By Amy Smutylo

Certified Nurse Practitioner

Central Ohio Geriatrics

Do you have problems sleeping at night?  Do you dread nightfall because you fear another long night of tossing and turning?  For older adults, insomnia can be a nightly struggle. The incidence of insomnia increases as we age2.  The two largest risk factors for insomnia are age and gender, with increased prevalence in older adults and women3.  When untreated, insomnia can lead to daytime sleepiness, fatigue, reduced participation in activities, depression and overall decreased quality of life2.  There is also an increased occurrence in accidents and falls, which can pose a great health risk to older adults3.

If you have problems sleeping at night, talk to your doctor. The first thing that the doctor will do is look for an underlying cause for the sleep disturbance. The insomnia may be related to a medical illness, a psychiatric condition, substance use or even a side effect of medication2.  Medical conditions that most often contribute to insomnia are decreased bladder control, arthritis, dementia, cardiovascular disease, pain and pulmonary disease5.  Stress from the loss of a loved one, relocation or financial concerns5 also can cause insomnia.  Untreated anxiety and depression can lead to sleepless nights.

Alcohol is often thought to help people fall asleep. However, alcohol prevents people from achieving deep sleep and causes sleep fragmentation later in the night1.  Alcohol metabolism slows as we age, and therefore has more pronounced effects1. 

If an underlying cause is revealed, the first course of treatment for insomnia should be to correct the suspected cause. 

Many people today are self-medicating with over-the-counter medications and herbs. Over-the-counter sleep aids, such Tylenol PM, often contain antihistamines.  People often perceive these as being safe because a prescription is not required.  Antihistamines are often not a wise choice for an older adult because of side effects of blurred vision, dizziness, urinary retention, dry mouth, confusion and increase incidence of falls2.  Antihistamines can be long-acting and lead to daytime sedation as well2.  A number of herbal agents available on the market are said to promote sleep, including valerian root, chamomile, kava-kava, passionflower and lavender oil2.  It is clear that more research is needed in this area.  Older adults should be careful with these agents, however, as they may interact with their prescription medications2.

After a doctor appointment, many patients think the visit was not fruitful unless they leave with prescriptions.  However, the best place to start when managing insomnia  — after determining that there is not an obvious underlying cause — is to improve sleep hygiene.  Sleep hygiene is the practice of achieving high-quality sleep. It is important to try these techniques for 2-3 weeks before considering alternative treatment options, because sleep patterns change slowly over time2.  

Below are recommendations to improve sleep hygiene:

• Avoid caffeine, alcohol, and nicotine

• Avoid heavy meals or large amounts of liquids 3 hours prior to sleep

• Avoid exposure to bright light at night

• Perform regular exercise in the morning or afternoon

• Make your sleep environment comfortable

• Only use the bed for sleep

• Minimize noise or extreme temperatures in the bedroom

• Reduce time spent awake in bed. If unable to fall asleep after 20 minutes, get up and engage in a relaxing activity, such as reading

• Keep a regular, consistent schedule of sleep and wake times, even on weekends

• Consider a relaxing bedtime routine

• Avoid daytime naps longer than 30 minutes

• Increase exposure to bright light during the day1

Melatonin is a hormone that is produced in the pineal gland in our brain that helps to induce sleep4.  As we age, the production of melatonin declines4.  Melatonin supplements are sold over-the-counter at pharmacies and in health food stores and can be beneficial if taken at least 1 hour before sleep.  Ask your doctor if this would be an option to try before considering prescription medications. 

If insomnia continues, after ruling out possible causes and attempting to follow proper sleep hygiene, then it may be reasonable for your practitioner to start medication.  For older patients, use of the lowest starting dose is recommended to minimize side effects.

Insomnia increases the risks of falls, daytime fatigue and a diminished quality of life. If you suffer from insomnia, be sure to talk with your doctor about how you can get more ZZZ’s. 

            1 Avidan, A. (2005). Epidemiology, assessment, and treatment of insomnia in elderly:                                                 treatment of insomnia in the geriatric patient. Retrieved on July 5th, 2011 from www.medscape.org/viewarticle/516282.

2 Martin, J. (2005). Insomnia: Diagnosis and treatment. Clinical Geriatrics, 13, (12) 3-6.

3 Rigaud, A. (2001). Melatonin in elderly patients with insomnia. A systematic review. Z Gerontol Geriatr, 34, (6) 491-497. 

 4 Roth, T. (2007). Insomnia: definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine, 3, (5) 8-10.

 5 Zucker-Goldstein,  M. (2001). Practical geriatrics: insomnia in late life. Psychiatric Services, 52, (12) 1573-1575.