat with a sedative-hypnotic drug for improved quality of sleep is 13, whereas the number needed to harm is 6.  Harm can include drowsiness, fatigue, headache, nightmares and gastrointestinal disturbances.  Despite this, 16-33% of older people living in the community use BDZs, , and 54% use them daily.  The NIH Consensus State of the Science Statements in 2005 hence recommended that BDZ should not be used beyond 35 days in management of insomnia.  Further in 2012, The beers criteria for potentially inappropriate medication use in older adults, strongly recommend, based on high-quality evidence, to avoid all BDZs in older adults. 
| Benzodiazepine Receptor Agonists or 'Z' Drugs|| |
These newer BZRAs or 'Z' class of drugs became popular alternatives to BDZ in management of insomnia. This is due to their comparable efficacy to BDZ, relatively short half-life and fewer side-effects. Although some long-term trials (e.g., 12 months) have not found evidence of tolerance, dependence or rebound insomnia,  these remain concerns with long-term use of the newer BZRAs.  A meta-analysis concluded that, although indirect comparisons suggest that newer BZRAs were safer than older medications, all hypnotic classes evaluated pose a risk of harm.  Finally, there is concern about the association of hypnotic use with considerable morbidity and mortality. 
| Melatonin|| |
The evidence for melatonin's effectiveness in insomnia is mixed.  In a study of melatonin versus placebo, there was the lack of significant effect on sleep time, sleep latency, number of awakenings and sleep efficiency. , However, pooled data from randomized, double-blind trials of prolonged-release melatonin showed statistically significant improvement in quality of sleep as measured by the Leeds Sleep Evaluation Questionnaire visual analog scale and decrease in subjective sleep latency. ,
Ramelteon, a novel MT1 and MT2 melatonin receptor selective agonist recently approved for the treatment of insomnia characterized by difficulty in sleep onset. It is a nonscheduled drug since it lacks the potential for abuse and does not interact with neurotransmitter receptors most associated with these phenomena. Although the effects of Ramelteon use >5 weeks are unknown, the available data confirms its safety and efficacy for short-term use. 
| Diphenhydramine|| |
Common anti-histamine in cold-cough over the counter medication, diphenylhydramine should not be used to treat insomnia in elderly, primarily due to its anticholinergic effects. In addition, a recent trial found diphenylhydramine to be not significantly better than placebo in improving total sleep time, sleep quality and sleep latency. 
| Sedative Psychotropic Drugs|| |
Despite prevalent off-license use of several pychotropic medications, that is, antidepressants (Trazadone, Amitryptiline and Mirtazepine) and anti-psychotics (Olanzapine, Quetiapine and Risperidone); there is little data supporting their use primarily for chronic insomnia. The largest study of Trazodone showed effects comparable to Zolpidem on sleep latency and sleep efficiency, but effects were nonsignificant at week 2. 
| Bright Light Therapy|| |
Bright light therapy is used to advance or delay the circadian clock independently of the sleep-wake pattern. The treatment involves making the patient perceive determined dosages of light for determined time intervals, using Light boxes and head-mounted visors. In general, for older adults with advanced sleep phase, bright light exposure (1000 Lux) in the evening or late afternoon is recommended to delay the sleep phase. 
Nonpharmacological Therapies: Nonpharmacological therapies in the management of late-life insomnia have gained relevance in recent times. It provides a safe and effective treatment option with prolonged beneficial effects and reduced need of pharmacotherapy and its unavoidable side-effect profile. These treatment options, however, are likely to be resource intensive (time consuming, expensive) and need more personal efforts and motivation.
Cognitive behavior therapy
It is well established in the literature that cognitive behavioral therapy (CBT) provided in various forms including individual, group or internet based therapy and were significantly better than placebo. It is also likely to have long lasting benefits, even when compared to pharmacotherapy, in the longer term even after the interventions have been stopped.
In a 6 weeks study involving 46 adults with chronic primary insomnia assigned to CBT, zopiclone 7.5 mg or placebo, the total wake time at 6 weeks was reduced by 52% in the CBT group (from 108 min to 51 min), as compared with 4% in the zopiclone group (from 103 min to 99 min) and 16% in the placebo group (from 154 min to 130 min).  At the 6 months follow-up, total sleep time continued to increase in the CBT group only (by 26 min [from 336 min at 6 weeks to 362 min at 6 months]), total wake time decreased further (from 52 min at 6 weeks to 47 min at 6 months), sleep efficiency improved (from 81% at 6 weeks to 83% at 6 months), and slow-wave sleep increased (from 80 min at 6 weeks to 84 min at 6 months).  CBT is however time and resource intensive and accessibility potentially an issue.
| Brief Behavioral Interventions|| |
Brief behavioral interventions can be a more cost effective alternative and consist of individualized 45-60 min sessions, followed by a 30 min follow-up session and two 25 min telephone calls. The intervention involves reducing time spent in bed not sleeping; getting up at the same time every day; not day napping; not going to bed unless tired; and not staying in bed unless asleep. 
| Other Interventions|| |
Exercise, and sleep psycho-education, and sleep restriction/compression are also useful in addressing chronic insomnia and show sustainable long-term results. In randomized controlled trials, participants who exercised 2-3 times/week for 3-6 months had significant reductions in PSQI scores compared with controls.  Sleep restriction, an evidence-based treatment for late-life insomnia  involves reducing the amount of unwanted awake time the patient experiences during the course of the night by matching the prescribed sleep time to actual time spent asleep. A recent placebo controlled trail found sleep restriction to be effective in the management of late-life insomnia. 
| Summary|| |
Late-life chronic insomnia is a common clinical presentation and several factors including presence of physical or mental co-morbid illness; medication use; duration of insomnia, etc. can contribute to the high prevalence of insomnia in later life. Understanding of this bi-directional interplay of insomnia with associated co-morbidities is crucial for effective assessment, diagnosis, and treatment. Several assessment tools are available to assist in easy and quick assessment of insomnia although most are subjective in nature and of limited use in degenerative cognitive disorders.
There is an acute need for the treating clinicians to consider appropriate management of insomnia and placing precedence on psychological treatments. Furthermore, in circumstances where pharmacotherapy is warranted, care must be taken to choose appropriate pharmacological agents and regularly reviewing its prescription to avoid unnecessary long-term treatments with these agents, due to the considerable increase in risk without any evidence of improvement in symptoms of insomnia.
| Key Learning Points|| |
- Chronic Insomnia is a very common presentation in late-life and usually associated with co-morbidity.
- Classification of Sleep disorders (DSM-V and ICDS-3) have been recently updated to improve accuracy of clinical diagnosis.
- Nonpharmacological treatments should be used as the first line.
- Routine BDZ use is no longer recommended.
- Melatonin class of drugs and shorter acting BDZR drugs are effective in a short term but not advocated for prolonged use.
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