Insomnia

Along with many physiological alterations in normal aging, sleep patterns change with aging, independent of other factors such as medical comorbidity and medications. Age-related changes in sleep include

• advanced sleep timing,
• shortened nocturnal sleep duration,
• increased frequency of daytime naps,
• increased number of nocturnal awakenings
• time spent awake during the night,
• decreased slow wave sleep, 
• other changes.

Most of these changes appear to occur between young and middle adulthood, as sleep parameters remain largely unchanged among healthy older adults. In addition, the circadian system and sleep homeostatic mechanisms become less robust with normal aging. In addition, the amount and pattern of sleep-related hormone secretion change in normal aging. All these changes contribute to or correlate with age-related changes in sleep. However, healthy older adults are less likely to report sleep problems. Finally, the causes of sleep disturbances in older adults are multifactorial, which include medical and psychiatric conditions, primary sleep disorders, and changes in environment, social engagement, and lifestyle. [1]

Primary sleep disorders

Several primary sleep disorders, which are common in older adults, contribute to poor sleep in older adults. These sleep disorders include

• insomnia
• , sleep-disordered breathing,
• periodic limb movements in sleep,
• restless legs syndrome, and
• REM sleep behavior disorder.

Epidemiological studies found that the prevalence of these primary sleep disorders is considerably higher in older adults than that in younger adults. Medical and psychological comorbidities of aging contribute to the increased prevalvance of insomina symptoms (approximately 50%) in older adults. Interestingly, the prevalence of insomnia in older adults with excellent health is similar to that of younger adults. The increase in SDB frequency in older adults may partially be due to an age-related reduction in pharyngeal muscle function and an increase in comorbidities in older adults. The presentation of these primary sleep disorders contribute to poor sleep in older adults, in terms of difficulties in falling asleep, increased number of nocturnal awakenings, EDS, and complaints of non-restorative sleep. [1]

 Nonpharmacological treatment options have favorable and enduring benefits compared to pharmacological therapy. [2]

Cognitive Behavioral Therapy for Insomnia

When sleep hygiene is not effective, Cognitive Behavioral

Therapy for Insomnia (CBT-I), effective in older adults, should

be attempted. The American College of Physicians recommends CBT-I as first-line management for insomnia in adults.

It consists of 6 to 10 sessions with a trained therapist that focus on cognitive beliefs and counterproductive behaviors that interfere with sleep. [2]

Benzodiazepines and Nonbenzodiazepine Sedatives

Both benzodiazepines and nonbenzodiazepine receptor agonists have a common mechanism of action. They work by binding to a specific receptor site on gamma-aminobutyric acid type A receptors, with the difference being nonbenzodiazepines are more selective for the alpha-1 subclass of receptors, which while causing sedation has minimal anxiolytic, amnesic, and

anticonvulsant effects compared to that of benzodiazepines. Both classes of drugs effectively treat insomnia-related parameters such as sleep onset latency, number of nighttime awakenings, total sleep time, and sleep quality in the short term, but

not with chronic use. Prolonged use of these drugs can lead to tolerance, dependence, rebound insomnia, residual daytime sedation, motor incoordination, cognitive impairment, and increased risk of falls in institutionalized older individuals. These drugs can

have additive effects if taken together. Because of these adverse effects, and the equivalent or superior response seen with

CBT-I for longer duration therapy, use of these drugs should be avoided in older individuals. The recent 2015 Beers criteria

strongly advise avoiding these drugs in the elderly. [2]