Older patients

The nature of sleep changes with age. Older age is associated with poorer objectively measured sleep with shorter sleep time, diminished sleep efficiency, and more arousals. These changes may be more marked in men than in women, as reported in a large study of over 5,000 elderly people living at home in the USA91. In the same study the association of subjective reporting of poor sleep with older age was conversely stronger in women. The higher prevalence of chronic health conditions, including sleep apnoea, in older adults did not explain changes of sleep parameters with aging and age/sex differences in these relationships.

Special consideration must be given to the treatment of insomnia in the elderly as the motor side-effects of sleep-promoting drugs can lead to an increase in falls.

Non-pharmacological management

Insomnia in elderly patients responds well to cognitive and behavioural therapies (CBT)97. Meta-analyses comparing CBT outcomes in adults >55 years have reported moderate-to-large effect sizes, regardless of age, in sleep-onset latency (SOL) and wake time after sleep onset3550.

Pharmacological management

A systematic review7 and meta-analysis25 of benzodiazepine hypnotics and Z-drugs both indicated that sedative hypnotics had an unfavourable risk/benefit ratio in elderly patients, particularly those at risk of falls and cognitive impairment.

The use of psychotropic drugs has consistently been linked with an increased risk of falls in older people9893140. An increased likelihood of falls has been associated with sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs and calcium channel antagonists98. A retrospective case control study indicated a 2.5-fold increase in the risk of falls in hospital when patients received zolpidem75.

  • National Institute for Health and Care Excellence (NICE)62.

    • Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling
  • British National Formulary (BNF)11

    • Benzodiazepines and the Z–drugs should be avoided in the elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury.
  • British Geriatrics Society12

    • Medication reviews are important – many drugs are particularly associated with adverse outcomes in frailty such as: … long acting benzodiazepines and some sulphonylureas, other sedatives and hypnotics increase falls risk.

The availability of a sleep-promoting medication which does not induce motor side effects provides an alternative treatment approach for older people who have insomnia. Prolonged-release melatonin has been shown to reduce sleep-onset latency and increase subjective sleep quality in patients over 55 of age with a diagnosis of primary insomnia419594 and should be considered as a treatment option in this patient population6197. Whilst direct comparison with benzodiazepines and Z-drugs are limited, prolonged-release melatonin does not exhibit the risk profile of traditional hypnotics in older patients1968.

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