More on insomnia disorders in older patients

Regarding Drs. Irene S. Hong’s and Jeffrey R. Bishop’s article, “Sedative-hypnotics for sleepless geriatric patients: Choose wisely” (Current Psychiatry, 2014;13(10):36-39, 46-50, 52 [https://bit.ly/1ApmcoO]), which undertook a comprehensive review of current therapies for insom­nia in geriatric patients, here are 3 clarifications.
   • I want to reinforce the latest thinking about the nature and patho­physiology of insomnia. DSM-5 clas­sifies insomnia as a disorder, not as a symptom of other problems; the concept of “secondary insomnia” is rejected in DSM-5. Insomnia typically is seen as comorbid with other medi­cal and psychiatric disorders. Often, insomnia predates the comorbid dis­order (eg, depression), but rarely is it resolved by treating the comorbid condition.
   • Good clinical practice, therefore, requires treating the comorbid condi­tion and the insomnia each directly.
   • The insomnia disorder manifests itself, in part, by a report of difficulty falling asleep or staying asleep. The authors use the example of sleep-onset insomnia as typical in older adults. However, sleep maintenance and early morning awakenings are the most common symptoms among geriatric insomnia patients.
   • The authors mention only in passing an important medication for sleep maintenance in adults and in the geriatric patient specifically: doxepin. Low-dose doxepin, at 3 mg (for the geriatric patient) and 6 mg, is FDA-approved as a nonscheduled hypnotic for sleep maintenance insomnia. This formulation^a is the only hypnotic clas­sified as safe for geriatric patients in the 2012 Beers Criteria Update of the American Geriatrics Society.¹ Unlike higher dosages of doxepin, the action of low-dose doxepin is, essentially, selective H1 antagonism.

^aSold as Silenor.