Treating Insomnia in Older Adults: Title and subTitle BreakTaking a Long-term View

Insomnia complaints in older adults are both prevalent and persistent.^{1 - 2} Insomnia in later life is a symptom with many etiologies: medical, psychiatric, behavioral, and circadian.^{3 - 4} The complications of chronic insomnia (ie, complaints of inadequate or nonrestorative sleep over at least 1 month but often for many years) include sedative–hypnotic agent dependence, self-medication with alcohol, depression, diminished quality of life, and in the case of older adults with dementing disorders, placement in long-term care facilities. Sleep disturbances in older adults have been linked to poor health, depression, angina, limitations in activities of daily living, and the chronic use of benzodiazepines.⁵

Increasing age brings about diminished ability to sleep, but no less need for sleep. Old age is associated with diminution in both the depth and continuity of sleep.⁶ Old age also brings increased prevalence of sleep-disordered breathing and periodic limb movements. Decrease in the ability to sleep is exacerbated by worry over not sleeping (a self-fulfilling prophecy) and by spending increased time in bed, a behavior that is destructive to sleep.

In the study by Morin et al⁷ published in this issue of THE JOURNAL, more than half of the elderly patients (85/163) adjudged to be eligible for the study of Morin et al⁷ on the basis of clinical screening and baseline assessment were excluded, ie, found to have insomnia either coexisting with or related to other sleep disorders such as sleep apnea (40/163), to medical or psychiatric conditions (17/163), or to an inability to stop taking sedative–hypnotic agents (22/163). These data point to the complex etiology of insomnia complaints in later life and to the risk for developing sedative–hypnotic agent dependence with long-term use. Hence, a careful clinical assessment of chronic insomnia complaints is warranted. As detailed in the article by Morin et al,⁷ such assessment should include a consideration of psychiatric disorders such as clinical depression or anxiety, as well as the use of sleep diaries, interview with a bed partner, and a high index of suspicion for sleep-disordered breathing or periodic limb movements. A clinical suspicion of sleep apnea or periodic limb movements in an older patient (eg, loud snoring, excessive daytime sleepiness, or a complaint of restless legs) should be followed up by clinical polysomnography.⁸

When not directly the result of a major psychiatric or medical disorder, or of sleep apnea or periodic limb movements, persistent insomnia is referred to as "primary" or "psychophysiological" insomnia.^{9 - 10} Primary insomnia is a chronic, relapsing disorder, and it is both a consequence of and a risk factor for clinical depression.¹¹

Benzodiazepine sedative hypnotic agents and zolpidem have a proven place in the short-term clinical management of chronic primary insomnia.¹² Our reviews of 30 years of treatment studies of chronic insomnia in nonelderly and elderly patients have shown short-term clinical trials evaluating the efficacy of benzodiazepines and other sedative hypnotic agents over generally fewer than 3 to 4 weeks.^{13 - 14} The current study documents efficacy for 8 weeks, similar to a previous comparison of temazepam with midazolam.¹⁵ Yet patients use these medications for long periods in the absence of good data on beneficial and adverse effects.^{16 - 17}

The dilemma for patients and their physicians is that insomnia complaints tend to be chronic and recurring; hence, long-term disease management strategies are greatly needed. In a study that represents a major advance for the field, Morin and colleagues⁷ have now demonstrated that older patients with chronic primary insomnia who are treated with cognitive behavioral therapy (CBT) targeted for late-life insomnia sustain meaningful clinical gains over a 2-year period after relatively brief treatment (8 weeks), while those treated with short-term sedative-hypnotic drug therapy do not. At the end of the initial 8-week period of treatment, three quarters of patients treated with either CBT alone or with the combination of CBT and temazepam no longer met diagnostic criteria for insomnia, vs 56% of those treated with temazepam alone and 14% of those treated with placebo. It is important to understand that CBT targeted several different facets of late-life insomnia through behavioral, cognitive, and educational components aimed at reducing time in bed, reducing exposure to stimuli destructive to sleep, and correcting erroneous attitudes and expectations about sleep in later life. The reductions of wakefulness after sleep onset, maintained over 2 years in patients who received CBT for 8 weeks (Figure 3, page 991), is a remarkable finding attesting to the holding power of this multifaceted intervention.

The study also points to the importance of attending to clinical disorders such as chronic insomnia and depression in general medical practice. Insomnia is a known risk factor for clinical depression: both disorders are prevalent and persistent, and both are associated with excess disability, reduced quality of life, and increased health care use. However, in general medical practice, only about 1 in 6 older patients with either chronic insomnia or clinical depression receives any treatment at all. As in the case of chronic primary insomnia, the preventive efficacy of psychosocial treatment in late-life depression, especially when combined with medication, also has been recently demonstrated.¹⁸ Effective long-term management of chronic insomnia may also prevent or delay the onset of episodes of major depression¹¹ and thus may represent an opportunity for preventive measures.

Generalizing the results of this efficacy study to primary care, where most older adults receive treatment for insomnia (if they receive any treatment at all), needs to be tested. As in the case of depression, such as illustrated by Katon et al¹⁹ and Schulberg et al,²⁰ collaborative models involving clinicians trained to deliver a well-specified psychosocial intervention to patients with insomnia in primary care clinics should be tested. Such an approach may help to develop necessary, cost-effective, population-based care for a common, debilitating, and chronic disorder.