A 75-year-old man comes to the office due to difficulty sleeping for the past several months. The patient says, "I think I would be fine if I could just get some sleep." He describes taking at least 45 minutes to an hour to fall asleep at night. He also awakens 2-3 times in the middle of the night and has difficulty falling back asleep, often staying up for an hour or more at a time. He wakes up naturally at his usual time of 6:30 AM but then feels tired throughout the day. The patient lives in a retirement community. His wife died last year and he lives alone. He misses his wife but has no other psychosocial stressors and enjoys playing golf and socializing with a group of friends. He does not feel anxious or depressed and is not sure what keeps him awake or why he is waking up so often. His medical history is significant for aortic stenosis, well-controlled hypertension, osteoporosis, benign prostatic hyperplasia, and constipation. His current medications include terazosin, alendronate, and over-the-counter fiber supplements and multivitamins. The patient does not smoke or use illicit drugs. He drinks alcohol rarely on social occasions. Physical examination is noncontributory. Which of the following is the most appropriate management of this patient's condition?

Question

A 75-year-old man comes to the office due to difficulty sleeping for the past several months.  The patient says, "I think I would be fine if I could just get some sleep."  He describes taking at least 45 minutes to an hour to fall asleep at night.  He also awakens 2-3 times in the middle of the night and has difficulty falling back asleep, often staying up for an hour or more at a time.  He wakes up naturally at his usual time of 6:30 AM but then feels tired throughout the day.  The patient lives in a retirement community.  His wife died last year and he lives alone.  He misses his wife but has no other psychosocial stressors and enjoys playing golf and socializing with a group of friends.  He does not feel anxious or depressed and is not sure what keeps him awake or why he is waking up so often.  His medical history is significant for aortic stenosis, well-controlled hypertension, osteoporosis, benign prostatic hyperplasia, and constipation.  His current medications include terazosin, alendronate, and over-the-counter fiber supplements and multivitamins.  The patient does not smoke or use illicit drugs.  He drinks alcohol rarely on social occasions.  Physical examination is noncontributory.  Which of the following is the most appropriate management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 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. (Choice A) 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. (Choices B and C) 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. (Choice D) 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. Educational objective: Cognitive-behavioral therapy is the preferred initial therapy for insomnia. Elderly patients have an increased risk for adverse effects of hypnotic medications, including daytime sedation, cognitive impairment, delirium, night wandering, agitation, balance problems, falls, and fractures. If medications are necessary, they should be prescribed with caution and in the smallest possible dose. References: Review of safety and efficacy of sleep medicines in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/27751669) Nonbenzodiazepine sedative hypnotics and risk of fall-related injury. (http://www.ncbi.nlm.nih.gov/pubmed/26943470)

A 75-Year-Old Man Comes to the Office Due to Difficulty