Diagnosis and Management of Insomnia in Older People W. Vaughn McCall, MD, MS Insomnia is a common but underrecognized problem in elderly patients. Five basic steps can help clinicians identify and treat insomnia. The first step is to ask a single question about sleep at every new patient visit, which goes a long way toward detection of patients with insomnia. The second step is to perform an initial evaluation of the problem, including symptoms, contributing factors, and effects on daytime function. Step three is to determine whether the patient is in crisis. True sleep emergencies are rare, and in most cases, treatment can be delayed until another appointment can be made for a full evaluation of the problem. A sleep evaluation constitutes the fourth step and focuses mainly on a thorough sleep history; blood tests and polysomnography rarely have a role. The final step is intervention. Nonpharmacological strategies are a mainstay of treatment for chronic insomnia, but hypnotics have a role in treating transient insomnia and chronic insomnia that does not improve with nonpharma- cological treatment or treatment of associated primary conditions. Pharmacological therapy usually consists of benzodiazepines with short half-lives or nonbenzodiaze- pines such as zolpidem and zaleplon, although lack of dem- onstrated efficacy against sleep maintenance difficulties, one of the primary symptoms of insomnia among older people, limits use of these agents. Emerging nonbenzodiazepine agents such as indiplon and eszopiclone may specifically address sleep maintenance problems in elderly patients and are pending Food and Drug Administration (FDA) approv- al. (Editor’s note: Since preparation of this manuscript, the FDA has approved eszopiclone for treatment of insomnia.) J Am Geriatr Soc 53:S272–S277, 2005. Key words: insomnia; elderly; diagnosis; nonpharmaco- logical treatment; pharmacological treatment I nsomnia is defined as one or more of the following sleep- related complaints: difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or sleep that is chronically nonrestorative or poor in quality. 1 To warrant a diagnosis of insomnia, these difficulties must occur despite adequate opportunity and circumstances for sleep and must be associated with at least one of the following forms of daytime impairments. 1 fatigue/malaise attentional concentration or memory impairment social/vocational dysfunction mood disturbance/irritability daytime sleepiness motivation/energy/initiative reduction proneness to errors or accidents at work or while driving tension headaches and gastrointestinal symptoms in re- sponse to sleep loss concerns or worries about sleep As discussed by Dr. Ancoli-Israel elsewhere in this sup- plement, insomnia is increasingly prevalent with age and can have important consequences, such as those listed above, for daytime functioning. Changes in sleep architecture are asso- ciated with aging, even in persons who do not consider themselves to have a sleep problem. Healthy older adults experience lightening of sleep as they age, with an increase in the number of brief arousals throughout the night. Findings of increased light sleep and loss of deep slow-wave sleep have corroborated this in the sleep laboratory. 2 (Please also refer to Dr. Ancoli-Israel’s article for further discussion of how and why aging affects sleep architecture.) Key features that dis- tinguish these normal sleep changes from insomnia include effects on daytime function. If distress and daytime conse- quences do not accompany sleep changes, the patient should not be considered to have a clinical diagnosis of insomnia. Even geriatric specialists rarely systematically diagnose and treat insomnia, despite its prevalence in elderly pa- tients. 3 This article recommends a step-by-step approach to diagnosing, evaluating, and treating insomnia in older peo- ple. By following this approach, clinicians can help reduce sleep disturbances in elderly patients. STEP 1: DETECTION OF INSOMNIA Because sleep difficulties are common in older people, cli- nicians caring for geriatric patients should ask at least one question about sleep at each new patient evaluation. It should then be determined whether any difficulties with sleep are associated with daytime deficits or nocturnal dis- tress, thereby warranting consideration for treatment. Address correspondence to W. Vaughn McCall, MD, MS, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail: vmccall@wfubmc.edu DOI: 10.1111/j.1532-5415.2005.53393.x From the Department of Psychiatry and Behavioral Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina. JAGS 53:S272–S277, 2005 r 2005 by the American Geriatrics Society 0002-8614/05/$15.00