Insomnia in the elderly, a pending subject

Insomnia in geriatric patients is a frequent pathology, which often goes unnoticed and is not given the necessary attention by carers and professionals.

Complaints of sleep-related problems are not as frequent, and complaints of other accompanying symptoms should alert the clinician, as atypical presentation is common. Old age, female gender, widowhood or separation are risk factors for insomnia. Detection is important because of the consequences on the quality of life, walking disorders and disability it generates, as well as an increase in cardiovascular risk, mortality and precipitating or prolonging chronic pathologies.

The first thing to do is to find out about the changes that occur during ageing in the sleep process by reducing deep sleep, increasing night-time awakenings and becoming more fragmented, increasing latency time (time until sleep starts), time spent in bed and increasing naps, as well as certain psychosocial changes such as socio-economic status, housing conditions, isolation, social network, hobbies.

Because of the importance of this, it is important to document the chronology, the accompanying symptoms, and to use the sleep diaries to assess life habits, problems at the beginning, maintenance of sleep or early awakening. As well as the actual consequences on the person's daily functioning. The information that the partner can provide is also relevant, as are the therapeutic measures that have been taken. When all the information has been gathered, the presence of a primary or secondary sleep disorder must be assessed in relation to different medical (chronic pain, dyspnoea, nocturia), psychological (affective disorders, anxiety, psychotic, personality disorders) or medical (corticoids, diuretics, adrenergic blockers) pathologies.

Once a diagnosis has been made and the consequences for the patient or his/her environment are known, the therapeutic approach must focus on non-pharmacological or behavioural aspects, with pharmacological aids available at specific times, as the risk-benefit ratio of the different hypnotics in the long term is negative. Both in the community and in the social resources (Day Centres, Gerontology Centres) the availability of professionals who are able to offer structured cognitive-behavioral therapies, serves as a great support in educational aspects and in the control of stimuli to achieve realistic objectives, emphasizing hygienic sleep measures.

In the case of using hypnotics, they are indicated in short periods of time at the minimum effective dose, adapting the doses indicated for the elderly patient. It should be noted that although they are effective in acute insomnia, they only reduce the latency time by 10 minutes and the total sleep time by less than an hour, producing tolerance in the first weeks, with many risks for the elderly, especially if they are taken chronically in the form of balance and cognitive disorders with an increased risk of confusion. In the long term it is not known whether the interventions prevent cardiovascular risk or the risk of later depression. As always, the multi-component approach is the one that can provide the best performance and maximum safety in vulnerable populations.

Wilson et al. British Association for Psychopharmacology consensus statement on evidence based treatment of insomnia, parasomnia and circadian rythm disorder. Journal of Psychopharmacology 2010;24(11):1578-1600.

"The dream is an involuntary poetic art.
Immanuel Kant (1724-1804)