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Dr. Sabita Malla, MD, FACP


Insomnia :

is defined as repeated difficulty with sleep initiation, maintenance, consolidation, or quality that occurs despite adequate time and opportunity for sleep and that results in some form of daytime impairment. As many as 95% of Americans have reported an episode of insomnia at some point during their lives.

For insomnia to be considered a disorder, it should be accompanied by daytime tiredness, loss of concentration, irritability, worries about sleep, loss of motivation, or other evidence of daytime impairment that is associated with the sleep difficulty

Prevalent Features associated with insomnia:

  • Female gender
  • Increased age
  • Lower educational attainment
  • Depression
  • Unemployment
  • Economic inactivity
  • Widowed, divorced, or separated status

Women are 1.4 times as likely as men to report insomnia symptoms

Physical examination may offer clues to underlying medical disorders predisposing to insomnia :

  • History suggestive of sleep apnea
  • Symptoms of restless legs syndrome or periodic limb movement disorder or any other neurologic disorder:
  • Daytime symptoms consistent with a medical cause of insomnia:


The AASM guidelines list two primary treatment goals, as follows:

  • To improve sleep quality
  • To improve related daytime impairments

The components of CBT include the following:

  • Sleep hygiene education
  • Cognitive therapy
  • Relaxation therapy
  • Stimulus-control therapy
  • Sleep-restriction therapy

Other measures that may be helpful include the following:

  • Acupressure
  • Dietary modification
  • Exercise (at least 6 hours before bedtime)

Elements of good sleep hygiene:

  • Develop regular sleep habits; this means keeping a regular sleep and wake time, sleeping as much as needed to feel refreshed the following day, but not spending more time in bed than needed
  • Avoid staying in bed in the morning to catch up on sleep
  • Avoid daytime naps; if a nap is necessary, keep it short (less than 1 hour) and avoid napping after 3 pm
  • Keep a regular daytime schedule; regular times for meals, medications, chores, and other activities helps keep the inner body clock running smoothly
  • Do not read, write, eat, watch TV, talk on the phone, or play cards in bed
  • Avoid caffeine after lunch; avoid alcohol within 6 hours of bedtime; avoid nicotine before bedtime
  • Do not go to bed hungry, but do not eat a big meal near bedtime either
  • Avoid sleeping pills, particularly over-the-counter remedies
  • Slow down and unwind before bed (beginning at least 30 minutes before bedtime (a light snack may be helpful); create a bedtime ritual such as getting ready for bed, wearing night clothes, listening to relaxing music, or reading a magazine, newspaper, or book
  • Avoid watching TV in the bedroom or sleeping on the sofa and then going to bed later in the night
  • Avoid stimulating activities prior to bedtime (eg, vigorous exercise, discussing or reviewing finances, or discussing stressful issues with a spouse or partner or ruminating about them with oneself)
  • Keep the bedroom dark, quiet, and at a comfortable temperature
  • Exercise daily; this is best performed in the late afternoon or early evening (but not later than 6-7 pm)
  • Do not force yourself to sleep; if you are unable to fall asleep within 15-30 minutes, get up and do something relaxing until sleepy (eg, read a book in a dimly lit room, watch a non-stimulating TV program); avoid watching the clock or worrying about the perceived consequences of not getting enough sleep

]Multiple factors affect sleep in the elderly:

  • nocturia,
  • pain syndromes,
  • and many medical disorders (eg, heart failure, chronic obstructive pulmonary disease, Parkinson disease).
  • Other factors include restless legs syndrome, sleep apnea (all of which have increased frequency in the elderly),
  • dementia,
  • Changing situational factors such as retirement, bereavement, or financial difficulties, which lead to anxiety and depression. 

Treatment of Insomnia in Elderly Patients

Diet and Exercise

Dietary measures in patients with insomnia are matters of timing and avoidance. The following recommendations may be useful:

  • Avoid caffeinated beverages in the late afternoon or evening, since the stimulant activity of adenosine antagonism can promote hyperarousal
  • Avoid alcohol in the evening, since this can worsen sleep-disordered breathing leading to frequent arousals; furthermore, while alcohol promotes sleep early in the night, it leads to more sleep disruption later in the evening
  • Avoid large meals near bedtime, particularly with gastroesophageal reflux disease or delayed gastric emptying.

Exercise in the late afternoon or early evening (at least 6 hours before bedtime) can promote sleep. However, vigorous physical activity in the late evening (< 6 hours before bedtime) can worsen insomnia.

As in younger patients, nonpharmacologic treatment should take precedence over pharmacologic treatment. Psychological and behavioral interventions are effective in older adults

Drugs tend to have a longer duration of effect in elderly patients as a result of changes in metabolism and elimination. This can lead to an increased incidence of falls and resulting bone fractures at night (if the patient gets up to use the bathroom when not fully awake or ataxic) and decrements in daytime alertness and performance (including increased incidence of motor vehicle accidents).

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