Pitfalls of insomnia management in the elderly: A narrative review

Abstract

Introduction: Insomnia is a common sleep disorder characterized by difficulty initiating or maintaining sleep, significantly impacting daytime functioning and quality of life. Its chronic nature, high prevalence among older adults, and association with multiple comorbidities make it a pressing health concern. Here, we provide an overview of insomnia in the elderly, highlighting the gap between scientific guidelines and real-world clinical practice and the common pitfalls in managing this fragile patient population.

Methods: We performed a comprehensive literature review to synthesize recent findings on insomnia pathophysiology, diagnosis, and treatment in the aging population.

Results: Insomnia in the elderly is frequently intertwined with comorbidities, which both contribute to and are exacerbated by sleep disturbances. The diagnostic process is complex, requiring differentiation between primary insomnia and conditions influenced by comorbidities, medications, and age-related sleep changes. A comprehensive clinical assessment remains the cornerstone of diagnosis. Treatment prioritizes non-pharmacological strategies, with cognitive-behavioral therapy for insomnia as the first-line approach, though accessibility remains a challenge. Pharmacotherapy should be reserved for short-term use, with careful consideration of adverse effects. However, pharmacological treatment often becomes chronic and deviates from clinical recommendations, relying on off-label medications. Insomnia management is further complicated by polypharmacy, which disrupts sleep and increases the risk of drug interactions and side effects, including falls and cognitive decline.

Conclusions: A multidimensional, patient-centered approach is essential for managing insomnia in older adults. Addressing comorbidities, optimizing pharmacological strategies, and improving access to non-pharmacological treatments are crucial steps towards enhancing outcomes and quality of life in this vulnerable population.

Keywords: Aging; Elderly; Insomnia; Pitfalls; Sleep; Treatment.