Innovations in Insomnia Management: A Review of Current Approaches and Novel Targets Including Orexin Receptor Antagonists

Abstract

Background: Sleep disturbances are a source of significant challenge to the care of geriatric hospitalized patients. Areas of Uncertainty: Commonly used medications to promote sleep are fraught with side effects especially in the geriatric population. The management of this issue is very important to many patients. Data Sources: We reviewed current data on the effectiveness of current pharmacologic and non-pharmacologic strategies to improve insomnia in elderly patients. Results: Environmental adjustments to the inpatient setting have been shown to improve sleep with no adverse effects. Cognitive behavioral therapy, has also been shown to improve objective and subjective sleep measures in older patients with similar efficacy to medications. Benzodiazepines are still popular medications despite evidence demonstrating adverse outcomes including falls, fractures, and cognitive decline. Nevertheless they have been shown to have a generally small effect on total sleep time. Nonbenzodiazepine receptor agonists have also been demonstrated to pose significant risks of harms to the elderly patient, including delirium and, again, falls and fractures as the price for a small increase in total sleep time. Ramelteon is also shown to have an even smaller effect on sleep time, however, with a more positive side effect profile. Suvorexant is a new agent that works through a novel mechanism inhibiting the orexin activating system. It has been shown to have similar objective efficacy on sleep as other medications mentioned already and was approved by FDA without major warnings. However, more study is required to determine if it will elude the risks of medications already available. Conclusions: Given the lack of adverse consequences, a persuasive case can be made for a comprehensive behavioral approach to sleep promotion before pharmacologic agents are attempted. Studies comparing individual medications are unavailable and thus cannot guide therapy further.