Hypnotics in the Therapy of Insomnia (Not Only) in the Elderly

Insomnia

We can define insomnia as the inability to initiate nighttime sleep and/or maintain it under appropriate conditions. According to the cause, we can divide it into primary and secondary. In the case of secondary insomnia, sleep is disrupted by numerous psychological or somatic causes, e.g., anxiety, depression, or addictions. Treatment here lies in adequately addressing the cause. In the case of primary insomnia, it may be a so-called psychophysiological insomnia − a condition where the patient had trouble falling asleep and fears that these difficulties will recur. They fear they won't be able to fall asleep, and this leads to increasingly deepening psychological tension that already prevents them from falling asleep.

Non-pharmacological treatment 

In the first phase, it is appropriate to discuss with the patient the possible influences that may negatively disrupt sleep. What is the patient's daily routine? Does the patient sleep during the day? Does the patient have suitable conditions for sleep (light, noise)? Does the patient consume alcohol, coffee, or tea before bed? We try to go over sleep hygiene principles with them, teach relaxation techniques, etc.

Pharmacological treatment 

In practice, unfortunately, we usually cannot manage without pharmacological treatment of insomnia. The armamentarium of hypnotics can be divided into several generations:

• 1st-generation hypnotics: barbiturates, which are no longer used in human medicine due to their numerous side effects. 
• 2nd-generation hypnotics: benzodiazepines, which can develop tolerance with long-term use.
• 3rd-generation hypnotics: so-called Z-drugs (zolpidem, zaleplon, zopiclone).
• Others: some antidepressants (e.g., trazodone or mirtazapine), older generation antihistamines (e.g., promethazine), some antipsychotics.

2nd-generation hypnotics

2nd-generation hypnotics, such as alprazolam or bromazepam, besides the mentioned risk of dose tolerance and accumulation of metabolites into adipose tissue, also have a relatively long biological half-life, where especially older patients may feel sedation carrying over to the next day. The role of these drugs can be significant, especially in cases where maintaining sleep is problematic.

3rd-generation hypnotics

When there is an inability to initiate sleep, 3rd-generation hypnotics, among which zolpidem is the most commonly used molecule, are advantageous. Besides affecting sleep latency, they also reduce the number of awakenings, extend sleep duration, and improve its quality without affecting sleep architecture. They have a short biological half-life, so undesirable effects like morning drowsiness should be minimal. The effect appears within 10–15 minutes and lasts approximately 5 hours. The maximum daily dose is 10 mg, but especially in older patients, it is advisable to start with half the dose and remain on it if effective.

Conclusion

Addressing patients' sleep difficulties in our clinics often simplifies to mere prescription of hypnotics. However, treatment must always be comprehensive, based on regimen measures and psychotherapeutic methods. When pharmacotherapy is necessary, especially in geriatric and frail patients, we can use available modern molecules, e.g., zolpidem, which has fewer side effects and is generally well tolerated.

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Sources:
1. Pretl M., Smolík P., Konštacký S. Insomnia. Novelization 2017. Recommended diagnostic and therapeutic procedures for general practitioners. Center of Recommended Procedures for General Practitioners, Society of General Medicine CLS JEP, Prague, 2017.
2. Polách L. et al. Mental Health Handbook. SYMEDIS PRO, Holešov, 2016.
3. SPC Stilnox. Current text revision on 18. 2. 2020. Available at: www.sukl.cz/modules/medication/download.php?file=SPC153610.pdf&type=spc&as=stilnox-spc