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New Options for Successful Outcomes
by Nalaka Gooneratne, M.D.
Geriatric Times November/December 2004 Vol. V Issue 6
Insomnia is experienced by 15% to 30% of older adults and is often chronic and unremitting (J Am Geriatr Soc 44[7]:778-784; Sleep 18[6]:425-432). While frequently viewed as a fairly benign condition, recent evidence suggests that it is associated with significant sequelae in terms of cognitive function, depression and mortality (Br J Gen Pract 43[376]:445-448; J Intern Med 251[3]:207-216; J Am Geriatr Soc 49[9]:1185-1189).
Despite this growing body of evidence, insomnia is often undertreated in older adults. One revealing study found that while 73% of physicians felt that sleep problems in older adults were important, they were frequently under-investigated (Sleep 15[2]:168-172). Nearly 80% rarely or never ordered a sleep study to evaluate the sleep complaints. However, more than half of the practitioners in this particular survey did routinely obtain sleep histories as part of their clinical exam--a promising sign.
If practitioners believe that sleep disorders are important and sleep histories are often obtained, what are the factors that underlie the relatively low rates of further evaluation with sleep studies? In many cases, such as primary insomnia, a sleep study is not necessarily required as part of the workup. However, another factor may be that many practitioners are skeptical about the treatment options available (Sleep 15[2]:168-172).
The two articles presented in this special report are particularly relevant because they directly address this issue. The first article, "Non-Pharmacological Treatment Options," is a review of the broad range of non-pharmacologic treatment modalities that are available. It benefits from the fact that the authors have hands-on experience implementing a non-pharmacologic treatment strategy for insomnia that has demonstrably reduced sedative-hypnotic use. The incorporation of several patient handouts in the tables/figures is also helpful.
The second article is likewise of benefit in that it provides a concise review of the factors that underlie sleep disruption in patients with Alzheimer's disease--a common patient population for geriatricians.
The emphasis in both articles is on non-pharmacologic approaches. For geriatricians, this is especially cogent because of the risks of polypharmacy and drug interactions in older adults. Indeed, many older adults are reluctant to discuss their sleep problems with their primary care doctor in part because they are concerned that the only way to treat the condition is with another medication. These two articles show us another route that can both help the patient and minimize complications. Insomnia in older adults need not be an intractable condition. Effective treatments exist and can be used to significantly enhance the quality of life of our older patients.
It is with much gratitude that Geriatric Times acknowledges Nalaka Gooneratne, M.D., for his extensive contribution in planning and reviewing this special report. Dr. Gooneratne is assistant professor of medicine and director of the geriatric sleep research program at the University of Pennsylvania School of Medicine.
