From the Guidelines
For a 77-year-old male with insomnia currently taking trazodone 100mg, I strongly recommend against continuing this medication due to its adverse effect profile and lack of strong evidence supporting its efficacy in chronic insomnia disorder, as advised by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
Considerations for Discontinuation
- The guidelines recommend against the use of trazodone for treatment of chronic insomnia disorder due to its adverse effect profile, which outweighs its benefits 1.
- A systematic review reported no differences in sleep efficiency or rate of discontinuation due to adverse events between trazodone and placebo in patients diagnosed with chronic insomnia, highlighting the limited efficacy of trazodone 1.
- The patient's age and potential comorbidities increase the risk of adverse effects associated with trazodone, such as orthostatic hypotension, falls, and cognitive impairment.
Alternative Treatment Options
- Consider optimizing sleep hygiene practices before adjusting medication, including maintaining a consistent sleep schedule, avoiding caffeine and alcohol before bedtime, limiting screen time, and creating a comfortable sleep environment.
- If medication adjustment is needed, consider switching to a low-dose alternative like mirtazapine 7.5-15mg or low-dose doxepin 3-6mg, which may have a more favorable safety profile in older adults.
- Avoid benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) due to increased fall risk, cognitive impairment, and dependence potential in older adults 1.
Monitoring and Follow-up
- Monitor the patient for signs of orthostatic hypotension, particularly when initiating therapy or increasing doses in this age group.
- Regularly assess the patient's sleep quality and adjust treatment as needed to minimize the risk of adverse effects and optimize sleep outcomes.
From the Research
Treatment of Insomnia in Older Adults
- Insomnia is a common problem in older adults, and treatment options include cognitive behavioral therapy, pharmacologic interventions, or a combination of both 2, 3.
- The patient in question is currently taking trazodone 100mg for insomnia, which has been studied as a treatment option for insomnia in various populations 4, 5, 6.
Efficacy and Safety of Trazodone for Insomnia
- Evidence for the efficacy of trazodone in treating insomnia is limited, with most studies being small and conducted in populations with depression 4.
- However, more recent studies suggest that trazodone may be effective for primary and secondary insomnia, including in non-depressed populations 5.
- The side effects of trazodone are dose-dependent, with drowsiness being the most common 5.
- One study found that trazodone combined with cognitive behavioral therapy improved sleep outcomes in patients with primary insomnia 6.
Considerations for Older Adults
- Older adults are at increased risk for adverse effects from certain medications, including benzodiazepines and non-benzodiazepine receptor agonists 2.
- Trazodone may be a viable option for older adults with insomnia, but its use should be carefully considered due to potential side effects such as sedation, dizziness, and psychomotor impairment 4.
- Other treatment options for insomnia in older adults include low-dose doxepin, melatonin, ramelteon, and dual orexin receptor antagonists 3.