What does it look like?
Sleep difficulty is ubiquitous in the psychiatric treatment setting and issues with insomnia can arise as components of another condition or exist independently.
- Primary insomnia can exist with difficulty falling asleep, remaining asleep, waking early, or combinations of these. The difficulty can often be chronic and patients can develop habits and anxiety around sleep that unknowingly perpetuate the problem.
- REM sleep behavior disorder (RBD) is relatively common in older adults, especially in patients with Parkinson’s disease or Dementia with Lewy Bodies. The bed partner will often voice concerns about extreme or even violent movements and behaviors that occur while sleeping.
- Obstructive sleep apnea should always be considered in assessing insomnia and fatigue, particularly if the patient also has cognitive complaints or depression.
- Patients with dementia commonly have disruptions of sleep cycles with periods of alertness overnight. Identifying this problematic behavior is important to help minimize risk of injury, wandering, and caregiver frustration.
How do I screen for it?
A history should include as much detail about sleep and the night routine as possible. Relevant information includes the time spent asleep, time spent in bed, use of sleep aids and evening medications, details of the evening routine, use of electronics or television in bed, exercise, and caffeine and alcohol use.
It is essential to carefully screen for the presence of depression and bipolar disorder in evaluating patients with insomnia. Subacute onset of insomnia is common in geriatric depression, and more common than the hypersomnia that can exist in younger adults with atypical depression.
Episodes of decreased need for sleep with increased energy or lack of fatigue should prompt you to screen for mania.
It is important to assess for stimulant medication or substance use that can contribute to insomnia. In practice, we have seen patients who abuse caffeine, erroneously take bupropion in the evening, and even take a grandchild’s stimulants.
Chronic sleep medication reliance and associated psychological dependence are often part of a complex, but common, syndrome called psychophysiological insomnia.
An effective initial step is to review basic sleep hygiene with patients. Do not assume that patients are familiar with these strategies because of the chronicity of insomnia. Many patients can be helped by reviewing these behaviors and motivating them to establish a helpful evening routine.
Cognitive behavioral therapy for insomnia (CBT-I) is the most effective and evidence-based treatment for chronic insomnia. The therapy works by helping patients identify and change behaviors that inadvertently interfere with sleep, establish a relaxing evening routine, and managing anxiety associated with insomnia.
Melatonin is particularly useful in disorders of circadian rhythm disturbances. Sleep experts can manipulate timing of melatonin and light therapy exposure to help shift aberrant sleep cycles. The utility of melatonin as a hypnotic agent is less clear, although its tolerability is a distinct advantage for older adults.
REM Sleep Behavior Disorder can often be successfully treated with melatonin at doses of 3-10mg. In some patients higher doses can have additional benefit. Benzodiazepines are also shown to be effective for this condition, but should be considered a second-line option.
Sedative-hypnotic medication use is often best avoided in the elderly because of the risk of confusion and falls. If warranted, they should be used for a brief course (1-4 weeks) with plan for discontinuation and alternative treatment. Short-acting agents are often preferred to minimize daytime side effects.
See the section on behavioral management of dementia for details regarding patients with shifted sleep cycles.
- Sleep hygiene recommendations http://sleepeducation.org/essentials-in-sleep/healthy-sleep-habits
- American Academy of Sleep Medicine sleep education website for patients http://sleepeducation.org/home
- Patient information on CBT for insomnia http://sleepeducation.org/treatment-therapy/cognitive-behavioral-therapy
- Clearinghouse document on sleep as you age http://www.med.umich.edu/i/pteducation/docs/SleepDisorders/SleepAsYouAge...
- Krystal AD. A compendium of placebo-controlled trials of the risks/benefits of pharmacologic treatments for insomnia: the empirical basis for clinical practice. Sleep Med Rev. 2009;13(4):265-74.
- Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159(1):5-11.