From the Guidelines
For elderly individuals, the safest sleeping medication is a low-dose nonbenzodiazepine BZRA, such as zolpidem, zaleplon, eszopiclone, or zopiclone, administered at the lowest effective dose and for the shortest possible duration, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. When considering sleep medications for the elderly, it is essential to weigh the benefits against the potential harms, including the risk of serious injuries caused by sleep behaviors, such as sleepwalking and sleep driving 1. Key considerations for sleep medication in the elderly include:
- Avoiding benzodiazepines due to their widely known harms and adverse effects, including risk for dependency and diversion, falls and cognitive impairment in older patients, hypoventilation in patients with respiratory conditions, and neuromuscular diseases 1
- Avoiding trazodone, as it has been reported to have no differences in sleep efficiency or rate of discontinuation due to adverse events compared to placebo in patients diagnosed with chronic insomnia 1
- Considering non-pharmacological approaches, such as maintaining consistent sleep schedules, avoiding caffeine and alcohol before bedtime, creating a comfortable sleep environment, and practicing relaxation techniques, before trying medication
- Using medication at the lowest effective dose for the shortest duration possible, as elderly individuals metabolize medications more slowly, making them more susceptible to side effects like daytime drowsiness, confusion, and increased fall risk 1
From the FDA Drug Label
Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg. Paradoxical reactions have been occasionally reported during benzodiazepine use Such reactions may be more likely to occur in children and the elderly. Use of lorazepam for prolonged periods and in geriatric patients requires caution, and there should be frequent monitoring for symptoms of upper GI disease.
The safest sleeping medication for the elderly cannot be determined from the provided information. Lorazepam may not be the safest option due to the potential for increased susceptibility to sedative effects, paradoxical reactions, and the need for caution with prolonged use in geriatric patients 2.
From the Research
Safest Sleeping Medication for Elderly
The safest sleeping medication for the elderly can vary depending on the individual's specific needs and health status. According to 3, the choice of a hypnotic agent in the elderly is symptom-based, and options such as ramelteon, short-acting Z-drugs, suvorexant, and low-dose doxepin can be considered.
- Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia
- Suvorexant or low-dose doxepin can improve sleep maintenance
- Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance
- Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings
Non-Pharmacological Interventions
Non-pharmacological interventions can also be effective in improving sleep quality in older adults. As stated in 4 and 5, approaches such as mindfulness, cognitive behavioral therapy, and physical activity have shown promise in improving sleep quality and health outcomes.
- Mindfulness and cognitive behavioral therapy can improve sleep quality and reduce stress
- Physical activity can improve objectively-measured sleep and self-reported sleep quality
- Sensory stimulation and combined interventions may also be beneficial, but more research is needed to confirm their effectiveness
Comparison of Medications
A study published in 6 compared the use of melatonin, trazodone, and doxepin in psychiatric patients with sleep disturbances. The results showed that:
- Trazodone was the most effective medication for enhancing sleep quality, but it was associated with frequent adverse effects
- Doxepin had a better tolerability profile than trazodone, but was linked to dry mouth
- Melatonin had the fewest adverse effects and significantly reduced daytime drowsiness, making it a safer option for patients concerned about adverse effects
Future Directions
As noted in 7, there is a need for increased research on the combination of traditional behavioral interventions with exercise to improve sleep quality in older adults. Exercise has been shown to be a safe and effective intervention for poor sleep, and combining it with behavioral interventions such as cognitive behavioral therapy for insomnia (CBT-I) may lead to even better outcomes.