Self Treatment of Insomnia in
the Elderly
Ashdin Tavaria M.D., Nalaka S. Gooneratne M.D.,
Clara Kwan M.D., Nirav Patel M.D.,
Lavanya Madhusudan, Kathy C. Richards, Ph.D.
May 18, 2010
Acknowledgement
Supported by:
– The Hartford Foundation
– Penn Center of Excellence
– National Institute of Health
Introduction
Sleep disorders are common in the
elderly, with up to 57% of older adults
complaining of difficulties with their sleep1
Prevalence of Insomnia by Age
Percent
40
Male Female
30
20
10
0
15-24
25-34
35-44
45-54
55-64
>65
Age Group
-Ohayon, J Psychiat Res
1997
Introduction
Sleep disorders can be associated with an
increased risk of
– Driving accidents 2-4
– Cardiovascular mortality 5
– Falls6
– Depression7
– Cognitive deficits 8
Mortality Hazard Ratio
Insomnia-associated Mortality
3
2.5
2
1.5
1
0.5
0
Nighttime
insomnia
Daytime
sleepiness
Early
awakening
Nursing home study of 272 patients
2 year follow-up
Adjusted for ADLs, age, gender
Manabe et al., Gerontology 2000
Sleep-onset
delay
Adjusted OR for Cognitive
Decline
Insomnia-associated Cognitive Impairment:
Results
4
3.5
3
2.5
2
1.5
1
0.5
0
Nondepressed,
Incident
Insomnia
Nondepressed,
Chronic
Insomnia
Depressed,
no insomnia
at f/u
Depressed,
Incident
Insomnia
Depressed,
Chronic
Insomnia
EPESE dataset, 3 year follow-up, n=6,444
Adjusted for demographic and health factors
Cricco et al., JAGS 2001
Introduction
Despite the significant prevalence of sleep
disorders, many older adults do not seek
evaluation or treatment of their sleep
problems
Instead engage in a number of selftreatment activities 9, 10
Study Methods
Purpose of this study was to explore
– Different types of self-treatment strategies
– Determine their perceived efficacy
Study Methods
Cross-sectional survey study consisting of
a mailed questionnaire
Adults over the age of 65 recruited from
the greater Philadelphia area
Penn Partners in Healthy Living Program
Data Base which is an elder outreach
program affiliated with the University of
Pennsylvania Health System
Results
A total of 242 study questionnaires were
completed
Average of 4.8 treatments used per study
participant (SD 2.9, range 0-13)
Correlation between the number of treatments
attempted and the PSQI sleep quality score
(r=0.37, p<0.0001)
– Suggested that study participants who had worse
sleep quality had attempted more sleep treatments.
Results
Bar graph showing the number of treatments used by subjects
Results
Activity
Percent
Sleep Hygiene
“Listened to radio, music or watched TV”
66.4
“Read a book, newspaper, magazine”
56.2
“Took a nap the next day”
44.0
“Did not nap the next day”
35.0
“Had a snack”
34.1
“Drank other liquids (tea, coffee, milk, etc.)”
32.6
“Drank a beer, wine or other alcohol”
13.0
“Spoke to someone on the telephone”
8.2
“Smoked a cigarette”
4.2
Environment
“Adjusted temperature of the room, adjusted
blankets or clothing”
47.0
“Went to a different room to sleep”
15.6
“Wear ear plugs”
1.4
Medications
“Took a pain medicine”
Results
“Took an over-the-counter sleeping pill (Tylenol PM, etc.)”
“Took a prescription sleeping pill (Valium, Ativan, Sonata,
etc.)”
Alternative Therapies
“Did relaxation exercise, hypnosis, meditated”
“Took a vitamins or herb”
“Took melatonin”
“Went for acupuncture treatment”
Other
“Had a hot bath or massage”
“Went for a walk or exercised (jogging, swimming, etc.)”
Percent
40.1
30.6
22.1
15.3
11.0
10.6
1.9
29.6
18.6
Efficacy of Different Types of
Self-treatment Strategies
Value
Prescription sleeping medicine
Change room
Change room temperature
Radio or TV
Read
Took medicine for pain
Took a nap the next day
OTC sleep med
Spoke to someone
Alcohol
Bath/massage
Value
0
0.5
1
1.5
2
2.5
3
Efficacy of Different Types of
Self-treatment Strategies
Results
Prescription sleeping pills were felt to be
the most effective treatment option (2.5)
Ear plugs (1.0) were felt to be the least
effective
Prescription medications had a perceived
efficacy that was significantly larger than
the other methods (p-value = 0.0024)
Results
In our study, most commonly used interventions
were watching TV or listening to the radio, or
reading
Pain medications were the most commonly used
form of medication highlighting the impact of
pain as a contributing factor to insomnia in the
elderly
Of particular concern, nearly half of all subjects
who used alcohol or over-the-counter sleeping
aids had not told this to their health care
provider
Results
Women are more likely to engage in broad
range of activities to improve their sleep
when compared to men
Caucasians tended to rely on
pharmacotherapy while African Americans
tended to use social tools
Discussion
Wide array of treatment options used by
elders for the management of their
insomnia
High usage rates of several treatments
highlights the importance of inquiring
about the broad range of treatment
choices made by older adults as they seek
to address their sleep complaints
Discussion
Some elderly patients are trying up to 13
different treatments
Discussion
Response rate may be affected by
participants may have become
discouraged by the end and chosen not to
fill out additional questionnaire
Patients may have underreported
negatively viewed activities or treatments
such as alcohol, smoking, or even
medications
Discussion
Self treatment can be dangerous
Patients are unaware of the interplay
between aging and physiology, chronic
diseases and drugs
Polypharmacy can result in adverse drugdrug interactions which can lead to
confusion, falls, and incontinence
– Over-the-counter sleep aids
Discussion
As Healthcare providers we must be
asking our patients about their sleep
patterns
If they are having disturbances we must
ask what if any self-treatment activities
they are engaging in
References
[1] Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints
among elderly persons: an epidemiologic study of three communities. Sleep. 1995; 18: 425-432.
[2] Findley L, Unverzagt M, Suratt P. Automobile accidents in patients with obstructive sleep apne a.
AJRCCM. 1988;138: 337-340.
[3] Ohayon MM, Caulet M, Philip P, Guilleminault C, Priest RG. How sleep and mental disorders are
related to complaints of daytime sleepiness. Arch Intern Med. 1997;157: 2645-2652.
[4] Gander PH, Marshall NS, Harris RB, Reid P. Sleep, sleepiness and motor vehicle accidents: a
national survey. Aust N Z J Public Health. 2005;29: 16-21.
[5] Newman AB, Spiekerman CF, Enright P, et al. Daytime sleepiness predicts mortality and
cardiovascular disease in older adults. The Cardiovascular Healt h Study Research Group. J Am
Geriatric Soc. 2000;48: 115-123.
[6] St George RJ, Delbaere K, Williams P, Lord SR. Sleep quality and falls in older people living in
self- and assisted-care villages. Gerontology. 2009;55: 162-168.
[7] Kim JM, Stewart R, Kim SW, Yang SJ, Shin IS, Yoon JS. Insomnia, depression, and physical
disorders in late life: a 2-year longitudinal community study in Koreans. Sleep. 2009;32: 12211228.
[8] Dealberto M, Pajot N, Courbon D, Alperovitch A. Breathing disorders during sleep and cognitive
performance in an older community sample: the EVA Study. J Am Geriatric Soc. 1996;44: 12871294.
[9] Maczaj M. Pharmacological treatment of insomnia. Drugs. 1993;45: 44-55.
[10] Sproule BA, Busto UE, Buckle C, Herrmann N, Bowles S. The use of non-prescription sleep
products in the elderly. Int J Geriatric Psychiatry. 1999;14: 851-857.
[11] Buysse DJ, Reynolds CF, 3rd, Monk TH, Hoch CC, Yeager AL, Kupfer DJ. Quantification of
subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality
Index (PSQI). Sleep. 1991;14: 331-338.
[12] Corless IB, Bunch EH, Kemppainen JK, et al. Self-care for fatigue in patients With HIV. Oncol
Nurs Forum. 2002;29: E60-69.