Older people are also more likely to have medical conditions that can cause pain or discomfort that disturbs their sleep. (Some studies, in fact, have found no significant increase in insomnia in older adults who are healthy.) These conditions include gastrointestinal distress, frequent urination, lung disease and heart conditions. Neurological disorders, such as restless legs syndrome (RLS), Parkinson's disease and Alzheimer's disease, can also affect sleep patterns.
Insomnia not only saps your energy and affects your mood, but also can put your health, work performance and quality of life on a downward spiral. Insomnia can be short-term (up to three weeks) or long-term (four weeks or more). Sleep deprivation can lead to irritability, depression, and memory and attention problems. It also has been linked with diabetes, obesity and heart disease, in addition to increased risk of automobile-related accidents and falls.
The Top 10
Here are 10 types of medications that can cause insomnia. If you're taking any of them and having sleep problems, you should talk with your doctor or pharmacist about adjusting the dosage, changing to another type of medication, or trying an alternative treatment or therapy.
Why they're prescribed: Alpha-blockers are used to treat a variety of conditions, including high blood pressure (hypertension), benign prostatic hyperplasia (BPH) and Raynaud's disease. These drugs relax certain muscles and help keep small blood vessels open. By keeping the hormone norepinephrine (noradrenaline) from tightening the muscles in the walls of smaller arteries and veins, they improve blood flow and lower blood pressure. Because alpha-blockers also relax other muscles throughout the body, they can help improve urine flow in older men with prostate problems.
Examples: alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), silodosin (Rapaflo), terazosin (Hytrin) and tamsulosin (Flomax).
How they can cause insomnia: Alpha-blockers are linked to decreased REM (rapid eye movement) sleep — the stage of sleep when people dream — and daytime sedation or sleepiness. The proportion of REM sleep drops markedly in old age, and people deprived of REM sleep can experience memory problems.
Alternatives: For older people, benzothiazepine calcium channel blockers, another form of blood pressure medication, are often safer and more effective than alpha-blockers. If the alpha-blocker has been prescribed to treat BPH, talk with your doctor about the possibility of switching to a 5-alpha-reductase inhibitor such as dutasteride (Avodart) or finasteride (Proscar), which are safer and generally better tolerated by older patients.
Why they're prescribed: Beta-blockers are typically prescribed to treat hypertension (high blood pressure) and arrhythmias (abnormal heart rhythms). These drugs slow the heart rate and lower blood pressure by blocking the effect of the hormone adrenaline. Beta-blockers are also used to treat angina, migraines, tremors and, in eyedrop form, certain kinds of glaucoma.
Examples: atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor, Toprol), propranolol (Inderal), sotalol (Betapace), timolol (Timoptic) and some other drugs whose chemical names end with "-olol."
How they can cause insomnia: Beta-blockers have long been associated with sleep disturbances, including awakenings at night and nightmares. They are thought to do this by inhibiting the nighttime secretion of melatonin, a hormone involved in regulating both sleep and the body's circadian clock. Low levels of melatonin have sometimes been observed in chronic insomnia.
Alternatives: For older people, benzothiazepine calcium channel blockers, another form of blood pressure medication, are often safer and more effective than beta-blockers.
A nightly dose of melatonin may also help. A small study published in the journal Sleep in 2012 found that patients on beta-blockers who also took melatonin fell asleep sooner, had more restful sleep, and slept longer — an extra 36 minutes a night, on average — than patients taking an inactive placebo. (This was determined with polysomnography, an overnight sleep test that records brain waves, muscle tone, heart rate and eye movements.)
Why they're prescribed: Corticosteroids are used to treat inflammation of the blood vessels and muscles as well as rheumatoid arthritis, lupus, Sjögren's syndrome, gout and allergic reactions.
Examples: cortisone, methylprednisolone (Medrol), prednisone (sold under many brand names, such as Deltasone and Sterapred) and triamcinolone.
Examples: cortisone, methylprednisolone (Medrol), prednisone (sold under many brand names, such as Deltasone and Sterapred) and triamcinolone.
How they can cause insomnia: People often ask why a drug that reduces inflammation would keep them awake. The answer lies in the adrenal glands, which are responsible for regulating the body's fight-or-flight response. Too much stress can keep the body awake and the mind stimulated by exhausting the adrenal glands; corticosteroids can do the same thing, wreaking havoc on all the systems that allow you to relax and sleep, causing insomnia and unpleasant dreams.
Alternatives: Ask your doctor or pharmacist whether you can take your medication in a single dose early in the day.
4. SSRI antidepressants
Why they're prescribed: SSRIs (selective serotonin-reuptake inhibitors) are used to treat symptoms of moderate to severe depression. SSRIs block the reabsorption (reuptake) of the neurotransmitter serotonin in the brain, which may help brain cells send and receive chemical messages, easing depression. They're called selective because they seem to primarily affect serotonin, not other neurotransmitters.
Examples: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).
How they can cause insomnia: Just as it isn't known exactly how SSRIs work, it isn't known exactly how these drugs interfere with sleep. Studies have shown, however, that SSRIs cause agitation, insomnia, mild tremor and impulsivity in 10 percent to 20 percent of the people who take them.
Although about half of people who take SSRIs say that the drugs make them feel better, many continue to struggle with symptoms that can make life miserable, especially insomnia. We know this from researchers at the University of Texas Southwestern Medical Center in Dallas, who combed through data from the STAR*D trial, the largest and longest study ever done on depression treatment, and published their findings in 2011. Almost all of the subjects in the Star*D trial, which was funded by the National Institute of Mental Health, said they continued to have problems with insomnia, with 81 percent reporting being unable to sleep in the middle of the night.
Alternatives: If you are experiencing anxiety or insomnia while on an SSRI (or any other antidepressant, for that matter), it's important to tell your prescribing doctor right away. Sleeplessness — in itself a marker of depression — can make you even more depressed.
Because antidepressants vary in their side effects, a change in dosage or switching to another medication may help you feel better without causing insomnia or other sleep disturbances. A selective serotonin/norepinephrine reuptake inhibitor (SSRI/SNRI), a newer-generation antidepressant, offers some advantages in improving relaxation and sleep. Of the three drugs in this category (clomipramine, duloxetine and venlafaxine), I find venlafaxine to have the least adverse side effects in older patients and to be easier to dose to a therapeutic level.
Many people find that cognitive behavior therapy works just as well as medication. (Cognitive therapy aims to help people overcome their difficulties by changing their thinking, behavior and emotional responses.) Others report success with such approaches as acupuncture, exercise, changes in diet, meditation, relaxation therapy and the like.
5. ACE inhibitors
Why they're prescribed: Angiotensin-converting enzyme (ACE) inhibitors are used to treat high blood pressure, congestive heart failure and other conditions. These drugs help relax blood vessels by preventing the body from producing angiotensin II, a hormone that causes blood vessels to narrow and, in turn, blood pressure to rise.
Examples of ACE inhibitors include: benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace) and trandolapril (Mavik).
How they can cause insomnia: ACE inhibitors boost the body's levels of bradykinin, a peptide that enlarges blood vessels. Bradykinin is thought to be the cause of the hacking, dry cough that up to a third of all patients who take an ACE inhibitor develop. This chronic, round-the-clock cough can be severe enough to keep anyone awake. ACE inhibitors can also cause potassium to build up in the body (another type of electrolyte imbalance) and lead to diarrhea, as well as leg cramps and achy joints, bones and muscles — all of which can disturb normal sleep.
Alternatives: If you're taking an ACE inhibitor for a cardiovascular problem, talk with your doctor or pharmacist about possibly switching to a benzothiazepine calcium channel blocker, another form of blood-pressure medication that is often better tolerated by older adults. This is especially important for African Americans and Asian Americans, who, because of differences in their renin-angiotensin systems, have much higher incidences of adverse side effects.
If your condition is accompanied by fluid retention, your doctor may consider adding a low dose of a long-acting loop diuretic, such as torsemide.
6. Angiotensin II-receptor blockers (ARBs)
Why they're prescribed: ARBs are often used to treat coronary artery disease or heart failure in patients who can't tolerate ACE inhibitors or who have type 2 diabetes or kidney disease from diabetes. Instead of blocking the body's production of angiotensin II, ARBs prevent it from exerting its blood vessel-constricting effects.
Examples of ARBs include: candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), telmisartan (Micardis) and valsartan (Diovan).
How they can cause insomnia: Like ACE inhibitors, ARBs frequently lead to potassium overload in the body, causing diarrhea as well as leg cramps and achy joints, bones and muscles — all of which can disturb normal sleep.
Alternatives: As with ACE inhibitors, I'd recommend you consult with your health care provider about the advisability of switching to a benzothiazepine calcium channel blocker, which is often better tolerated by older adults. This is especially important for African Americans and Asian Americans, who because of differences in their renin-angiotensin systems, have much higher incidences of adverse side effects.
A low dose of a long-acting loop diuretic such as torsemide may also be desirable.
7. Cholinesterase inhibitors
Why they're prescribed: Cholinesterase inhibitors are commonly used to treat memory loss and mental changes in individuals with Alzheimer's disease and other types of dementia.
Examples: donepezil (Aricept), galantamine (Razadyne) and rivastigmine (Exelon). The main side effects of these drugs include diarrhea, nausea and sleep disturbances.
How they can cause insomnia: These drugs are thought to work by inhibiting the enzyme in the body that breaks down acetylcholine (a neurotransmitter that's important for alertness, memory, thought and judgment) and thus boosting the amount available to brain cells. This, in theory, slows the patient's loss of memory and helps him or her perform daily activities with fewer problems. But blocking the breakdown of acetylcholine — which is everywhere in the body, not just in the brain — can interfere with all kinds of involuntary body processes and movements, including those related to sleep.
In addition to insomnia and abnormal dreams, the identified side effects of cholinesterase inhibitors include serious changes in heart rhythm, diarrhea, nausea and vomiting as well as leg cramps and muscle spasms — all of which can interfere with normal sleep patterns.
Alternatives: It's important to remember that cholinesterase inhibitors cannot reverse Alzheimer's disease or slow the underlying destruction of nerve cells. And because the Alzheimer's-afflicted brain produces less acetycholine as the disease progresses, all medications in this class eventually lose whatever effectiveness they may be presumed to have.
For these reasons, it may be worthwhile to talk with your doctor (or the doctor treating your loved one) about whether the adverse effects of the drug prescribed outweigh its possible benefits. In my experience, that's nearly always the case.
8. Second-generation (nonsedating) H1 antagonists
Why they're prescribed: H1 antagonists, which are in a class of drugs commonly known as antihistamines, inhibit the body's production of histamine — the chemical that's released when you have an allergic reaction. Elevated histamine levels cause such common allergic reaction symptoms as itching, sneezing, runny nose, watery eyes, nasal congestion and hives.
Second-generation H1 antagonists, also known as nonsedating antihistamines, do not have the same side effects as first-generation antihistamines, such as diphenhydramine (Benadryl), which suppress the central nervous system, causing severe drowsiness.
Examples of second-generation H1 antagonists include: azelastine (Astelin) nasal spray, cetirizine (Zyrtec), desloratadine (Clarinex), fexofenadine (Allegra), levocetirizine (Xyzal) and loratadine (Claritin).
How they can cause insomnia: In varying degrees, all H1 antagonists block acetylcholine, a nervous system neurotransmitter, and thus can cause anxiety and insomnia.
Alternatives: Since these second-generation antihistamines are typically active in the body for around eight hours, you may find that taking your daily dose in the morning may be all that's needed to resolve any sleep-related problems it may be causing.
9. Glucosamine and chondroitin
Why they're used: Glucosamine and chondroitin are dietary supplements that are used to relieve joint pain, improve joint function and lessen inflammation. (Both are found naturally in the human body.) Many arthritis supplements contain glucosamine and chondroitin, both of which are regulated by the Food and Drug Administration as a food rather than a drug.
How they can cause insomnia: Researchers aren't sure exactly how glucosamine and chondroitin work, but studies identify a range of gastrointestinal side effects, including nausea and diarrhea, as well as headaches and insomnia.
Alternatives: While many people take glucosamine and chondroitin, alone or together, for osteoarthritis, they may not help at all. A recent analysis of many studies of these supplements failed to find evidence that they slow joint destruction or relieve pain.
A 2010 survey of Consumer Reports subscribers found that among those who identified osteoarthritis as one of their most bothersome conditions, yoga and massage were rated twice as helpful as glucosamine and chondroitin.
If you choose to use one or both of these supplements, you should be aware that glucosamine has a longer half-life (the time it's active in the body) than chondroitin. So if glucosamine is part of your medication regimen, taking your daily dose in the morning should prevent problems with insomnia.
You may also wish to consider asking your doctor for a prescription of tramadol 50mg tablets and taking one with an acetaminophen 325mg tablet two to three times a day. This should work well to relieve pain.
Why they're prescribed: Statins are used to treat high cholesterol.
The top-selling statins are atorvastatin (Lipitor), lovastatin (Mevacor), rosuvastatin (Crestor) and simvastatin (Zocor).
How they can cause insomnia: The most common side effect of all types of statins is muscle pain, which can keep people who take them awake at night and unable to rest. In the worst cases, the pain caused by statins can be immobilizing.
Studies show that statins can interfere with muscle growth by inhibiting the production of satellite cells in the muscle. Muscle weakness and aches throughout the body can be symptoms of statin-induced rhabdomyolysis, a breakdown of skeletal muscle that causes muscle fibers to be released into the bloodstream, sometimes harming the kidneys.
Researchers have found that fat-soluble statins — which include Lipitor, Mevacor, Vytorin and Zocor — are more likely to cause insomnia or nightmares because they can more easily penetrate cell membranes and make their way across the blood-brain barrier, which protects the brain from chemicals in the blood.
Alternatives: If you're among the millions of older Americans who haven't been diagnosed with heart disease but are taking these drugs to lower your slightly elevated cholesterol, ask your doctor or other health care provider about making changes to your diet and getting regular exercise instead of using statins. You also might try lowering your blood levels of homocysteine — which is linked to high cholesterol — by taking a combination of sublingual (under-the-tongue) vitamin B12 (1,000 mcg daily), folic acid (800 mcg daily) and vitamin B6 (200 mg daily).
Ask the Pharmacist is written by Armon B. Neel Jr., PharmD, CGP, in collaboration with journalist Bill Hogan. They are coauthors of Are Your Prescriptions Killing You? (Atria Books).
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