Assisting Seniors With Insomnia: A Comprehensive Approach

Darrell Hulisz, RPh, PharmD; Christine Duff, PharmD Candidate

Disclosures

US Pharmacist. 2009;34(6):38-43. 

In This Article

Etiology of Insomnia

Insomnia can be categorized in numerous ways. One way to classify insomnia is in three categories based on duration. Transient insomnia is often self-limited and usually lasts no longer than 7 days; short-term insomnia lasts for 1 to 3 weeks; and chronic insomnia lasts longer than 3 weeks. Chronic insomnia is usually associated with medical, psychiatric, psychological, or substance-use disorders. Insomnia also can be classified as primary or secondary. Primary insomnia is not caused by a health problem; it is a sleep disturbance that cannot be attributed to a medical, psychiatric, or environmental cause. Secondary insomnia, on the other hand, is caused by an underlying medical condition or a medication.

Changes in sleep architecture are common with advancing age. Sleep initiation is more difficult in the elderly, and thus more time is spent awake in bed before falling asleep. Delta-wave sleep decreases, and sleep becomes more fragmented.[1] Waking earlier than planned is another common complaint in the elderly. Changes in the circadian rhythm caused by the normal aging process dictate patterns of falling asleep and waking up earlier in the older population. Daytime napping can also compound the problem. For these reasons, insomnia is more common in people over the age of 65. While some accept this as a typical part of aging, others seek medical or pharmaceutical care.

Insomnia can be caused by stress or by disturbances in the normal sleep-wake cycle. Comorbidities such as physical disability, respiratory problems, medication use, depressive symptoms, environmental factors, poor living conditions, and loss of a spouse, close friend, or relative have all been associated with higher rates of insomnia in individuals over the age of 65.[1] Conditions such as depression, anxiety, asthma, chronic obstructive pulmonary disease, congestive heart failure, thyroid disease, gastroesophageal reflux disease, pain, sleep apnea, and neurologic disorders also are linked to the development of insomnia. Depression and dementia, which are quite common in the elderly, have been associated with sleep disturbances in this population.

Several types of medications have been known to cause insomnia in older people. These include central nervous system (CNS) stimulants (diet pills or amphetamines), antidepressants, corticosteroids, diuretics, anticonvulsants, and certain antihypertensives (e.g., beta-adrenergic blockers). Additionally, alcohol and nicotine can have a profound negative effect on the quality and quantity of sleep.

From the foregoing discussion, it follows that the causes of insomnia usually fall into one of three types: 1) medical and psychiatric, 2) iatrogenic, and 3) psychosocial (Table 1).

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