Efficacy, acceptability, and tolerability of all available treatments for insomnia in the elderly: a systematic review and network meta-analysis.

OBJECTIVES: Symptoms of insomnia are highly prevalent in the elderly. A significant number of pharmacological and non-pharmacological interventions exist, but, up-to-date, their comparative efficacy and safety has not been sufficiently assessed. METHODS: We integrated the randomized evidence from every available treatment for insomnia in the elderly (>65 years) by performing a network meta-analysis. Several electronic databases were searched up to May 25, 2019. The two primary outcomes were total sleep time and sleep quality. Data for other 6 efficacy and 8 safety outcomes were also analyzed. RESULTS: Fifty-three RCTs with 6832 participants (75 years old on average) were included, 43 of which examined the efficacy of one or more drugs. Ten RCTs examined the efficacy of non-pharmacological interventions and were evaluated only with pairwise meta-analyses because they were disconnected from the network. The overall confidence in the evidence was very low primarily due to the small amount of data per comparison and their sparse connectedness. Several benzodiazepines, antidepressants, and z-drugs performed better in both primary outcomes, but few comparisons had data from more than one trial. The limited evidence on non-pharmacological interventions suggested that acupressure, auricular acupuncture, mindfulness-based stress reduction program, and tart cherry juice were better than their control interventions. Regarding safety, no clear differences were detected among interventions due to large uncertainty. CONCLUSIONS: Insufficient evidence exists on which intervention is more efficacious for elderly patients with insomnia. More RCTs, with longer duration, making more direct interventions among active treatments and presenting more outcomes are urgently needed.

[Drug treatment of sleep disorders in the elderly]. / Arzneimittelbehandlung von Schlafstörungen im Alter.

Changes in the pattern of sleep, e.g. more frequent nocturnal awakenings, are normal in the elderly. There is also a greater incidence of medical and psychiatric sleep disorders (depression, dementia). Initially, a thorough diagnostic assessment should be performed in order to identify disorders which can be treated specifically. For the symptomatic drug treatment of insomnias, the specific metabolic and pharmacokinetic, as well as possible interactions, should be considered. The new benzodiazepine receptor agonists (zopiclone, zolpidem and zaleplone), with their favourable risk-benefit profile, can be considered as first-choice treatments in elderly patients; in general, they should be preferred to the classical benzodiazepines. When a longer treatment is necessary, certain (non-anticholinergic) antidepressants and neuroleptics can be considered (the latter especially in cases of abnormal nocturnal behaviour). Herbal drugs and other hypnotically active compounds play a secondary role. Drug treatment of insomnia should always be carried out in the context of a general treatment plan which also includes non-pharmacological elements. In elderly patients, "chronotherapeutic" methods, which accentuate the sleep-wake rhythm, are of crucial importance.