Steps to a Good Night’s Sleep

Almost 60 million Americans suffer from insomnia, many people take prescription or over-the-counter sleep medications to help them sleep through the night. Insomnia also tends to increase as we age, almost half of older adults have problems sleeping.

How can pharmacists help older adults who have trouble sleeping? Jeannie Lee, PharmD, has some answers.

Dr. Lee, assistant head and associate professor of the Department of Pharmacy Practice and Science in the University of Arizona College of Pharmacy, works to understand and optimize pharmacists’ care of geriatric patients. A certified geriatric pharmacist, she practices interprofessionally at the Southern Arizona VA Health Care System and Banner – University Medical Center Tucson and she serves as a research associate at  the University of Arizona Center on Aging. Dr. Lee, who holds a cross-appointment in the UA College of Medicine – Tucson, often teaches health professionals about medications and behavioral strategies for sleep in older adults.

“Because I am a pharmacist and know the risks associated with sleep medications in older adults, I always reserve sleeping pills as a last option for my patients,” she says. “Also, using the popular prescription medications to help sleep increases the total sleep time by an average of less than 15 minutes. Thus, we need to weigh the risks against the benefit of these medications.”

Below, Dr. Lee answers  questions about insomnia and ways to counter it.

Q: Do many older adults have trouble sleeping?

A: Many adults experience insomnia, and trouble sleeping is more common in older people. As many as 57 percent of older adults complain of insomnia. Chronic insomnia is defined as experiencing unsatisfactory sleep at least three nights a week for at least three months.

Q: What are some sleep strategies that work for older adults?

A: Many people have improved their sleep quality by incorporating some combination of exercise, such as tai chi, acupuncture, cognitive therapy, cognitive-behavioral therapy and various sleep hygiene strategies into their routine. “Sleep hygiene” means habits that help people sleep well on a regular basis.

Some practical sleep hygiene strategies include:

• sleeping as long as necessary to feel rested and not staying in bed longer
• following a regular sleep schedule and bedtime routine
• avoiding caffeinated beverages after noon, and avoiding alcohol and smoking within two hours of bedtime
• exercising regularly, at least four or five hours before bedtime
• creating a comfortable sleeping environment
• avoiding daytime naps

Q: What about using over-the-counter (OTC) products to aid sleep?

A: Many OTC sleep products contain sedating antihistamines (for example, diphenhydramine and doxylamine), which can build up in an older adult’s system and cause side effects, such as morning-after drowsiness, grogginess, confusion, memory issues, falls and accidents. I would highly discourage the use of these products. In fact, they are included in the American Geriatrics Society Beers Criteria, a list of inappropriate medications for older adults. However, for patients who still have sleeping problems after using sleep hygiene and non-medications strategies, I would suggest a trial of OTC melatonin, which causes no morning-after problems and may help with the night-day cycle. It is also possible that people produce and secrete less melatonin with aging.

Q: What are the common prescription sleeping medications?

A: Many types of sleep medications are on the market. The most common ones fall into a class of drugs known as sedative-hypnotics, which work by depressing or slowing down the body’s functions. Some common prescription sleep aids include:

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  Zolpidem (Ambien) – most commonly prescribed, but should be avoided in older adults due to side effects, including increased delirium, falls and fractures with minimal improvement in sleep (on Beers Criteria)
• Temazepam (Restoril) – FDA approved since 1981, but should be avoided in older adults due to increased risk of cognitive impairment, delirium, falls, fractures and car accidents (on Beers Criteria)
• Zolpidem tartrate (Ambien CR) – a sustained-release version of Ambien, which should be avoided for reasons described above (on Beers Criteria)
• Eszopiclone (Lunesta) – in the same class as zolpidem and should be avoided in older adults for the same reasons (on Beers Criteria)
• Ramelteon (Rozerem) – works on melatonin receptor and is safer for older adults than other prescription sleep aids, no morning-after effects or abuse potential

Q: Do these sleep aid medications work?

A: According to a recent study, sedative-hypnotic drugs no longer are considered the best long-term treatment for insomnia. These medications come with increased risks of memory and concentration problems, daytime fatigue, falls and motor vehicle accidents. Older adults already are at increased risk for these problems. Sleep medications also are very dangerous when they interact with other medications or are taken at too high a dose. You and your provider or pharmacist should thoroughly discuss your unique situation before you take these medications. Education, sleep hygiene and other behavioral and environmental strategies should be used first to correct expectations, set a bedtime routine, create a comfortable sleeping environment and improve sleep.