QUESTION. Ms. Antai-Otong, I am a psychiatric consultation liaison nurse and I work with primary care patients. A large percentage of these patients have sleep problems. Many of these patients are older adults with several co-occurring medical problems. Because of the negative side-effect profile of over-the-counter (OTC) medications, such as diphenhydramine, herbs, and benzodiazepines (BDZs), I am hesitant to recommend or prescribe these agents. Please discuss the assessment and treatment of insomnia in older adults.
ANSWER. There are legitimate reasons for hesitating to recommend OTC sleep medications or prescribe hypnotic agents to older adults. Research indicates that even the newer non-BDZ receptor agonists produce similar cognitive side effects as BDZ, albeit with fewer risks. Findings from a meta-analysis of risks and benefits of hypnotics in older people suggested that although improvements in sleep with hypnotics are statistically relevant, the extent is small. Data from this study also suggested an increased risk of falls and cognitive-related side effects associated with these agents did not justify their use in older adults (Glass, Lanctôt, Hermann, Sproule, & Busto, 2005). Despite these concerns, a discussion of non-BDZ receptor agonist hypnotics is worthwhile with the caveat that short-term drug use should only be considered when insomnia produces severe, disabling, or individual stress. Furthermore, the etiology of the insomnia should be identified and treated. Nonpharmacologic interventions such as deep breathing exercise, relaxation techniques, and sleep hygiene must be an integral part of treatment for transient primary insomnia.