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Insomnia is defined simply as not getting enough sleep. It is defined as either a difficulty falling asleep or as overly frequent night awakenings. Older adults need to be aware that it is not uncommon to sleep less and to have more frequent night awakenings. In fact, older adults are often misdiagnosed with insomnia when they are really experiencing changes in sleeping patterns that are common as people age. Misdiagnoses can often lead to unnecessary treatment.

Causes of Insomnia

Insomnia can be caused by a number of different things. A change in environment (i.e. new work schedule, jet lag), daily stress, and even ingesting small amounts of caffeine (i.e. coffee, cola, tea, chocolate) can cause insomnia. Even drugs that make people feel sleepy, like alcohol, can induce insomnia by altering sleep patterns. It is also important to mention that older adults are often prescribed drugs that can cause or contribute to insomnia. For example, benzodiazepines used to treat insomnia can actually cause insomnia with chronic use.

How Common is Insomnia?

According to the Southwestern Research Institute, 30-40% of Americans suffer from insomnia at least once per year. As a result, more than 15% of adults in America use sedative/hypnotic drugs yearly.

Sleep disturbances are a big problem among the elderly. The Age Venture News Service reports that 30% of adults over 65 suffer from insomnia. This is about 10 million elderly insomnia sufferers in America. It has also been shown that sleep disturbances affect elderly people who live in assisted living facilities with greater prevalence than elderly people who live at home. This is important because sleep disturbances like sleep walking are one of the most common causes of institutionalization in the elderly.

A survey conducted by the National Institute of Drug Abuse found that two thirds of all people over the age of 65 are on prescribed medications. The most commonly prescribed medication for those over 65, excluding cardiovascular drugs, are sedatives and/or tranquilizers. These drugs include "hypnotics", which are used to facilitate sleep for people with insomnia.

How Does Insomnia Affect Quality of Life?

Insomnia that is left untreated can create a number of problems. As mentioned earlier, many elderly people are institutionalized as a result of sleep disturbances like sleep walking. Also, people with insomnia tend to suffer more frequently from depression and anxiety. In general, insomnia can also leave the sufferer feeling tired and unable to perform normal daily activities. An inability to perform daily functions can adversely affect family life, relationships, jobs, or anything else that involves human interaction.

It is not uncommon in the management of insomnia for people to be prescribed drugs called benzodiazepines. Even though these drugs may relieve the symptoms of anxiety, they can cause problems in addition to their side effects. Studies have associated long term benzodiazepine use with an increased risk of falls which can result in an increased risk of fractures and mortality. Clearly, both treated and untreated insomnia can adversely affect quality of life. Therefore, it is important to properly select the appropriate therapy option.

Non-Drug Therapies

To effectively manage insomnia, the first thing to consider is changing daily routine. Changes that help facilitate sleep include: changing bedtime routine (i.e. reading or watching television), avoiding exercise before bedtime, taking a warm bath or drinking a warm glass of milk before bed, exercising during the day, avoiding daytime napping, etc.

Usually when insomnia is not remedied by changing something in the daily routine, then it is usually a result from a medication, sensitivity to a food (i.e. caffeine), or a psychological or biological problem. In the case of psychological problems, psychotherapy has been shown to be especially effective at relieving the problem. Whatever the situation, non-prescription sleeping pills and analgesics (i.e. Tylenol, ibuprofen) should be avoided. Their use is substantiated only when there is pain from surgery or a medical condition that causes or contributes to the insomnia. As previously mentioned, sleeping medications often worsen insomnia with chronic use.

Drug Therapies

Managing insomnia with prescription drugs is only a successful short-term option. Many hypnotics will cause dependence, decrease in effectiveness, or have severe side effects if used on a long-term basis. Therefore, it is always best to consider non-drug therapy options first. It is also important to note that alternative treatments exist like Melatonin that may be effective especially if the insomnia results from a biological imbalance. It is always best to seek medical advice to determine the best management option.

The most common form of drug therapy in the treatment of insomnia is the use of benzodiazepines. About thirty years ago benzodiazepines replaced barbiturates (a highly addictive and toxic class of drugs) because they were thought to be less toxic and less addictive. Later, benzodiazepines were found to be very addictive, and thus should NEVER be used as a long-term therapy. For example, Xanax is a benzodiazepine that is widely prescribed for anxiety, depression, and insomnia yet is highly addictive.

A recent email to AgeNet's Ask a Pharmacist column stated that, "My mom, age 87, has been on Xanax for a long time, and is trying to get off it. . . none of her doctors. . . will help her get off this dangerous, addictive drug. She didn't need it then. She doesn't need it now. How can we find a medical pro who will get her off this stuff? Side effects for her have included insomnia, anxiety, hypertension, nightmares/hallucination, depression, headaches, etc."

It is imperative to understand that doctors may not realize the impact that a benzodiazepine may have on a person's quality of life. In addition, people can't expect their doctors to have an easy solution to benzodiazepine addiction.

As a short-term treatment option, the best benzodiazepines are Ativan (Lorazepam) and Serax (Oxazepam). This judgement is based upon comparing relative toxicities within the benzodiazepine class. In any case, benzodiazepine use should be closely monitored since it can cause dependence, and as previously mentioned, can increase the risk of falls which can result in fractures or mortality.

Non-benzodiazepine drugs are available that have been shown to be just as effective at relieving symptoms associated with insomnia. For example, Ambien (Zolpidem) works much like benzodiazepines but its improved side effect profile makes it a preferred hypnotic for the management of insomnia. Another drug, Desyrel (Trazodone), is an excellent hypnotic for older adults, even though it is generally used as an antidepressant in younger adults.

We hope this review is of benefit in providing you with information that may help you become informed about the various management options for insomnia.

Preferred Hypnotics

Preferred Hypnotics	Cost	Manufacturer	Generic	Cost
Ambien	$$$	brand	Zolpidem	$

Acceptable Hypnotics

Acceptable Hypnotics	Cost	Manufacturer	Generic	Cost
Ativan	$$	brand	Lorazepam	$
Serax	$$	brand	Oxazapam	$
Desyrel	$$$	brand	Trazodone	$

Non-preferred Hypnotics

Non-preferred Hypnotics	Cost	Manufacturer	Generic	Cost
Restoril	$$$	brand	Temazapam	$
Halcion	$$$	brand	Triazolam	$

Excluded Hypnotics

Excluded Agents	Cost	Manufacturer	Generic	Cost
Dalmane	$$$	brand	Flurazepam	$
Librium	$$$	brand	Chlordiazepoxide	$
Tranxene	$$$	brand	Clorazepate Dipotassium	$
Valium	$$$	brand	Diazepam	$
Klonopin*	$$$	brand	Clonazepam	$$

* Although Klonopin is an excluded form of insomnia management, it may be very useful in managing insomnia that results directly from Restless Leg Syndrome.

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