Self-care options for sleep disorders in older adults

OTCs Today

Providing self-care options for older adults with sleep complaints can be challenging. One study found that 57% of individuals older than 65 years experience some level of chronic sleep disturbance.1 Two types of sleep disturbance typically are seen: sleep initiation (difficulty falling asleep) and sleep maintenance (difficulty staying asleep). Sleep maintenance can be more troubling for older adults because they typically stay awake longer when waking compared with younger adults.1 Navigating the many available sleep aids can be confusing for any patient.

Although OTC sleep aids have many brand names, the majority of products contain first-generation antihistamines as the active ingredient. Diphenhydramine and doxylamine are well documented to cause drowsiness, leading to their use as aids in sleep initiation. However, the American Geriatrics Society (AGS) lists these as potentially inappropriate medications for use in older adults. Specifically, AGS notes that the class carries highly anticholinergic effects, and the clearance of these drugs is reduced in older adults, leading to confusion, dry mouth, constipation, and urinary retention. In addition, tolerance can develop, leaving patients at risk for adverse events with lack of the intended benefit.2 Although the first-generation antihistamines are classically used to aid in sleep initiation, patients with sleep maintenance concerns would be unlikely to benefit from this therapy.

The dietary supplement melatonin is an alternative to FDA-approved sleep aids. Melatonin is a natural hormone produced in the human body, and it serves to regulate natural sleep patterns. Melatonin supplementation is commonly used in sleep disorders and has been reported to aid sleep in older adults.3 Melatonin can be an alternative in older adults because generally it is well tolerated and does not possess anticholinergic effects. For managing insomnia related to sleep initiation and sleep maintenance, melatonin dose can range from 0.3 to 5 mg and should be taken 30 minutes before bedtime. Adverse effects related to melatonin are rare but can include nausea and vomiting, headache, irritability, and morning-after drowsiness.3,4 Patients should consult their physician or pharmacist before self-treating with melatonin. Although no concrete recommendations exist regarding length of use with melatonin, if patients have not benefited within 10 days, they should seek medical attention.

Pharmacists should be knowledgeable about counseling on sleep hygiene for older adults who need assistance with sleep initiation and maintenance. Of important note, as people age, they do not require as much sleep. Common sleep hygiene recommendations include the following1–5:

  • Avoid spending time in bed for activities other than sleeping.
  • If difficulty falling asleep occurs, leave the bed and engage in a relaxing activity.
  • Keep a regular sleep schedule.
  • Avoid excessive daytime naps.
  • Maintain an appropriate level of physical activity throughout the day, but avoid activity right before bed.
  • Keep a comfortable bedroom temperature.
  • Avoid heavy meals or excessive fluid intake before bed.
  • Limit use of caffeine, alcohol, and nicotine.
  • Avoid consistent use of sleep aids.

Pharmacists have a responsibility to recommend safe and effective OTC medications to patients seeking self-care for sleep. In the case of older adults, the best option may be to counsel on proper sleep hygiene. If a patient implements proper sleep hygiene habits and does not see an improvement in sleep after 10 days, with or without treatment, referral to a physician is recommended.

References

  1. McCall WV. Sleep in the elderly: burden, diagnosis, and treatment. Prim Care Companion J Clin Psychiatry. 2004;6(1):9–20.
  2. American Geriatrics Society. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.
  3. Olde Rikkert MG, Rigaud AS. Melatonin in elderly patients with insomnia: a systematic review. Z Gerontol Geriatr. 2001;34(6):491–7.
  4. Buscemi N, Vandermeer B, Pandya R, et al. Melatonin for treatment of sleep disorders. Evid Rep Technol Assess (Summ). 2004;(108):1–7.
  5. Thorpy M. Sleep hygiene. www.sleepfoundation.org/article/ask-the-expert/sleep-hygiene. Accessed October 23, 2013.