Insomnia, Older Adults and Doxepin
Sep 6, 2016
By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
I can't keep up. I'm huffing and puffing up this hill. I haven't seen Emily in 20 minutes. I'm barely keeping up to Eric. Eric! Eric, who literally last week, had to walk up this hill with his bike. How does someone improve that much in one week? Maybe it is all the adult baiting he has been doing. On our flat rides, he lets an adult get close to him, then he takes off. Abbi Therien and her friend Summer do really well on our training rides eventhough they talk continuously for 2 hours. And Allison Lunsted is gamely pushing through a strained calf to keep cycling. All these kids range in age from 11 to 14. They are all leaving me behind. I think I'm getting old.
Trouble sleeping is also more common as we get older. Prevalence estimates for insomnia double from about 10% of people ages 15 to 24 to about 20% aged 75 and over. As the Canadian population ages, insomnia will become more and more of an issue. Insomnia also seems to be more severe in the elderly. Older adults complain often of not being able to stay asleep and waking up too early. When older adults can't sleep, we worry about it causing memory problems, trouble concentrating, trouble with tasks requiring a lot of attention, and problems driving. Insomnia also increases the risk for falls.
There are some general rules you should follow to help get a good night's sleep. Go to sleep and get up at the same time every day. Use the bedroom only for sleep and sex. Don't keep your cell phone in the bedroom. Don't read, knit, work, or watch TV in the bedroom. Do not drink coffee, tea or cola 4-6 hours before sleep, and try to drink as little of these caffeinated beverages as possible during the day. If you cannot sleep after 15 to 20 minutes, get out of bed and go to another room and read in a dimly lit area. Avoid watching TV, iPad, phone or computer while trying to get back to sleep, as the bright light from the screen may wake you up more. Go back to bed only when feeling sleepy again. Avoid watching the clock. Some people even turn the clock face away them. Finally, avoid daytime naps.
If you still aren't sleeping well after adopting good sleep habits, and the problem isn't the snoring person beside you, you might need a medication. If that is the case, talk to your doctor. First your doctor will check you for any underlying health problems. For example, insomnia can be a symptom of another condition like painful arthritis. If we treat the arthritis pain, sometimes the insomnia will go away on its own.
If your doctor decides you need a sleep medication, there are several to choose from. Many over the counter sleep medications contain diphenhydramine. It is safe in many patients, but it doesn't work as well as the prescription sleep aids. It starts working in 30-60 minutes, but probably shouldn't be used more than 3 nights in a row or the patient will become tolerant to the effects. One of the common prescription medications for sleep problems are the benzodiazepines. A common benzodiazepine used for sleep is temazepam. Temazepam takes 1-2 hours to kick in and lasts 6-10 hours. Benzodiazepines work well for sleeping, but can become habit forming. Because temazepam can last for 10 hours in some people, morning drowsiness can be a problem. A different prescription sleep aid is zopiclone. Zopiclone starts working in 15-30 minutes and lasts 8 hours or longer. Because it is not a benzodiazepine, it is less likely to be habit forming. It has the interesting side effect of leaving a bitter, metallic taste in the mouth. If you drink something acidic like orange juice in the morning, that usually washes the taste away. If you drink something plain like water it can make it worse.
There are potential problems with our standard treatments for insomnia. Medications like benzodiazepines and zopiclone increase the risk of falls and fractures as they can make people unsteady, especially if the person gets up during the night. Patients can experience mental fogginess, they can experience withdrawal symptoms and rebound insomnia if they stop the benzo or zopiclone, and they can still be groggy the next morning after using a benzo or zopiclone.
Some alternative sleep aids for older adults are trazadone, mirtazapine and melatonin. These each have some evidence that they are safe and effective, but I'm going to talk about doxepin. I hadn't heard of doxepin being used in insomnia before, and it is always nice to have another tool in the tool box.
Doxepin is a tricylic antidepressant. This class of medications works well to treat depression and anxiety. However, they aren't used as often any more because they have lots of side effects including sleepiness, dry mouth, dizziness and possible heart problems. However, some interesting things happen if you use a really low dose of doxepin.
Low dose doxepin is marketed under the brand name Silenor and it comes in 3 and 6mg strengths. At this low dose it only seems to block the H1 histamine receptor, which seems to eliminate many of it's side effects. I always think of histamine in relation to allergies. However, histamine is one of the key neurotransmitters involved in wakefulness. So if you block the H1 histamine receptor, you feel sleepy.
Low dose doxepin has been approved for insomnia in the US since 2010. It has been approved in Canada since 2014. In 2014 Carlos Rojas-Fernandez et. al did a meta-analysis of 5 trials about low dose doxepin and published their results in the September/October 2014 Canadian Pharmacists Journal. They concluded the current evidence supports using low doxepin for insomnia in older adults. The researchers would like further studies to be done to compare doxepin to other insomnia medication. They also think more study is needed to see if it is appropriate to use low dose doxepin in the frail elderly and those with cognitive impairments.
A general warning with all the sleeping medications, is don't mix your sleeping medication with alcohol. Alcohol can prolong the effects of a sleeping medication, effect your breathing , and mixing alcohol and sleeping medications have lead to very dangerous things like driving and having no memory of doing so.
We may not sleep or cycle better as we age. But some things do get better and better as they get older. This year the Riding Mountain Challenge, MS Bike ride from Dauphin to Clear Lake turns 20! I remember fondly when the RMC was just a toddler. The 20th Anniversary Ride September 10th and 11th will be better than ever and the Dauphin Clinic Pharmacy is a proud sponsor again. MS fund raisers like the Riding Mountain Challenge will help us end MS. We just need you to help by sponsoring a cyclist.
The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.
We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca
As always if you have any questions or concerns about these or other products, ask your pharmacist.
Huffington Post 31 Tips for Better Sleep -
Eric Shewfelt MS Riding Mountain Challenge Donation Page:
Emily Shewfelt MS Riding Mountain Challenge Donation Page: