Steve Iliffe, FRCGP, Professor of Primary Care for Older People, Research Department of Primary Care, University College London, UK.

Long-term benzodiazepine use in older adults with sleep disorders is potentially hazardous, but it is also becoming easier to manage as approaches to withdrawal become feasible in primary care, without adverse consequences. This article reviews the evidence and describes practical approaches to reducing consumption of benzodiazepine hypnotics.
Key words: benzodiazepines, insomnia, older adults, primary care, hypnotics.

Børge Sivertsen, PhD, Department of Clinical Psychology, University of Bergen, Bergen, Norway.

Chronic primary insomnia is a sleep disorder with no known secondary etiology, and the prevalence increases with advancing age. Insomnia is associated with a range of adverse consequences, both on an individual and societal level. While pharmacotherapy is still the most common form of treatment of late-life insomnia, it is associated with a number of side effects, and recent evidence shows cognitive-behavioural therapy (CBT) to be more effective in managing chronic primary insomnia. This article will discuss the development, consequences, assessment and treatment of chronic primary insomnia among older adults.
Key words: sleep initiation and maintenance disorders, aged, morbidity, treatment, insomnia.

Philippe Voyer, RN, PhD, Associate Professor, Faculty of Nursing, Laval University; Researcher, Laval University Geriatric Research Unit,St-Sacrement Hospital, Quebec, QC.
Michel Préville, MD, Associate Professor, Faculty of Medicine, Université de Sherbrooke; Researcher, Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, QC.
and Researchers of the Étude sur la santé des aînés team.

Sleep complaints by older adults constitute a very common situation faced by health care providers. However, not all professionals respond to the complaint the same way. Some will briefly assess the complaint and resort rather quickly to medication while others will assess the complaint carefully in order to exclude the diagnosis of primary insomnia and prescribe alternative interventions to improve sleep. When medicine is prescribed, the type of compound often selected is benzodiazepine. However, benzodiazepine carries a significant risk of adverse reaction, including drug dependency, both of which are clinical problems that should not be underrated, especially when treating a subjective complaint and not a specific diagnosis.
Key words: insomnia, benzodiazepine, dependency, addiction, older adults.

Amit Morris, BSc, School of Medicine, Queen’s University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Henry J. Moller, MD, FRCP(C), DABSM, Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Chronic insomnia is common among older adults and has significant negative consequences for health and well being. A comprehensive approach to treatment begins with identification and management of any underlying conditions. Treatment of insomnia includes both non-pharmacologic and pharmacologic options. Non-pharmacologic approaches form the foundation of treatment; hypnotic medications can also be effective but may be associated with adverse drug effects. Zopiclone and zaleplon appear to be associated with fewer side effects than benzodiazepines.

Key words: insomnia, older adults, drug therapy, behavioural therapy, hypnotics.

Amit Morris, BSc, School of Medicine, Queen's University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and
Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Insomnia is very common among older adults and may have serious consequences. The assessment of insomnia can be challenging, given the number of possible causes and the fact that insomnia is often not a presenting complaint. Inquiring about patients’ sleep and performing a thorough evaluation of any concerns will allow a rational and targeted approach to treatment.

Key words: insomnia, sleep, older adults, aging, diagnosis.

Christina S. McCrae, PhD, Assistant Professor, Center for Gerontological Studies, Institute on Aging, and Department of Psychology, University of Florida, Gainesville, FL, USA.

Candece Glauser, MA, Department of Psychology and Institute on Aging, University of Florida, Gainesville, FL, USA.

A variety of patient and environmental factors make nursing home residents particularly vulnerable to insomnia or poor sleep. Although precise estimates are not available, research suggests that up to 75% of institutionalized older adults suffer from disturbed sleep.^1-3 Identifying the contributory factors and intervening to resolve or limit their impact on sleep is the key to effective management. Frequently, these factors can be difficult to control, and as a result, standard sleep evaluation and treatment practices may need to be modified for use in long-term care settings.

Evaluation
Insomnia may be present if an individual has more than 30 minutes of unwanted awake time on six or more days during a two-week period. Evaluation involves having patients record various aspects of their sleep habits, such as bed and wake times, in a sleep diary, daily for two weeks. Polysomnographic (PSG) evaluation is not necessary to diagnose insomnia; however, it may be necessary in some cases in order to rule out other sleep disorders such as sleep apnea.