AGS: Non-drug Therapies Ease Insomnia in Elderly

SEATTLE, May 3 -- Light, physical activity and other non-drug therapies may be as effective against insomnia in the elderly as pharmacologic interventions, researchers said here.

Environmental factors may be particularly important for residents in long-term-care facilities, according to a panel of presenters at a Takeda Pharmaceuticals-sponsored satellite symposium at the American Geriatrics Society meeting.

Aging is usually accompanied by decreases in total sleep time and sleep quality as well as a shift in circadian rhythms toward an "early-to-bed, early-to-rise" pattern, said Phyllis Zee, M.D., Ph.D., of Northwestern University in Chicago.

These disruptions are even more severe in patients with dementia and those in nursing homes, she said.

One of the causes may be change in exposure to light.

Studies have shown degradation with aging in the response of retinal ganglion cells, which act as circadian photoreceptors, and melatonin to shorter wavelengths of light.

However, aging does not appear to alter response of the circadian clock to broad-spectrum light, she said.

"So it looks like the message here is to increase intensity or duration of exposure to broad spectrum light," Dr. Zee said though there is only early data on efficacy.

For older patients with advanced circadian rhythms, exposure to light in the evening will help delay sleepiness, she said. It also improves sleep efficiency, total sleep time, and daytime performance, she added.

She suggested using commercially available light boxes, which have the advantage of no ultraviolet light exposure, for an hour a day with patients sitting about a foot or 1.5 feet from the light source.

Another strategy is to increase physical activity.

Dr. Zee and colleagues conducted a study of twice daily social and physical activity sessions among community dwelling, healthy elderly patients with insomnia. The sessions improved cognitive performance and increased slow-wave sleep, they reported in the journal Sleep in 2000.

A subsequent study showed that even a single session of playing group games and 50 minutes of light to moderate exercise significantly improved sleep quality.

These strategies are important for dementia patients in nursing homes as well, said Sonia Ancoli-Israel, Ph.D., of the University of California in San Diego.

Studies she led looking at sleep-and-wake patterns among nursing home residents showed they were "on average never asleep for a full hour and never awake for a full hour over 24 hours."

Likewise, light exposure was dismal, with residents almost never getting adequate bright light exposure during the day or sufficient darkness at night, she said.

Her tips for care facilities included:

• Determine the cause of a patient's sleep problem.
• Initiate specific treatment.
• Limit naps to one hour in the early afternoon.
• Adjust medications.
• Avoid all caffeine, including chocolate.
• Improve the environment by keeping it bright during the day, and dark and quiet at night.
• Match roommates when possible by nighttime behaviors.

Behavioral treatments, while requiring a motivated patient, can be as effective as pharmacotherapy, said Dan Buysse, M.D., of the University of Pittsburgh. These may include sleep hygiene education, relaxation training, and sleep restriction therapy.

A meta-analysis in the American Journal of Psychiatry in 2002 in adults of all ages showed that sleep latency was significantly improved by both pharmacotherapy and behavioral therapy to a similar degree (P

While melatonin has not proven to be as effective as hoped, the melatonin receptor antagonist ramelteon (Rozerem) has, he said.

Furthermore, ramelteon may have a somewhat more favorable side-effect profile compared with the benzodiazepine receptor agonists, which are known to increase risk of falls, he said.

Regardless of whether the treatment is pharmacologic or not, "insomnia absolutely should be treated" in this patient group, Dr. Ancoli-Israel said.

Insomnia affects 25% of Americans ages 65 to 79, Dr. Zee said. The prevalence of insomnia complaints is even more common, at 57%, said Dr. Ancoli-Israel.

"Don't think it's normal because they are older; don't think it's normal because they are sick," Dr. Ancoli-Israel said.

In one study she was involved in, the consequence for insomnia among older women was a 30% to 40% increase in falls and increased mortality.

Furthermore, disturbed sleep can cause difficulties with attention, response time, memory, and cognitive performance-all of which can be misinterpreted as dementia-Dr. Ancoli-Israel added.