CLINICAL SCIENCE SESSION (CSS)

*Kepaniteraan Klinik Senior / Desember 2020

**Pembimbing/ dr. Diva Mariska Tarastin,Sp.Kj

INSOMNIA PADA LANSIA

Dwi Mutiara Ramadhani, S.Ked*

Andi Wahyuni Ahmad, S.Ked*
dr. Diva Mariska Tarastin,Sp.Kj **

KEPANITERAAN KLINIK SENIOR

BAGIAN SMF/PSIKIATRI RSJ PROVINSI JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2020
 Clinical Science Session (CSS)

Insomnia pada Lansia

DISUSUN OLEH
Dwi Mutiara Ramadhani, S.Ked
G1A219127
Andi Wahyuni Ahmad, S.Ked
G1A219139

Telah diterima dan dipresentasikan sebagai salah satu tugas

Bagian kepaniteraan klinik senior
Bagian smf/psikiatri rsj provinsi jambi
Program Studi Pendidikan Kedokteran Universitas Jambi

Laporan ini telah diterima dan dipresentasikan

Jambi, Januari 2020

PEMBIMBING

dr. Diva Mariska Tarastin,Sp.Kj

 KATA PENGANTAR

Segala puji dan syukur kepada Allah SWT atas segala limpahan rahmat dan karunia-Nya
sehingga penulis dapat menyelesaikan referat yang berjudul “Insomnia pada Lansia” sebagai
salah satu syarat dalam mengikuti Kepaniteraan klinik senior bagian smf/psikiatri Rumah Sakit
Jiwa Daerah Provinsi Jambi
Penulis mengucapkan terimakasih kepada dr. Diva Mariska Tarastin,Sp.Kj yang telah
bersedia meluangkan waktu dan pikirannya untuk membimbing penulis selama menjalani
Kepaniteraan Klinik Senior di Ilmu Bagian Ilmu jiwa di Rumah Sakit Jiwa Daerah Provinsi
Jambi.
Penulis menyadari bahwa masih banyak kekerangan pada referat ini, sehingga penulis
mengharapkan kritik dan saran untuk menyempurnakan referat ini. Penulis mengharapkan
semoga referat ini dapat bermanfaat bagi penulis dan pembaca.

Jambi, Desember 2020

penulis
pii: jc-17- 00295 http://dx.doi.org/10.5664/jcsm.7172

RE V I EW A R T IC L ES

Insomnia in the Elderly: A Review

Dhaval Patel, MD; Joel Steinberg, MD; Pragnesh Patel, MD
Department of Geriatrics, Wayne State University School of Medicine, Detroit, Michigan

Background: Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the
subjective complaint of difficulty falling or maintaining sleep, or nonrestorative sleep, producing significant daytime symptoms including difficulty concentrating
and mood disturbances.
Methods: A search of the literature was conducted to review the epidemiology, definition, and age-related changes in sleep, as well as factors contributing
to late-life insomnia and scales utilized for the assessment of insomnia in older people. The aim is to summarize recent diagnostic guidelines and both
nonpharmacological and pharmacological strategies for the management of insomnia in the older population.
Results: Insomnia remains a clinical diagnosis. There are several demographic, psychosocial, biologic, and behavioral factors that can contribute to late-life
insomnia. Older adults are at higher risk for the medical and psychiatric effects of insomnia.
Conclusions: The most important aspect in evaluation of insomnia is detailed history taking and thorough physical examination. Nonpharmacological
treatment options have favorable and enduring benefits compared to pharmacological therapy.
Keywords: cognitive behavioral therapy, elderly, insomnia, pharmacological treatment
Citation: Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med. 2018;14(6):1017–1024.

SCO PE O F T H E PRO B LE M awakenings or problems returning to sleep after awaken-

The population of older adults continues to expand rapidly
from the current 205 million persons aged 60 years or older,
to a projected 2 billion by 2050.1 One of the most common
sleep disturbances in the older population is insomnia.2–4 As
many as 50% of older adults complain about difficulty initiat-
ing or maintaining sleep.5 Prevalence of insomnia is higher in
older individuals than in the younger population.6 The overall
prevalence of insomnia symptoms ranges from 30% to 48%
in the elderly,5,7,8 whereas the prevalence of insomnia disor-
der ranges from 12% to 20%.9 Insomnia is often classified by
the predominant symptom of either difficulty in sleep onset
or sleep maintenance. Sleep maintenance symptoms are most
prevalent among individuals with insomnia (50% to 70%), fol-
lowed by difficulty in initiating sleep (35% to 60%) and non-
restorative sleep (20% to 25%).10 A study of 6,800 older adults
(age 65 years or older) observed an incidence rate for insomnia
symptoms of 5% per year,11 with a yearly incidence of 7.97%
at 1-year follow-up.12 Approximately 50% of the patients with
symptoms of insomnia will have a remission during the follow-
up period, with higher remission rates among older males rela-
tive to females.12,13
D E FI N I T I O N
Insomnia is broadly defined as dissatisfaction with sleep ei-
ther qualitatively or quantitatively. This is usually associated
with one or more of the following: (1) difficulty initiating sleep,
(2) difficulty maintaining sleep, characterized by frequent
ings, and (3) early-morning awakening with inability to return
to sleep.14 The fifth edition of the Diagnostic and Statistical
Manual for Mental Disorders (DSM-5) emphasizes that a sleep
disturbance causes clinically significant distress or functional
impairment, and occurs at least 3 nights a week for at least
3 months despite adequate opportunity to sleep, whereas the
International Statistical Classification of Diseases and Related
Health Problems, 10th revision (ICD-10) requires at least 1
month of symptoms not explained by another sleep-wake dis-
order, illicit substance use, or coexisting medical and psychi-
atric disorders. The term “nonrestorative sleep” is no longer
an accepted diagnostic symptom for the DSM-5; however, it
still remains in the ICD-10 criteria. The pathophysiology of
insomnia disorder induces a state of hyperarousal during sleep
and wakefulness. Hyperarousal is manifested as an elevated
whole-body metabolic rate during sleep and wakefulness, el-
evated cortisol and adrenocorticotropic hormone during the
early sleep period, and reduced parasympathetic tone in heart
rate variability.15 An important change with respect to diag-
nostic classifications was defined in the DSM-5 and the third
edition of the International Classification of Sleep Disorders
(ICSD-3). Insomnia in the ICSD-3 is defined as a complaint of
trouble initiating or maintaining sleep that is associated with
daytime consequences and is not attributable to environmen-
tal circumstances or inadequate opportunity to sleep. This re-
places earlier categories of primary and secondary forms of
insomnia in favor of a broad category for insomnia disorder
when insomnia is comorbid with medical or psychiatric condi-
tions.16 In a study of 6,800 elderly patients (older than 65 years),
Foley et al. demonstrated that 93% have one or more comorbid

Journal of Clinical Sleep Medicine, Vol. 14, No. 6 1017 June 15, 2018
D Patel, J Steinberg and P Patel
conditions and other factors, most commonly depression,
chronic pain, cancer, chronic obstructive pulmonary disease,
cardiovascular diseases, medication use, and factors associ-
ated with aging (retirement, inactivity, or caregiving).11,17–20
The increased prevalence of chronic conditions in later life
may explain most insomnia symptoms in the older population;
1% to 7% of insomnia in later life occurs independently of
chronic conditions.20,21 Reduced mobility, retirement, and re-
duced social interaction are sources of sleep disturbances.22–24
Caregiving may be responsible for ruminations and anxiety
while trying to sleep. Women who are caregivers are found to
have increased prevalence of sleep complaints.18,25 Women are
more often the primary caregivers for their children, parents,
or partner, in addition to working outside of the home, affect-
ing their total sleep time. Women are also more likely than men
to complain of sleep problems and see a general practitioner for
those complains.
FAC TO RS CAUS I N G I N S O M N I A
Spielman and colleagues demonstrated a three-factor model
for understanding the etiology and persistence of insomnia.
This model identifies predisposing, precipitating, and perpetu-
ating factors that combine to raise the likelihood of insomnia
above the insomnia threshold.26
Predisposing Factors
These include demographic, biologic, psychological, and social
characteristics. Women older than 45 years are 1.7 times more
likely to have insomnia than men.7 Those divorced, separated,
or widowed are also more likely to have insomnia than married
individuals.7 Lower levels of education or income may contrib-
ute to insomnia in some cases.7,27 Smoking, alcohol use, and re-
duced physical activity are other factors associated with higher
rates of insomnia in older adults.7,18
Precipitating Factors
These factors generally include stressful life events or medical
conditions that may disrupt sleep. Older adults with respira-
tory symptoms, physical disability, and fair to poor perceived
health are at increased risk of insomnia.11 Medications such as
beta blockers, glucocorticoids, nonsteroidal anti-inflammatory
drugs, decongestants, and antiandrogens may be one of the
factors contributing to insomnia. Several studies have demon-
strated that patients with depression and generalized anxiety
disorder have higher rates of insomnia.11,13,28
Perpetuating Factors
These factors often consist of behavioral or cognitive
changes that arise as a result of acute insomnia. An acute ep-
isode of insomnia will not necessarily develop into chronic
insomnia without these provoking behavioral and cognitive
events. Examples include spending excessive time in bed,
frequent naps, and conditioning (increased anxiety before
sleep onset due to fear of spending another sleepless night).
Nonpharmacological treatment options often target these
perpetuating factors.
Journal of Clinical Sleep Medicine, Vol. 14, No. 6
Insomnia in the Elderly: A Review
CH A N G ES I N S LE E P W I T H AG I N G
Along with many physiologic changes seen with aging, signifi-
cant changes also occur in sleep and circadian rhythm across
the lifespan. Differentiated by waveforms on electroencephalo-
gram and other physiologic signals, sleep is currently classified
into four stages. The first three are non-rapid eye movement
(NREM) stages: stage N1, N2, and N3 sleep. Rapid eye move-
ment (REM) sleep occurs in the fourth stage, stage R sleep.29
Stage N1 sleep is the lightest stage and it accounts for 18%
of older adults’ sleep time.30 In stage N2 sleep, brain waves
slow, body temperature begins to drop, and heart rate slows as
sleep deepens, accounting for 48% of sleep time. Sleep further
deepens in stage N3 sleep, characterized by very slow brain
waves referred to as delta or slow wave sleep. This stage ac-
counts for 16% of sleep.30 Stage R sleep is “paradoxical sleep”
because brain activity is similar to that in awake state with
increased sympathetic tone characterized by rise in blood pres-
sure and heart rate but with muscle atonia.31 Dreaming occurs
in this stage of sleep and accounts for 18% of sleep time in
older adults.30 Total sleep time decreases considerably from 10
to 14 hours a night in the pediatric age range, to 6.5 to 8.5 hours
a night as a young adult, then decreases at a slower rate in the
older age range to 5 to 7 hours a night, and plateaus at about
60 years of age.32 The natural shortening of their total sleep
time in some older adults may generate unrealistic expecta-
tions about sleep duration, producing anxiety that could cause
or worsen insomnia.
Beginning in middle age, adults spend less time in slow
wave sleep and REM sleep. Sleep efficiency continues to de-
crease past age 60 years. There is a prominent increase in
wakefulness after sleep onset, but no change is observed in
sleep latency.32 It is common for healthy older adults to ex-
hibit a temporally advanced sleep phase (falling asleep early
and waking up early).5 However, this may not be true for older
adults with insomnia symptoms, who have a delayed circadian
phase.33 These individuals tend to have circadian dispersion
and lack of synchronization compared to healthy subjects.33
Early awakenings may result in frequent daytime naps, which
further accentuates the problem of insomnia during the night.34
Important time cues (zeitgebers) for circadian rhythm may
erode as one ages; for example, elderly individuals may lack
fixed work schedules or meal times due to retirement, which
further contributes to insomnia. Healthy elderly individuals
sleep as well as younger subjects according to an epidemio-
logical study done by Ohayon.7 Research shows that older indi-
viduals may be more tolerant of sleep deprivation than younger
ones. A study on psychomotor vigilance task performance af-
ter several nights of sleep deprivation in women aged 20 to
30 years compared to older women aged 55 to 65 years found
younger women had more prominent impairments with sleep
deprivation compared to an older age group.35 The American
Insomnia Survey of 10,094 individuals 18 years and older
noted self-reported complaints of insomnia rates were lower
in older adults (older than 65 years) compared to the younger
group (18 to 64 years). This highlights the importance of ap-
proaching any complaint of insomnia in the older population
with more vigilance.9
1018 June 15, 2018
D Patel, J Steinberg and P Patel
M O R B I D I T Y AS S O C I AT E D W I T H I N S O M N I A
Insomnia is associated with significant morbidity if left un-
treated. The strongest level of evidence is for mental illness.
Older individuals with insomnia have a 23% increase in risk of
development of depression symptoms.36 Several studies have
documented an increased risk of depression in older patients
with persistent insomnia.37–39 A recent study noted 44% of older
patients with persistent insomnia continued to have depression
6 months later as compared to only 16% of those without in-
somnia.39 Insomnia and mental disorders such as depression
and anxiety have a bidirectional relationship.40 Additionally,
insomnia also confers an increased risk of suicidal tedencies.41
A meta-analysis of insomnia symptoms and its association with
heart disease, after adjusting for age and other cardiovascular
risk factors, identified that risk ratios for heart disease from
insomnia symptoms ranged from 1.47 to 3.90.42 Sleep loss and
insomnia are associated with hypertension, myocardial infarc-
tion, and perhaps stroke.43–46 In the Sleep Heart Health Study, a
community-based cohort, adults (middle-aged and older) who
reported 5 hours of sleep or less were 2.5 times more likely to
have diabetes, compared with those who slept 7 to 8 hours per
night.47 Another study has also demonstrated that people with
insomnia are at greater risk for metabolic syndrome.48 Recent
research also demonstrates that insomnia symptoms may lead
to increased rates of cancer such as prostate cancer.49 Long-
term insomnia symptoms are also associated with greater risk
of developing cognitive impairment.50,51 A cross-sectional cor-
relation between poor sleep quality and cortical atrophy has
been shown in community-dwelling older adults.52 Insomnia is
regarded as an independent risk factor for work disability, sick
leave, and reduced work performance.53 Economically driven
analyses conclude that insomnia is associated with high direct
and indirect costs for the health care system and society.54
D I AG N O S I S
The evaluation and diagnosis of insomnia is a clinical one,
based on a thorough clinical history of the sleep problems and
relevant comorbidities obtained from the patients, their part-
ners, and/or caregivers. Evaluation of insomnia symptoms
presents challenges as they may occur as a primary disorder
or result from other comorbid conditions. The clinician should
evaluate the nature, frequency, evolution, and duration of
symptoms, as well as the response to treatment. Using vari-
ous sleep diaries and questionnaires, a thorough assessment
of insomnia can be achieved. A Consensus Sleep Diary that
includes detailed questions can assist in obtaining additional
sleep history.55 The temporal aspects of sleep (time at which
a patient goes to bed, attempts at sleep, wake-up time, and fi-
nal time out of bed), quantitative aspects (sleep onset latency,
number and duration of awakenings, wakefulness after sleep
onset, total sleep time), and qualitative aspects (subjective
sleep quality, satisfaction) should be noted. Behavioral fac-
tors, such as the use of electronic devices before going to bed,
should also be addressed because these can suppress bedtime
melatonin production, adversely affecting circadian rhythm.56
Journal of Clinical Sleep Medicine, Vol. 14, No. 6
Insomnia in the Elderly: A Review
Environmental factors including bedroom temperature, light
intensity, sound level, and sleep patterns of the partner should
also be assessed. The clinician should also inquire about symp-
toms generated by other sleep disorders including obstructive
sleep apnea (snoring, breathing pauses), restless leg syndrome
(urge to move the extremities), parasomnias (unusual sleep
behaviors), and circadian rhythm disorders (unusual sleep
timings). Determining the use of alcohol, caffeinated drinks,
cigarettes, and any other substance that can adversely affect the
quality of sleep is also very important. An insomnia evalua-
tion should also include a history and physical examination re-
lated to medical and psychiatric disorders that can exacerbate
insomnia. Neurological disorders (stroke, migraine), chronic
pain, endocrine disorders (hypothyroidism/hyperthyroidism),
chronic obstructive pulmonary disease, asthma, gastroesopha-
geal reflux, and congestive heart failure can lead to or worsen
insomnia. The clinician should also ask about depression, bi-
polar disorder, and anxiety disorders. Medication use should
be reviewed, as sedatives, antidepressants, antihypertensives,
steroids, and antihistamines can interfere with sleep.
Modalities That Assist the Clinician in the Evaluation
of Insomnia
Wrist Actigraphy
Wrist actigraphy, which monitors and stores movement data
for up to 28 days, can be used to monitor treatment response
and to screen for other circadian disorders.57–59
Polysomnography
Polysomnography is not recommended for the evaluation for
insomnia, but contributes to the evaluation of sleep apnea or
parasomnias.60
Insomnia Rating Scales
Numerous insomnia rating scales record symptoms and moni-
tor the response to treatment.
The Insomnia Severity Index measures the subjective symp-
toms and negative outcomes of insomnia over the previous 2
weeks. On this scale, scores higher than 14 suggest “clinical in-
somnia.”61 The Pittsburgh Sleep Quality Index, a 19-item ques-
tionnaire, measures 7 domains of sleep over the prior month.
Global scores higher than 5 indicate clinically significant sleep
disturbances.62
Imaging Studies
Daytime imaging studies are not needed for diagnosis of in-
somnia; however, if performed, MRI studies detect gray mat-
ter reduction in the frontal lobes of the brain63–65 and reduced
hippocampal volume.66–68
T R E AT M E N T
If left untreated, insomnia can have multiple medical and
psychological consequences, emphasizing the importance
of insomnia at any age. Treatment can be divided into non-
pharmacological and pharmacological options.16,24,25,69 Aging
1019 June 15, 2018
D Patel, J Steinberg and P Patel
increases body fat, and reduces total body water and plasma
proteins, resulting in increased drug elimination half-life and
the potential risk of adverse effects. Older adults should there-
fore be treated with nonpharmacological options prior to phar-
macological options.16,70
Nonpharmacological
There are several nonpharmacological options for the treat-
ment of insomnia, including relaxation techniques, improving
sleep hygiene, and cognitive behavioral therapy. These options
are effective in managing insomnia for extended periods of
time, even in patients with cognitive impairment.71
Sleep Hygiene Education
Education regarding sleep hygiene consists of several inter-
ventions that promote healthy stable sleep and a nondisrup-
tive sleep environment. These include avoiding daytime naps,
maintaining a regular sleep schedule, limiting substances such
as caffeinated beverages, nicotine, and alcohol that adversely
affect sleep, and exercising at least 6 hours before bedtime.72,73
Cognitive Behavioral Therapy for Insomnia
When sleep hygiene is not effective, Cognitive Behavioral
Therapy for Insomnia (CBT-I), effective in older adults, should
be attempted.73–75 The American College of Physicians recom-
mends CBT-I as first-line management for insomnia in adults.76
It consists of 6 to 10 sessions with a trained therapist that focus
on cognitive beliefs and counterproductive behaviors that in-
terfere with sleep.
Sleep Restriction Therapy
This therapy involves restricting time in bed to the number of
hours of actual sleep, until sleep efficiency improves. If after 10
days sleep efficiency remains lower than 85%, sleep time in bed
should be restricted by 15 to 30 minutes until sleep efficiency
improves. Time in bed is gradually advanced by 15 to 30 minutes
when the time spent asleep exceeds 85% of total time in bed.77
Stimulus Control Therapy
This therapy attempts to reassociate use of the bed and the de-
sired bedtime to sleep only. This includes going to bed only
when one feels tired, not using bed for reading, working, or
lounging, leaving the bed if unable to sleep in 15 to 20 minutes,
and maintaining a constant wake-up time each morning.78
Relaxation Techniques
These include progressive muscle tensing and relaxing, guided
imagery, paced diaphragmatic breathing, or meditation.25
Brief Behavioral Therapy for Insomnia
Due to financial constraints and lack of psychological re-
sources needed for CBT-I, a shorter form of therapy known
as brief behavioral therapy for insomnia is also available and
involves core techniques from CBT-I, directed at improving
circadian regulation of sleep in more than two sessions. It has
been found to be effective in the geriatric population, with ben-
efits persisting for 6 months and beyond.79 Internet-based be-
havioral therapies have also been found to be effective in older
Journal of Clinical Sleep Medicine, Vol. 14, No. 6
Insomnia in the Elderly: A Review
populations.80 Multicomponent cognitive behavioral therapy
that involves sleep hygiene measures, relaxation techniques,
sleep restriction, and stimulus control is also as effective in
older adults as a stand-alone treatment.81,82
Pharmacological
There are several pharmacological options available for use in
older patients with insomnia. Pharmacological treatments are
primarily classified as benzodiazepine sedatives, nonbenzo-
diazepine sedatives, melatonin receptor agonists, antidepres-
sants, and orexin receptor antagonists. Recently published
clinical practice guidelines of the American Academy of Sleep
Medicine for the pharmacological treatment of chronic insom-
nia represent an evidence-based review of each class of drug
commonly used in the treatment of insomnia.83
Benzodiazepines and Nonbenzodiazepine Sedatives
Both benzodiazepines and nonbenzodiazepine receptor ago-
nists have a common mechanism of action. They work by bind-
ing to a specific receptor site on gamma-aminobutyric acid type
A receptors, with the difference being nonbenzodiazepines are
more selective for the alpha-1 subclass of receptors, which
while causing sedation has minimal anxiolytic, amnesic, and
anticonvulsant effects compared to that of benzodiazepines.84
Both classes of drugs effectively treat insomnia-related param-
eters such as sleep onset latency, number of nighttime awaken-
ings, total sleep time, and sleep quality in the short term, but
not with chronic use.85–87
Prolonged use of these drugs can lead to tolerance, depen-
dence, rebound insomnia, residual daytime sedation, motor
incoordination, cognitive impairment, and increased risk of
falls in institutionalized older individuals.88 These drugs can
have additive effects if taken together. Because of these ad-
verse effects, and the equivalent or superior response seen with
CBT-I for longer duration therapy, use of these drugs should
be avoided in older individuals. The recent 2015 Beers criteria
strongly advise avoiding these drugs in the elderly.89
Pharmacokinetic properties of these drugs dictate the differ-
ences between the drug effects on sleep parameters. Zolpidem
has a shorter half-life (2 to 3 hours) and so may have less poten-
tial for residual daytime adverse events than zopiclone, which
has a longer half-life (5 to 6 hours). However, the shorter half-
life of zolpidem renders it less useful in treating sleep mainte-
nance insomnia. These drugs have a faster onset of action and
therefore can be used in treating sleep onset insomnia (reduce
sleep onset latency).84
Although the benefits outweigh the harms, there have been
reports of impairment in daytime concentration tasks, such as
driving while on zopiclone.90,91 In women, in whom zolpidem
clearance occurs more slowly than in men, morning blood lev-
els following the recommended previous bedtime dose could
be considerably higher, affecting psychomotor performance.92
In 2013, this led the United States Food and Drug Administra-
tion (FDA) to require the manufacturers of zolpidem to lower
the recommended dose, particularly for women, from 10 mg to
5 mg for immediate-release preparations, and 12.5 mg to 6.5
mg for extended-release forms. It also required manufacturers
to lower the recommended doses for men.
1020 June 15, 2018
D Patel, J Steinberg and P Patel
Antidepressants
Various antidepressants, including phenylpiperazine com-
pounds (trazodone), tricyclic antidepressants (doxepin), and
serotonergic antidepressant (mirtazapine), have sedating prop-
erties and are often used for the treatment of insomnia.
Trazodone: It is widely prescribed for insomnia in doses of 25
to 100 mg. A study on trazodone comparing its effect with zol-
pidem in 21 to 65 year olds showed it has similar efficacy for
sleep latency and sleep efficiency, with these effects dissipating
after the first week.93 Adverse events such as dizziness, cardiac
arrhythmias, orthostatic hypotension, and potential priapism
can be significant in the elderly population.94 Clinical practice
guidelines from the American Academy of Sleep Medicine
suggest that clinicians not use trazodone for sleep onset or
maintenance insomnia because its harms outweigh benefits.83
Doxepin: Of all the antidepressants, only doxepin is FDA ap-
proved for insomnia at doses of 3 to 6 mg. It is selective for
histamine 1 receptors. Studies of men and women age 65 years
and older with doses of 1 mg and 3 mg have shown that doxepin
1 mg and 3 mg significantly improved measures of sleep on-
set (patient reported), sleep duration, sleep quality, and global
treatment outcomes over the 12-week study period.95 Higher
doses of doxepin 3 mg and 6 mg to adults (18 to 64 years) with
chronic primary insomnia has also been reported to lead to
significant and sustained improvements in sleep maintenance
and early morning awakenings.96
Mirtazapine: This antidepressant with strong 5-HT2 antago-
nism may also improve insomnia. In a study of adults age 18
to 75 years old with mean age of 40.9 years, the mirtazapine
group had significant improvement in sleep latency, sleep ef-
ficiency, and awakenings after sleep onset after only 2 weeks
of treatment.97 It may be preferred over other drugs as it pro-
duces sedative effects solely through histamine receptor antag-
onism.97 Because of conflicting evidence and habituation to its
sedative effects, it should not be used to treat insomnia in the
absence of depression.
Melatonin Receptor Agonists
Ramelteon: It is also FDA approved for treatment of insom-
nia. In a study of older adults (age 65 years or older), treatment
with ramelteon significantly reduced patient reports of sleep
latency over 5 weeks of treatment with no significant rebound
insomnia or withdrawal effects.98 It is not associated with de-
pendence, memory disturbances, and nocturnal gait instability
in older individuals.99,100
Herbal Supplements
Valerian: As a dietary supplement it lacks FDA approval
and monitoring. Its mechanism of action is believed to occur
through interaction with the neurotransmitter gamma amino-
butyric acid and its receptors. There are limited studies of va-
lerian in elderly individuals and data are lacking in terms of its
efficiency in treating insomnia.
Melatonin: Melatonin at a dose of 2 mg has been approved
in Europe for the short-term treatment of insomnia in patients
Journal of Clinical Sleep Medicine, Vol. 14, No. 6
Insomnia in the Elderly: A Review
age 55 years and older based on decline in melatonin produc-
tion seen with age.101 Treatment has been shown to be effec-
tive for primary insomnia in some studies; however, formal
recommendations for the use of melatonin in the treatment of
insomnia requires further research.83,101,102
Orexin Receptor Antagonists
Suvorexant: It is the first FDA-approved dual orexin recep-
tor antagonist and may be prescribed up to a 20-mg dose. It
targets wakefulness-promoting neuropeptides that regulate
the sleep-wake cycle, demonstrating its efficacy in decreasing
sleep latency and in increasing total sleep time. Suvorexant has
been studied in both elderly (age 65 years or older) and non-
elderly (age 18 to 64 years) patients, identifying no significant
efficacy or safety differences between these two groups.103 Al-
though it is well tolerated by older adults, long-term data are
still lacking.103–105
CO N CLUS I O N S
Insomnia is very prevalent in older adults. Using the history
and physical examination along with insomnia scales, clini-
cians can evaluate and treat insomnia in our rapidly aging
population. Behavioral and cognitive behavioral therapies offer
very effective longer duration treatment and are recommended
as first-line treatment options for insomnia compared to hyp-
notic medications in older adults.
A B B R E V I AT I O N S
CBT-I, cognitive behavioral therapy for insomnia
DSM, Diagnostic and Statistical Manual for Mental Disorders
FDA, United States Food and Drug Administration
ICD, International Statistical Classification of Diseases and
Related Health Problems
ICSD, International Classification of Sleep Disorders
NREM, non-rapid eye movement
REM, rapid eye movement
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102. Riemersma-van der Lek RF, Swaab DF, Twisk J, Hol EM, Hoogendijk WJ, Van SUBMISSION & CORRESPONDENCE INFORMATION
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D I SCLO S U R E S TAT E M E N T
All authors have seen and approved the manuscript. The authors report no conflicts
of interest.

Journal of Clinical Sleep Medicine, Vol. 14, No. 6 1024 June 15, 2018
REVIEW ARTICLES

Insomnia pada Lansia: A Review

Dhaval Patel, MD; Joel Steinberg, MD; Pragnesh Patel, MD

Department of Geriatrics, Wayne State University School of Medicine, Detroit, Michigan

Latar Belakang: Insomnia tetap menjadi salah satu gangguan tidur yang paling umum
ditemui pada populasi klinik geriatrik, yang sering ditandai dengan keluhan subjektif
berupa kesulitan jatuh atau mempertahankan tidur, atau tidur nonrestorative,
menghasilkan gejala siang hari yang signifikan termasuk kesulitan berkonsentrasi dan
gangguan mood.
Metode: Pencarian literatur dilakukan untuk meninjau epidemiologi, definisi, dan
perubahan terkait usia dalam tidur, serta faktor-faktor yang berkontribusi pada insomnia
di usia lanjut dan skala yang digunakan untuk penilaian insomnia pada orang tua.
Tujuannya adalah untuk meringkas pedoman diagnostik terbaru dan strategi
nonfarmakologis dan farmakologis untuk pengelolaan insomnia pada populasi yang
lebih tua.
Hasil: Insomnia tetap merupakan diagnosis klinis. Ada beberapa faktor demografis,
psikososial, biologis, dan perilaku yang dapat menyebabkan insomnia di usia lanjut. Orang
dewasa yang lebih tua berisiko lebih tinggi terkena efek medis dan kejiwaan dari insomnia.
Kesimpulan: Aspek terpenting dalam evaluasi insomnia adalah anamnesis rinci dan
pemeriksaan fisik menyeluruh. Pilihan pengobatan nonfarmakologis memiliki manfaat
yang menguntungkan dan bertahan lama dibandingkan dengan terapi farmakologis.
Kata kunci: terapi perilaku kognitif, lansia, insomnia, pengobatan farmakologis
D Patel, J Steinberg and P Insomnia in the Elderly: A
Patel Review

RUANG LINGKUP MASALAH

Populasi lansia terus berkembang pesat dari saat ini 205 juta orang berusia 60 tahun atau
lebih, menjadi proyeksi 2 miliar pada tahun 2050.1 Salah satu gangguan tidur yang paling
umum pada populasi lansia adalah insomnia. 2-4 Sebanyak 50% orang dewasa yang lebih tua
mengeluh tentang kesulitan memulai atau mempertahankan tidur. 5 Prevalensi insomnia
lebih tinggi pada individu yang lebih tua dibandingkan pada populasi yang lebih muda. 6
Prevalensi keseluruhan gejala insomnia berkisar dari 30% sampai 48% pada orang
tua,5,7,8gangguan sedangkan prevalensiinsomnia berkisar antara 12% sampai 20%. 9 Insomnia
sering diklasifikasikan berdasarkan gejala utama baik kesulitan dalam onset tidur atau
pemeliharaan tidur. Gejala pemeliharaan tidur paling umum di antara individu dengan
insomnia (50% sampai 70%), diikuti oleh kesulitan dalam memulai tidur (35% sampai
60%) dan tidur non-restoratif (20% sampai 25%).10 Sebuah penelitian terhadap 6.800 orang
dewasa yang lebih tua (usia 65 tahun atau lebih) mengamati tingkat kejadian untuk gejala
insomnia 5% per tahun,11 dengan kejadian tahunan 7,97% pada 1 tahun tindak lanjut. 12
Sekitar 50% dari pasien dengan gejala insomnia akan mengalami remisi selama masa
tindak lanjut, dengan tingkat remisi yang lebih tinggi di antara pria yang lebih tua
dibandingkan dengan wanita.12,13

DEFINISI
Insomnia secara luas didefinisikan sebagai ketidakpuasan tidur dengan baik secara
kualitatif maupun kuantitatif. Hal ini biasanya dikaitkan dengan satu atau lebih hal berikut:
(1) kesulitan memulai tidur, (2) kesulitan mempertahankan tidur, ditandai dengan seringnya
terbangun atau masalah kembali tidur setelah bangun, dan (3) bangun pagi dengan
ketidakmampuan untuk kembali ke tidur. 14 Edisi kelima dari Manual Diagnostik dan
Statistik untuk Gangguan Mental (DSM-5) menekankan bahwa gangguan tidur
menyebabkan gangguan atau gangguan fungsional yang signifikan secara klinis, dan terjadi
setidaknya 3 malam seminggu selama setidaknya 3 bulan meskipun cukup kesempatan
untuk tidur, sedangkan Klasifikasi Statistik Internasional untuk Penyakit dan Masalah
Kesehatan Terkait, revisi ke-10 (ICD-10) memerlukan setidaknya 1 bulan gejala yang tidak
dijelaskan oleh gangguan tidur-bangun, penggunaan zat terlarang, atau gangguan medis dan
psikologis yang terjadi bersamaan. Istilah "tidur nonrestorative" tidak lagi menjadi gejala
D Patel, J Steinberg and P Insomnia in the Elderly: A
Patel Review

diagnostik yang diterima untuk DSM-5; Namun, itu masih tetap dalam kriteria ICD-10.
Patofisiologi gangguan insomnia menginduksi keadaan hyperarousal selama tidur dan
terjaga. Hyperarousal dimanifestasikan sebagai peningkatan laju metabolisme seluruh
tubuh selama tidur dan terjaga, peningkatan kortisol dan hormon adrenokortikotropik
selama periode awal tidur, dan penurunan tonus parasimpatis pada variabilitas denyut
jantung.15

Perubahan penting sehubungan dengan klasifikasi diagnostik didefinisikan dalam DSM-5

dan edisi ketiga dari International Classification of Sleep Disorders (ICSD-3). Insomnia di
ICSD-3 didefinisikan sebagai keluhan kesulitan memulai atau mempertahankan tidur yang
terkait dengan konsekuensi siang hari dan tidak disebabkan oleh keadaan lingkungan atau
kesempatan yang tidak memadai untuk tidur. Ini menggantikan kategori awal dari bentuk
primer dan sekunder dari insomnia yang mendukung kategori yang luas untuk gangguan
insomnia ketika insomnia adalah komorbiditas dengan kondisi medis atau psikiatri. 16
Dalam sebuah penelitian terhadap 6.800 pasien usia lanjut (lebih tua dari 65 tahun), Foley
et al. menunjukkan bahwa 93% memiliki satu atau lebih kondisi komorbiditas dan faktor
lain, paling umum depresi, nyeri kronis, kanker, penyakit paru obstruktif kronik, penyakit
kardiovaskular, penggunaan obat, dan faktor yang terkait dengan penuaan (pensiun, tidak
aktif, atau pengasuhan).11,17-20 Peningkatan prevalensi kondisi kronis di kemudian hari
dapat menjelaskan sebagian besar gejala insomnia pada populasi yang lebih tua; 1% hingga
7% insomnia di kemudian hari terjadi secara independen dari kondisi kronis. 20,21 Penurunan
mobilitas, pensiun, dan interaksi sosial yang berkurang adalah sumber gangguan tidur. 22–24
Pengasuhan mungkin bertanggung jawab atas perenungan dan kecemasan saat mencoba
untuk tidur. Wanita yang merupakan pengasuh ditemukan mengalami peningkatan
prevalensi keluhan tidur.18,25 Wanita lebih sering menjadi pengasuh utama bagi anak-anak,
orang tua, atau pasangan mereka, selain bekerja di luar rumah, memengaruhi total waktu
tidur mereka. Wanita juga lebih mungkin daripada pria untuk mengeluh masalah tidur dan
menemui dokter umum untuk keluhan tersebut.
D Patel, J Steinberg and P Insomnia in the Elderly: A
Patel Review

FAKTOR PENYEBAB INSOMNIA

Spielman dan rekannya mendemonstrasikan model tiga faktor untuk memahami etiologi
dan persistensi insomnia. Model ini mengidentifikasi faktor-faktor predisposisi, pemicu,
dan pelestarian yang digabungkan untuk meningkatkan kemungkinan insomnia di atas
ambang insomnia.26

Faktor Predisposisi
Ini termasuk karakteristik demografis, biologis, psikologis, dan sosial. Wanita yang berusia
lebih dari 45 tahun 1,7 kali lebih mungkin mengalami insomnia dibandingkan pria. 7 Mereka
yang bercerai, berpisah, atau janda juga lebih mungkin mengalami insomnia daripada
individu yang sudah menikah.7 Tingkat pendidikan atau pendapatan yang lebih rendah
dapat menyebabkan insomnia dalam beberapa kasus. 7,27 Merokok, penggunaan alkohol, dan
aktivitas fisik berkurang adalah faktor lain yang terkait dengan tingkat insomnia yang lebih
tinggi pada orang dewasa yang lebih tua. 7,18

Faktor Pencetus
-faktor ini umumnya mencakup peristiwa kehidupan yang penuh tekanan atau kondisi
medis yang dapat mengganggu tidur. Orang dewasa yang lebih tua dengan gejala
pernapasan, cacat fisik, dan kesehatan yang dipersepsikan buruk akan meningkatkan risiko
insomnia.11 Obat-obatan seperti penghambat beta, glukokortikoid, obat antiinflamasi
nonsteroid, dekongestan, dan antiandrogen mungkin menjadi salah satu faktor yang
berkontribusi terhadap insomnia. Beberapa penelitian telah menunjukkan bahwa pasien
dengan depresi dan gangguan kecemasan umum memiliki tingkat insomnia yang lebih
tinggi.11,13,28

Faktor melanggengkan
-faktor ini sering terdiri dari perubahan perilaku atau kognitif yang muncul sebagai akibat
dari insomnia akut. Episode akut insomnia tidak akan selalu berkembang menjadi insomnia
kronis tanpa kejadian perilaku dan kognitif yang memprovokasi ini. Contohnya termasuk
menghabiskan waktu berlebihan di tempat tidur, sering tidur siang, dan mengondisikan
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(peningkatan kecemasan sebelum tidur karena takut melewatkan malam tanpa tidur lagi).
Pilihan pengobatan nonfarmakologis sering menargetkan faktor-faktor yang mengabadikan
ini.

PERUBAHAN TIDUR DENGAN PENUAAN

Seiring dengan banyak perubahan fisiologis yang terlihat dengan penuaan, perubahan
signifikan juga terjadi pada tidur dan ritme sirkadian sepanjang umur. Dibedakan oleh
bentuk gelombang pada elektroensefalogram dan sinyal fisiologis lainnya, tidur saat ini
diklasifikasikan menjadi empat tahap. Tiga tahap pertama adalah tahapan non-rapid eye
movement (NREM): tahap tidur N1, N2, dan N3. Tidur rapid eye move- ment (REM)
terjadi pada tahap keempat, tidur tahap R. 29 Tahap tidur N1 adalah tahap paling ringan dan
menyumbang 18% waktu tidur orang dewasa yang lebih tua. 30 Dalam tidur tahap N2,
gelombang otak melambat, suhu tubuh mulai turun, dan detak jantung melambat saat tidur
semakin nyenyak, terhitung 48% dari waktu tidur. Tidur semakin memperdalam tidur
tahap N3, yang ditandai dengan gelombang otak yang sangat lambat yang disebut tidur
delta atau gelombang lambat. Tahap ini mencakup 16% dari tidur. 30 Tahap tidur tidur
adalah "tidur paradoks" karena aktivitas otak mirip dengan kondisi terjaga dengan
peningkatan tonus simpatis yang ditandai dengan peningkatan tekanan darah dan detak
jantung tetapi disertai atonia otot.31 Mimpi terjadi pada tahap tidur ini dan menyumbang
18% dari waktu tidur pada orang dewasa yang lebih tua. 30 Total waktu tidur menurun
drastis dari 10 menjadi 14 jam semalam dalam rentang usia anak-anak, menjadi 6,5 hingga
8,5 jam malam sebagai orang dewasa muda, kemudian menurun pada tingkat yang lebih
lambat pada rentang usia yang lebih tua hingga 5 hingga 7 jam semalam, dan dataran
tinggi pada usia sekitar 60 tahun.32 Pemendekan alami dari total waktu tidur mereka pada
beberapa orang dewasa yang lebih tua dapat menghasilkan harapan yang tidak realistis
tentang durasi tidur, menghasilkan kecemasan yang dapat menyebabkan atau
memperburuk insomnia.
Dimulai pada usia paruh baya, orang dewasa menghabiskan lebih sedikit waktu dalam
tidur gelombang lambat dan tidur REM. Efisiensi tidur terus menurun setelah usia 60
tahun. Ada peningkatan yang mencolok dalam keadaan terjaga setelah mulai tidur, tetapi
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tidak ada perubahan yang diamati pada latensi tidur. 32 Adalah umum bagi orang dewasa
lanjut usia yang sehat untuk keluar dari fase tidur lanjutan sementara (tidur lebih awal dan
bangun lebih awal).5 Namun, ini mungkin tidak berlaku untuk orang dewasa yang lebih tua
dengan gejala insomnia, yang memiliki fase sirkadian tertunda. 33 Individu ini cenderung
memiliki dispersi sirkadian dan kurangnya sinkronisasi dibandingkan dengan subjek
sehat.33 Bangun lebih awal dapat menyebabkan seringnya tidur siang, yang selanjutnya
menonjolkan masalah insomnia pada malam hari. 34 Isyarat waktu penting (zeitgebers)
untuk ritme sirkadian dapat terkikis seiring bertambahnya usia; misalnya, orang lanjut usia
mungkin tidak memiliki jadwal kerja tetap atau waktu makan karena masa pensiun, yang
selanjutnya berkontribusi pada insomnia. Orang tua yang sehat tidur serta subjek yang
lebih muda menurut studi epidemiologi yang dilakukan oleh Ohayon. 7 Penelitian
menunjukkan bahwa individu yang lebih tua mungkin lebih toleran terhadap kurang tidur
daripada yang lebih muda. Sebuah studi tentang kinerja tugas kewaspadaan psikomotor
setelah beberapa malam kurang tidur pada wanita berusia 20 hingga 30 tahun
dibandingkan dengan wanita yang lebih tua berusia 55 hingga 65 tahun menemukan
wanita yang lebih muda memiliki gangguan yang lebih menonjol dengan kurang tidur
dibandingkan dengan kelompok usia yang lebih tua.35 The American Insomnia Survey
terhadap 10.094 orang berusia 18 tahun ke atas mencatat keluhan tingkat insomnia yang
dilaporkan sendiri lebih rendah pada orang dewasa yang lebih tua (lebih tua dari 65 tahun)
dibandingkan dengan kelompok yang lebih muda (18 sampai 64 tahun). Ini menyoroti
pentingnya pendekatan keluhan insomnia pada populasi yang lebih tua dengan lebih
waspada.

MORBIDITAS YANG TERKAIT DENGAN INSOMNIA

Insomnia dikaitkan dengan morbiditas yang signifikan jika tidak diobati. Tingkat bukti
terkuat adalah untuk penyakit mental. Orang yang lebih tua dengan insomnia memiliki
peningkatan risiko 23% untuk mengembangkan gejala depresi. 36 Beberapa penelitian telah
mendokumentasikan peningkatan risiko depresi pada pasien yang lebih tua dengan
insomnia persisten.37-39 Sebuah studi baru-baru ini mencatat 44% pasien yang lebih tua
dengan insomnia persisten terus mengalami depresi 6 bulan kemudian dibandingkan
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dengan hanya 16% dari mereka yang tidak mengalami insomnia. 39 Insomnia dan gangguan
mental seperti depresi dan kecemasan memiliki hubungan dua arah. 40 Selain itu, insomnia
juga meningkatkan risiko kecenderungan untuk bunuh diri. 41 Sebuah meta-analisis gejala
insomnia dan hubungannya dengan penyakit jantung, setelah disesuaikan dengan usia dan
faktor risiko kardiovaskular lainnya, mengidentifikasi bahwa rasio risiko penyakit jantung
dari gejala insomnia berkisar antara 1,47 hingga 3,90. 42 Kurang tidur dan insomnia
berhubungan dengan hipertensi, infark miokard, dan mungkin stroke.43–46 Dalam Sleep
Heart Health Study, sebuah kelompok berbasis komunitas, orang dewasa (paruh baya dan
lebih tua) yang melaporkan 5 jam tidur atau kurang, 2,5 kali lebih mungkin menderita
diabetes, dibandingkan dengan mereka yang tidur 7 hingga 8 jam. per malam. 47 Penelitian
lain juga menunjukkan bahwa orang dengan insomnia memiliki risiko lebih besar untuk
sindrom metabolik.48 Penelitian terbaru juga menunjukkan bahwa gejala insomnia dapat
menyebabkan peningkatan angka kanker seperti kanker prostat. 49 Gejala insomnia jangka
panjang juga terkait dengan risiko yang lebih besar untuk mengembangkan gangguan
kognitif.50,51 Korelasi cross-sectional antara kualitas tidur yang buruk dan atrofi kortikal
telah ditunjukkan pada lansia yang tinggal di komunitas. 52 Insomnia dianggap sebagai
faktor risiko independen untuk ketidakmampuan kerja, cuti sakit, dan penurunan prestasi
kerja.53 Analisis ekonomi menyimpulkan bahwa insomnia dikaitkan dengan biaya langsung
dan tidak langsung yang tinggi untuk sistem perawatan kesehatan dan masyarakat.54

DIAGNOSA
Evaluasi dan diagnosis insomnia adalah salah satu klinis, berdasarkan pada riwayat klinis
menyeluruh dari masalah tidur dan komorbiditas relevan yang diperoleh dari pasien,
pasangan mereka, dan / atau pengasuh. Evaluasi gejala insomnia menghadirkan tantangan
karena dapat terjadi sebagai gangguan primer atau akibat dari kondisi komorbid lainnya.
Dokter harus mengevaluasi sifat, frekuensi, evolusi, dan durasi gejala, serta respons
terhadap pengobatan. Dengan menggunakan berbagai buku harian tidur dan kuesioner,
penilaian insomnia yang menyeluruh dapat dicapai. Buku Harian Tidur Konsensus yang
mencakup pertanyaan terperinci dapat membantu mendapatkan riwayat tidur tambahan. 55
Aspek temporal dari tidur (waktu di mana pasien pergi tidur, upaya untuk tidur, waktu
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bangun, dan waktu akhir dari tempat tidur), aspek kuantitatif (latensi onset tidur, jumlah
dan durasi bangun, terjaga setelah onset tidur, total waktu tidur), dan aspek kualitatif
(kualitas tidur subjektif, kepuasan) harus diperhatikan. Faktor perilaku, seperti penggunaan
perangkat elektronik sebelum tidur, juga harus diperhatikan karena ini dapat menekan
produksi melatonin sebelum tidur, yang berdampak buruk pada ritme sirkadian.56

Faktor lingkungan termasuk suhu kamar, intensitas cahaya, tingkat suara, dan pola tidur
pasangan juga harus dinilai. Dokter juga harus menanyakan tentang gejala yang ditimbulkan
oleh gangguan tidur lainnya termasuk apnea tidur obstruktif (mendengkur, jeda
pernapasan), sindrom kaki gelisah (dorongan untuk menggerakkan ekstremitas), parasomnia
(perilaku tidur yang tidak biasa), dan gangguan ritme sirkadian (tidur yang tidak biasa)
pengaturan waktu). Menentukan penggunaan alkohol, minuman berkafein, rokok, dan zat
lain yang dapat mempengaruhi kualitas tidur juga sangat penting. Evaluasi insomnia juga
harus mencakup riwayat dan pemeriksaan fisik yang berhubungan dengan gangguan medis
dan psikiatri yang dapat memperburuk insomnia. Gangguan neurologis (stroke, migrain),
nyeri kronis, gangguan endokrin (hipotiroidisme / hipertiroidisme), penyakit paru obstruktif
kronik, asma, refluks gastroesofagus, dan gagal jantung kongestif dapat menyebabkan atau
memperburuk insomnia. Dokter juga harus bertanya tentang depresi, gangguan dua kutub,
dan gangguan kecemasan. Penggunaan obat harus ditinjau ulang, karena obat penenang,
antidepresan, antihipertensi, steroid, dan antihistamin dapat mengganggu tidur.

Modalitas Itu Membantu Clinician diEvaluasi Insomnia

Wrist actigraphy

actigraphyWrist, yang monitor dan data pergerakan toko hingga 28 hari, dapat digunakan
untuk respon pengobatan memantau dan ke layar untuk gangguan sirkadian lainnya. 57–59

Polisomnografi

Polisomnografi tidak direkomendasikan untuk evaluasi insomnia, tetapi berkontribusi pada

evaluasi apnea tidur atau parasomnia.60

Skala Penilaian Insomnia

Banyak skala penilaian insomnia mencatat gejala dan memantau respon terhadap
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pengobatan.
Indeks Keparahan Insomnia mengukur gejala subjektif dan hasil negatif dari insomnia
selama 2 minggu sebelumnya. Pada skala ini, skor yang lebih tinggi dari 14 menunjukkan
"kelainan klinis".61 Pittsburgh Sleep Quality Index, sebuah kuesioner 19 item, mengukur 7
domain tidur selama bulan sebelumnya. Skor global yang lebih tinggi dari 5 menunjukkan
gangguan tidur yang signifikan secara klinis. 62

Studi Pencitraan Studi

pencitraan siang hari tidak diperlukan untuk diagnosis infomnia; namun, jika dilakukan,
studi MRI mendeteksi pengurangan materi abu-abu di lobus frontal otak63-65 dan volume
hipokampus berkurang.66–68

PENGOBATAN
Jika tidak diobati, insomnia dapat memiliki beberapa
konsekuensi medis dan psikologis, menekankan pentingnya insomnia pada usia berapa
pun. Pengobatan dapat dibagi menjadi pilihan nonfarmakologis dan farmakologis.16,24,25,69
Penuaan meningkatkan lemak tubuh, dan mengurangi total air tubuh dan protein plasma,
menghasilkan peningkatan waktu paruh eliminasi obat dan potensi risiko efek samping.
Oleh karena itu, orang dewasa yang lebih tua harus diperlakukan dengan pilihan
nonfarmakologis sebelum pilihan farmakologis. 16,70

Nonpharmacological
Ada beberapa pilihan nonfarmakologi untuk ment memperlakukan insomnia, termasuk
teknik relaksasi, meningkatkan kesehatan tidur, dan terapi perilaku kognitif. Pilihan ini
efektif dalam mengelola insomnia untuk waktu yang lama, bahkan pada pasien dengan
gangguan kognitif.71

Pendidikan Higiene Tidur

Pendidikan tentang higiene tidur terdiri dari beberapa intervensi yang mendorong tidur
stabil yang sehat dan lingkungan tidur yang tidak mengganggu. Ini termasuk menghindari
tidur siang, menjaga jadwal tidur yang teratur, membatasi zat-zat seperti minuman
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berkafein, nikotin, dan alkohol yang mempengaruhi tidur, dan berolahraga setidaknya 6
jam sebelum tidur.72,73

Terapi Perilaku Kognitif untuk Insomnia

Ketika higiene tidur tidak efektif, Terapi Perilaku Kognitif untuk Insomnia (CBT-I), efektif
pada orang dewasa yang lebih tua, harus dicoba. 73–75 American College of Physicians
merekomendasikan CBT-I sebagai manajemen lini pertama untuk insomnia pada orang
dewasa.76 Ini terdiri dari 6 sampai 10 sesi dengan terapis terlatih yang berfokus pada
keyakinan kognitif dan perilaku kontraproduktif yang mengganggu tidur.

Terapi Pembatasan Tidur

ini melibatkan pembatasan waktu di tempat tidur hingga jumlah jam tidur sebenarnya,
sampai efisiensi tidur membaik. Jika setelah 10 hari efisiensi tidur tetap lebih rendah dari
85%, waktu tidur di tempat tidur harus dibatasi 15 sampai 30 menit sampai efisiensi tidur
membaik. Waktu di tempat tidur ditingkatkan secara bertahap 15 hingga 30 menit ketika
waktu yang dihabiskan untuk tidur melebihi 85% dari total waktu di tempat tidur. 77

Terapi Pengendalian Stimulus

ini mencoba untuk menghubungkan kembali penggunaan tempat tidur dan waktu tidur yang
diinginkan untuk tidur saja. Ini termasuk tidur hanya ketika seseorang merasa lelah, tidak
menggunakan tempat tidur untuk membaca, bekerja, atau bersantai, meninggalkan tempat
tidur jika tidak dapat tidur dalam 15 sampai 20 menit, dan mempertahankan waktu bangun
yang konstan setiap pagi.78

Terapi Teknik Relaksasi

Ini termasuk pengencangan dan relaksasi otot progresif, perumpamaan terarah, pernapasan
diafragma serba guna, atau meditasi.25

Terapi Perilaku Singkat untuk Insomnia

Karena kendala keuangan dan kurangnya sumber daya psikologis yang diperlukan untuk
CBT-I, bentuk terapi yang lebih pendek yang dikenal sebagai terapi perilaku singkat untuk
insomnia juga tersedia dan melibatkan teknik inti dari CBT-I, yang diarahkan untuk
meningkatkan regulasi sirkadian tidur di lebih dari dua sesi. Telah terbukti efektif pada
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populasi geriatri, dengan manfaat yang bertahan selama 6 bulan dan seterusnya. 79 terapi
perilaku berbasis Internet juga telah terbukti efektif padalebih tua

populasi yang.80 Terapi perilaku kognitif multikomponen yang melibatkan tindakan

kebersihan tidur, teknik relaksasi, pembatasan tidur, dan kontrol stimulus juga sama
efektifnya pada orang dewasa yang lebih tua sebagai pengobatan yang berdiri sendiri. 81,82

Farmakologis
Ada beberapa pilihan farmakologis yang tersedia untuk digunakan pada pasien lansia
dengan insomnia. Perawatan farmakologis terutama diklasifikasikan sebagai obat
penenang benzodiazepine, sedatif nonbenzo-diazepine, agonis reseptor melatonin,
antidepresan, dan antagonis reseptor orexin. Pedoman praktik klinis yang baru-baru ini
diterbitkan dari American Academy of Sleep Medicine untuk pengobatan farmakologis
insomnia kronis merupakan tinjauan berbasis bukti dari setiap kelas obat yang biasa
digunakan dalam pengobatan insomnia.83

Benzodiazepine dan Nonbenzodiazepine Sedatif

Baik benzodiazepine dan nonbenzodiazepine reseptor obat penenang memiliki mekanisme

kerja yang sama. Mereka bekerja dengan mengikat ke situs reseptor tertentu pada reseptor
gamma-aminobutyric acid tipe A, dengan perbedaan menjadi nonbenzodiazepine lebih
selektif untuk subkelas alpha-1 reseptor, yang sementara menyebabkan sedasi memiliki
efek anxiolytic, amnesic, dan antikonvulsan yang minimal. dibandingkan dengan
benzodiazepin.84 Kedua kelas obat secara efektif menangani parameter yang berhubungan
dengan insomnia seperti latensi onset tidur, jumlah terbangun di malam hari, total waktu
tidur, dan kualitas tidur dalam jangka pendek, tetapi tidak dengan penggunaan kronis. 85–87
Penggunaan jangka panjang dari obat-obatan ini dapat menyebabkan toleransi,
ketergantungan, insomnia rebound, sisa sedasi siang hari, inkoordinasi motorik, gangguan
kognitif, dan peningkatan risiko jatuh pada orang tua yang dilembagakan. 88 Obat ini dapat
memiliki efek aditif jika diminum bersamaan. Karena efek samping ini, dan respon yang
setara atau superior terlihat dengan CBT-I untuk terapi durasi yang lebih lama,
penggunaan obat ini harus dihindari pada orang yang lebih tua. Kriteria Beers 2015 baru-
baru ini sangat menyarankan untuk menghindari obat ini pada orang tua.89
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Sifat farmakokinetik obat ini menentukan perbedaan antara efek obat pada parameter
tidur. Zolpidem memiliki waktu paruh yang lebih pendek (2 sampai 3 jam) sehingga
mungkin memiliki potensi yang lebih kecil untuk kejadian samping yang tidak diinginkan
pada siang hari dibandingkan zopiclone, yang memiliki waktu paruh lebih lama (5 sampai
6 jam). Namun, waktu paruh yang lebih pendek dari zolpidem membuatnya kurang
berguna dalam mengobati insomnia pemeliharaan tidur. Obat ini memiliki onset kerja yang
lebih cepat dan oleh karena itu dapat digunakan untuk mengobati insomnia saat tidur
(mengurangi latensi saat tidur). 84
Meskipun manfaatnya lebih besar daripada kerugiannya, ada laporan tentang gangguan
pada tugas konsentrasi siang hari, seperti mengemudi saat menggunakan zopiclone. 90,91
Pada wanita, di mana pembersihan zolpidem terjadi lebih lambat daripada pada pria, kadar
darah pagi setelah dosis waktu tidur yang direkomendasikan sebelumnya bisa jauh lebih
tinggi, mempengaruhi kinerja psikomotor. 92 Pada tahun 2013, hal ini menyebabkan
Administrasi Makanan dan Obat Amerika Serikat (FDA) meminta produsen zolpidem
untuk menurunkan dosis yang dianjurkan, terutama untuk wanita, dari 10 mg menjadi 5
mg untuk sediaan pelepasan segera, dan 12,5 mg untuk 6,5 mg untuk bentuk pelepasan
yang diperpanjang. Itu juga mengharuskan produsen untuk menurunkan dosis yang
direkomendasikan untuk pria.

Antidepresan

Berbagai antidepresan, termasuk senyawa fenilpiperazin (trazodon), antidepresan trisiklik

(doxepin), dan antidepresan serotonergik (mirtazapine), memiliki sifat penenang dan sering
digunakan untuk pengobatan insomnia.
Trazodone: Ini secara luas diresepkan untuk insomnia dalam dosis 25 sampai 100 mg.
Sebuah studi tentang trazodone membandingkan efeknya dengan zolidem pada usia 21
sampai 65 tahun menunjukkan bahwa trazodone memiliki kemanjuran yang sama untuk
latensi tidur dan efisiensi tidur, dengan efek ini menghilang setelah minggu pertama. 93 Efek
samping seperti pusing, aritmia jantung, hipotensi ortostatik, dan potensi priapisme dapat
menjadi signifikan pada populasi lansia. 94 Pedoman praktik klinis dari American Academy
of Sleep Medicine menyarankan bahwa dokter tidak menggunakan trazodon untuk
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gangguan tidur atau pemeliharaan insomnia karena bahayanya lebih besar daripada
manfaatnya.83

DoxEPIN: Dari semua antidepresan, hanya doxepin yang disetujui FDA untuk insomnia
dengan dosis 3 sampai 6 mg. Ini selektif untuk reseptor histamin 1. Studi pada pria dan
wanita berusia 65 tahun ke atas dengan dosis 1 mg dan 3 mg telah menunjukkan bahwa
doxepin 1 mg dan 3 mg secara signifikan meningkatkan ukuran onset tidur (dilaporkan oleh
pasien), durasi tidur, kualitas tidur, dan hasil pengobatan global. selama masa studi 12
minggu.95 Dosis yang lebih tinggi dari doxepin 3 mg dan 6 mg untuk orang dewasa (18
sampai 64 tahun) dengan insomnia primer kronis juga telah dilaporkan menyebabkan
perbaikan yang signifikan dan berkelanjutan dalam pemeliharaan tidur dan bangun pagi. 96

MIRTAzAPINE: Antidepresan dengan antagonisme 5-HT2 yang kuat ini juga dapat
memperbaiki insomnia. Dalam sebuah penelitian terhadap orang dewasa berusia 18 hingga
75 tahun dengan usia rata-rata 40,9 tahun, kelompok mirtazapine mengalami peningkatan
yang signifikan dalam latensi tidur, efisiensi tidur, dan bangun setelah onset tidur hanya
setelah 2 minggu pengobatan.97 Ini mungkin lebih disukai daripada obat lain karena
menghasilkan efek sedatif hanya melalui antagonis reseptor histamin. 97 Karena bukti yang
bertentangan dan pembiasaan terhadap efek sedatifnya, obat ini tidak boleh digunakan
untuk mengobati insomnia jika tidak ada depresi.

Melatonin Reseptor Agonis

RSEBUAHmELTEoN: Itu juga disetujui FDA untuk pengobatan insomnia. Dalam sebuah
studi pada orang dewasa yang lebih tua (usia 65 tahun atau lebih), pengobatan dengan
ramelteon secara signifikan mengurangi laporan pasien tentang latensi tidur selama 5
minggu pengobatan tanpa insomnia atau efek penarikan yang signifikan. 98 Ini tidak terkait
dengan ketergantungan, gangguan memori, dan ketidakstabilan gaya berjalan di malam hari
pada individu yang lebih tua.99,100

Suplemen Herbal

VAlERIAN: Sebagai suplemen makanan, suplemen ini tidak memiliki persetujuan dan
D Patel, J Steinberg and P Insomnia in the Elderly: A
Patel Review

pemantauan FDA. Mekanisme kerjanya diyakini terjadi melalui interaksi dengan asam
amino-butirat gamma neurotransmitter dan reseptornya. Ada studi terbatas tentang varerian
pada individu lanjut usia dan data kurang dalam hal efisiensinya dalam mengobati
insomnia.

MELAToNIN: Melatonin dengan dosis 2 mg telah disetujui di Eropa untuk pengobatan

jangka pendek insomnia pada pasien usia 55 tahun ke atas berdasarkan penurunan
produksi melatonin yang terlihat seiring bertambahnya usia. 101 Pengobatan telah terbukti
efektif untuk insomnia primer dalam beberapa penelitian; Namun, rekomendasi resmi
untuk penggunaan melatonin dalam pengobatan insomnia membutuhkan penelitian lebih
lanjut.83.101.102

Antagonis Reseptor Orexin

SUVoREXANT: Ini adalah antagonis reseptor orexin ganda pertama yang disetujui FDA dan
dapat diresepkan hingga dosis 20 mg. Ini menargetkan neuropeptida yang meningkatkan
kesadaran yang mengatur siklus tidur-bangun, menunjukkan kemanjurannya dalam
mengurangi latensi tidur dan dalam meningkatkan total waktu tidur. Suvorexant telah
dipelajari pada pasien lanjut usia (usia 65 tahun atau lebih) dan non-lansia (usia 18 hingga
64 tahun), mengidentifikasi tidak ada perbedaan kemanjuran atau keamanan yang
signifikan antara kedua kelompok ini.103 Meskipun dapat ditoleransi dengan baik oleh
orang dewasa yang lebih tua, data jangka panjang masih kurang. 103–105

KESIMPULAN
Insomnia sangat umum terjadi pada orang dewasa yang lebih tua. Menggunakan riwayat
dan pemeriksaan fisik bersama dengan skala insomnia, dokter dapat mengevaluasi dan
mengobati insomnia pada populasi kita yang menua dengan cepat. Terapi perilaku dan
perilaku kognitif menawarkan pengobatan dengan durasi lebih lama yang sangat efektif
dan direkomendasikan sebagai pilihan pengobatan lini pertama untuk insomnia
dibandingkan dengan pengobatan hipnotik pada orang dewasa yang lebih tua.
D Patel, J Steinberg and P Insomnia in the Elderly: A
Patel Review

SINGKATAN
CBT-I, terapi perilaku kognitif untuk insomnia
DSM, Manual Diagnostik dan Statistik untuk Gangguan Mental FDA,Administrasi
Makanan dan Obat Amerika Serikat
ICD, Klasifikasi Statistik Internasional Penyakit dan Masalah Kesehatan Terkait
ICSD, Klasifikasi Internasional Gangguan Tidur NREM, non-cepat gerakan mata
REM, gerakan mata cepat

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