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PRESCRIBING FOR OLDER ADULTS
Treatment of insomnia among the elderly population
Insomnia is a common issue that is frequently experienced by older individuals. Insomnia in older adults is frequently erroneously perceived as a typical aspect of the aging process. Insomnia, the prevailing sleep condition, refers to a personal account of inadequate or unsatisfying sleep while having sufficient chances to sleep. Even though over 50% of senior individuals experience insomnia, it is commonly not adequately addressed. This discussion will examine the factors that contribute to insomnia in older adults, the process of evaluating patients, and the many nonpharmacological and pharmacological methods used to treat insomnia.
Recommend one FDA-approved drug for insomnia.
Rational pharmacotherapy for insomnia is guided by five fundamental principles: employing the minimal effective dosage, administering medication intermittently (2 to 4 times weekly), prescribing medication for a short duration (no longer than 3 to 4 weeks), and gradually discontinuing medication to minimize rebound insomnia. The choice of medication should be determined by the existence and intensity of symptoms experienced during the day, namely the effect on the patient’s ability to function during the day and their overall quality of life. Anticipated pharmacological results encompass enhanced sleep onset, sustained sleep without residual effects, and enhanced functionality the following day. This strategy minimizes the risk of misuse by reducing the number of drug doses needed. Nevertheless, numerous people could derive advantages from prolonged utilization, a strategy that does not always need taking medication every night but rather administering it when symptoms arise.
Medications that have shorter elimination half-lives are typically favored to reduce daytime drowsiness.
Benzodiazepines
Benzodiazepines (BZDs) enhance the quality of sleep-in individuals with insomnia by reducing the duration of REM sleep, shortening the time it takes to fall asleep, and reducing the frequency of waking up during the night.
Aging does not impact the absorption of BZDs. However, the decline in lean body mass, decrease in plasma proteins, and rise in body fat observed in older persons lead to higher levels of unbound drug and a longer drug-elimination half-life.
It is advisable to avoid long-acting benzodiazepines (BZDs).
One off-label drug for insomnia
Antihistaminic
Antihistaminic drugs, such as diphenhydramine, can be utilized for their sedative properties. They are linked to cognitive decline, excessive daytime sleepiness, and anticholinergic side effects.
There is insufficient evidence to demonstrate that antihistamines have a positive effect on insomnia or sleep duration. Moreover, these drugs are generally not recommended for usage in older individuals due to the possibility for adverse effects.
One nonpharmacological intervention for treating insomnia.
Insomnia is often not addressed enough, and healthcare providers do not use nonpharmacologic therapies as much as they could. The initial approach to managing insomnia that is caused by a medical condition, such as pain or difficulty breathing, should prioritize treating the underlying ailment.
Prioritizing nonpharmacologic “sleep hygiene” activities that address the root cause of the issue should be the initial approach and should be maintained even if medication becomes necessary.
Physiological therapies, like as engaging in a daytime walk while being exposed to daylight at the appropriate time, can be beneficial for individuals with insomnia. Optimal temperature regulation, sufficient air circulation, and a dim sleep environment can significantly enhance the quality of sleep-in older individuals.
Cognitive Behavioral Therapy
Behavioral treatment seeks to modify maladaptive sleep patterns, decrease autonomic arousal, and modify dysfunctional beliefs and attitudes that might sustain insomnia. Behavioral interventions encompass techniques such as relaxation therapy, sleep restriction, sensory regulation, and cognitive therapies. Progressive muscle relaxation is a strategy used to decrease physical arousal, while attention-focusing approaches such as imagery training and meditation are designed to decrease cognitive arousal before sleep. Relaxation techniques are especially well-suited for persons who experience stress and anxiety.
Explain the risk assessment you would use to inform your treatment decision making.
Drug-drug interactions are a significant concern because of the multiple medications commonly used by older individuals. It is frequently seen that older individuals are prescribed medication to treat approximately five distinct medical issues. Thus, the drug-drug reaction serves as one of the primary risk assessments to inform our treatment decisions. Boris et al. (2021) conducted the study. Will the chemical we are considering adding to the patient’s existing polypharmacy regimen be compatible or result in a drug-drug interaction? A further crucial concern is to administer psychiatric medications that do not exacerbate the risk of falls in this population, which is already predisposed to falling. Poelgeest et al. (2019). Furthermore, it is crucial for clinicians to assess the functionality of the patients’ kidneys and liver before giving medications that can potentially harm these organs, as this is an important issue to consider in terms of risk.
What are the risks of the FDA-approved medicine?
The Food and Drug Administration (FDA) is warning that several widely used prescription insomnia medications have been associated with infrequent yet severe incidents of sleep-related behaviors, such as sleepwalking, sleep driving, and engaging in activities while not completely awake. These intricate sleep habits have also led to fatalities.
What are the benefits of the FDA-approved medicine?
The main advantage of most sleep aids is their ability to induce sleepiness, facilitating the process of falling asleep and enhancing the probability of maintaining uninterrupted sleep throughout the night.
By enhancing sleep quality in the immediate term, numerous sleep aids can mitigate daytime somnolence and cognitive impairment caused by sleep loss. They can assist in resetting your sleep schedule, so allowing you to obtain more sleep.
What are the risks of the off-label drug?
The use of off-label medication in the elderly patient may result in drug interactions or exacerbate existing health issues. There is a lack of robust trials to establish the safety and effectiveness of the medicine in elderly people. It is important to carefully assess potential long-term adverse effects.
What are the benefits of the off-label drug?
Physicians are given the opportunity to utilize new therapy alternatives that are based on the most recent data.
Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.
Clinical Practice Guidelines (CPGs) are evidence-based publications that offer precise clinical management advice for a specific condition or process. They play a crucial role in directing the selection of different treatments for insomnia. Relevant clinical practice guidelines (CPGs) can aid healthcare professionals and patients in determining the most suitable healthcare options for certain clinical situations. Furthermore, implementing rigorous protocols can effectively govern the conduct of medical professionals, enhance patient contentment, and serve as a valuable instrument in addressing public health issues. On the other hand, guidelines that are of poor quality can lead to inadequate treatment of patients or even put their health at risk. They can also result in the wastage of medical resources and steer clinical research in the wrong direction.
References
Elseviers, M. M., Lopes, L. C., Benko, R., Canis, M., Godman, B., Motter, F. R., & Oliveira, M. G. (2023, August 2). Evidence for Assessing Drug Safety and Drug Use in Older People – Volume II. Frontiers Media SA.
Demurtas, J., & Veronese, N. (2021, December 30). The Role of Family Physicians in Older People Care. Springer Nature.
Walsh, K., Scharf, T., Van Regenmortel, S., & Wanka, A. (2021, March 30). Social Exclusion in Later Life. Springer Nature.
Modesto-Lowe, V., Harabasz, A. K., & Walker, S. A. (2021, May). Quetiapine for primary insomnia: Consider the risks. Cleveland Clinic Journal of Medicine, 88(5), 286–294. https://doi.org/10.3949/ccjm.88a.20031
van Poelgeest, E. P., Pronk, A. C., Rhebergen, D., & van der Velde, N. (2021, March 15). Depression, antidepressants and fall risk: therapeutic dilemmas—a clinical review. European Geriatric Medicine, 12(3), 585–596. https://doi.org/10.1007/s41999-021-00475-7
