• Definition and Prevalence
• Clinical Presentation
• Risk Factors
• Diagnosis and Differential Diagnosis
• Treatment and Management
• Pharmacologic Treatment

Pharmacologic Treatment
The use of sedative-hypnotics in the elderly population must be approached with caution. Because of changes in metabolic and elimination rates, the lowest effective dose must be used. The specific type of sleep disturbance should be determined to establish the appropriate type of sedative; that is, a short-acting, fast-absorbing hypnotic would be appropriate for sleep-onset insomnia (e.g., zolpidem or zaleplon), whereas a medium-acting hypnotic should be used for sleep maintenance insomnia (e.g., temazepam). Long-acting hypnotics are usually contraindicated, as they are bound to create excessive daytime sleepiness and diminished performance the following day, and may increase the risk of car accidents. Ultra-short-acting hypnotics, such as zaleplon, may be used both at the beginning of the night and again, if needed, in the middle of the night, without residual sedation in the morning.

Pharmacologic treatment should be used in combination with behavioral therapy. In a small trial, Morin et al. compared the effectiveness of behavioral, pharmacologic, and combined behavioral and pharmacologic treatment for insomnia in the elderly.

All three modes of treatment were effective compared to placebo in the short term, and the combined approach was slightly better than the behavioral or pharmacologic approaches alone. However, long-term follow-up revealed that those who received pharmacologic treatment alone showed a worsening of their sleep, whereas those who received behavioral treatment alone maintained their gains from posttreatment. For the combined approach group, follow-up results were more variable, that is, some patients maintained their gains in the long run while some did not.

The use of melatonin for the alleviation of insomnia in the elderly has received much attention both in the scientific community and in the general media. Melatonin is a natural hormone that is secreted during the nighttime and is associated with sleep promotion and circadian rhythm regulation. The amount of melatonin secreted at night has been found to drop in the elderly, and this has been associated with the decline in sleep quality in older adults. Melatonin replacement in elderly insomniacs has been found to improve sleep efficiency. In a recent study, insomnia patients were able to discontinue benzodiazepine treatment and maintain good sleep quality with melatonin substitution.

However, melatonin may be effective only in those insomnia patients whose melatonin levels are particularly low or depleted. Furthermore, caution should be used, as there is still much debate regarding the correct dosage and timing of administration. Finally, melatonin is currently sold as a food supplement and lacks proper quality control.