Try These Comprehensive Approaches to Treating Insomnia

Effective Non-pharmacological Treatment Is Cognitive Behavioral Therapy

July 26, 2019

AAPA recently spoke to Sharon O’Brien, MPAS, PA-C, a member of the American Academy of Sleep Medicine, who practiced sleep medicine for the past 10 years both in Charlotte and Asheville, North Carolina, and who serves as an author for “Clinical Advisor,” about managing insomnia in the elderly. Here is what she shared.

Why are elderly patients prone to insomnia and what are the common presentations of insomnia?
As we age, circadian rhythms shift with changes in core body temperature, melatonin, and cortisol levels. Common presentations include a decrease in sleep drive, frequent awakenings during the night, and early awakenings with difficulty returning to sleep.

What factors contribute to chronic insomnia?
Age, medical conditions, medications, and financial stressors can be factors that affect elderly patients. They are more likely to experience the death of a spouse and loss of their circle of friends, which can leave them isolated and lonely.

What treatment is appropriate for insomnia?
There are various pharmacological and non-pharmacological approaches to treating insomnia. Following good sleep hygiene is one of the most important things that can be done. Also, ruling out other sleep disorders, such as sleep apnea and restless leg syndrome, is important, as these can be contributors to poor sleep. Controlling pain, which is common in older adults, is vital to a good night’s sleep. If insomnia continues, despite these modalities, medications such as zolpidem, doxepin, and suvorexant can also be considered.

What are some non-pharmacological approaches to treatment?
The most effective non-pharmacological therapy for treatment of insomnia is cognitive behavioral therapy, also known as CBTi. Sleep hygiene education is also very helpful. I recommend practitioners give patients, complaining of insomnia symptoms, a list of sleep hygiene pearls, as often patients see right away where their habits may be jeopardizing their sleep. Melatonin and valerian root are over-the-counter supplements that can be considered. Blue light-blocking glasses, Ebb Therapeutics cooling headband, and Alpha Stim are other non-pharmacological modalities that can be considered.

Are there side effects to drugs used in this area?
I advise caution with sleep aids as these can increase daytime somnolence, cause dizziness and fatigue, and an increased risk of falls. Patients are often on multiple pharmaceuticals, so the benefit versus risk needs to be considered.

When should a patient be referred to a sleep medicine specialist as opposed to being treated in primary care?
If a provider has tried non-pharmaceutical therapies, discussed sleep hygiene, and the patient is still complaining of sleep issues, or the patient has significant daytime somnolence with snoring at night, a polysomnogram may be beneficial to rule out comorbid sleep conditions such as obstructive and central sleep apnea, REM sleep behavior disorder, and periodic leg movements during sleep.

[Current Approaches to Managing Insomnia in the Elderly Supplement]

What else is important for PAs know about this issue?
Managing insomnia in the elderly can be challenging. There are factors that must be considered in the elderly that we don’t typically think about in a young or middle-aged patient. Given the increasing health issues as we age, polypharmacy, the risk of falls, cognitive impairments, the struggles of living on a fixed income, and loss of family and community support, all are contributing factors in the patient’s sleep health. Sometimes, it can be difficult teasing out which struggle might be causing the problem. Don’t give up if your first treatment doesn’t work, or even the second. Patients are appreciative when you give them time and attention, even if it takes a while to find the best course of care for that individual.

Contact Sharon O’Brien at [email protected].