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Dialogue with elderly patients

Dr Roger Henderson

As a group, the elderly are especially at risk from the potentially significant side effects caused by the use of hypnotics used in the short-term treatment of insomnia.1 As such, it is always preferable to explore good sleep habits as the first intervention. Prolonged-release melatonin (Circadin®) may improve sleep-related parameters in people with primary insomnia over the age of 55 however and the British Association for Psychopharmacology guidelines recommend that it should be used first if a hypnotic is indicated in the elderly.1

Sleep hygiene advice is therefore very important in the elderly once medical comorbidities have been ruled out as a possible reason for the insomnia. Such advice has the aim of making people more aware of the behavioural and environmental factors that can be detrimental to a good nights sleep bearing in mind the fact that many people in their 70's require less than six hours of sleep per night. The key advice that should be given regarding sleep hygiene include: 2

• Establishing a fixed regimen for bedtime and waking up. (This applies even if someone has had a poor night's sleep so do not sleep in if this has occurred)

• Trying to avoid taking naps in the day – this can sometimes affect the body's natural rhythm and makes sleeping at night more difficult

• Avoid watching the clock through the night. After some time you should feel tired enough to go back to bed

• Maintain the bedroom at a comfortable temperature

• Avoid alcohol, nicotine and caffeine for six hours before bedtime – caffeine stays in the body for many hours. Alcohol may get you to sleep but will almost certainly wake you in the small hours

• Do not eat late at night

• Try to relax before going to bed – aromatherapy, massage or a warm milky drink can all help

• Although exercise can be beneficial to sleep if done in the day, avoid exercising within 4 hours of bedtime

If poor sleeping patterns persist despite this then psychological treatments should be considered. These include cognitive behavioural therapy, stimulus control, and progressive muscle relaxation techniques. 1

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