Karl Doghramji, MD: Because behavioral abnormalities in older individuals are so common, the initial approach to the management of an older individual’s insomnia directly should really rest on behavioral modification, sleep hygiene, and other cognitive behavioral methods. And this, by the way, has been the recommendation of a number of societies, including the American College of Physicians and the American Academy of Family Physicians.
What does that mean? Well, sleep hygiene improvements could be an integral part of behavioral treatment. Things like ensuring a regularity in terms of both bedtime and waking time in the morning on a regular basis. Systematically waking an older individual up at the same time every morning and preventing napping as much as possible during the course of the day, which could take from the propensity to sleep the following night. Avoiding napping as much as possible may be very helpful.
Maximizing exposure to light in the morning by taking older individuals to settings where there are bright-lit rooms, for example, could be very helpful. And also, maximizing daytime exercise. It has been shown time and time again that exercise, aerobic exercise on a regular basis, enhances sleep in individuals and enhances the quantity and the perceived quality of sleep and diminishes daytime sleepiness.
There are a number of therapies that can modify the quality of sleep, 1 of which is called sleep restriction therapy. Older individuals have a propensity to wake up a great deal during sleep, making their sleep inefficient and less productive. So limiting the amount of time they spend in bed over the course of weeks and months could actually produce more sleep depth and continuity over the course of time. This is something called sleep restriction therapy, which seems to work very well with older individuals. These are some of the behavioral methods, which may work very well with older individuals.
The American Academy of Family Physicians and the American College of Physicians, as well as other societies, have recommended that the first approach to the direct management of insomnia in older individuals should really be behavioral modification and cognitive behavioral therapy. And this is in recognition of 2 facts. No. 1, the cognitive behavioral therapy is effective, works well, and has very, very few adverse effects. And its effects are more long-lasting than pharmacotherapy. That’s No. 1.
No. 2, we recognize now more and more that pharmacotherapy can have significant adverse effects in the older patients, who tend to be more fragile, more vulnerable to the effects of medications. Now that’s not to say that pharmacotherapy should be avoided. However, the first approach to the direct management of insomnia really should be cognitive behavioral therapy.