Nonpharmacological management, rather than hypnotic medications, is the recommended first-line treatment for insomnia. Cognitive-behavioral therapy (CBT) for insomnia is the treatment of choice and should be recommended to this patient. CBT typically combines several approaches, including addressing dysfunctional thoughts about sleep with cognitive therapy, and behavioral measures such as sleep hygiene, sleep restriction, stimulus control, and relaxation techniques. Benefits of CBT persist beyond the active treatment period.
Hypnotic medications should be reserved for patients who do not improve with CBT and should be used with particular caution in the elderly. The elderly are at high risk of adverse effects from hypnotic drugs as these patients are slower to metabolize and eliminate most medications, resulting in a longer duration of effect. Common adverse effects include daytime sedation, cognitive impairment, delirium, night wandering, agitation, balance problems, falls, and fractures.
Diphenhydramine is an antihistamine with sedative properties that can be used to promote sleep. However, it has anticholinergic properties that can cause confusion and worsen benign prostatic hyperplasia and constipation.
Benzodiazepines are not recommended for treatment of chronic insomnia. These should be avoided in the elderly due to the risks of residual daytime sedation, cognitive impairment, abuse and dependence, and motor incoordination resulting in falls and hip fracture.
The nonbenzodiazepine zolpidem is effective for the short-term treatment of insomnia but is also associated with adverse effects, including cognitive impairment, somnolence, dizziness, and falls. It should not be used as an initial treatment for insomnia in the elderly. When prescribed for elderly patients, the lowest dose should be used.