From the Guidelines
For older adults seeking alternatives to diazepam for sleep, safer options include eszopiclone, zolpidem, or suvorexant, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. These medications have been shown to improve sleep outcomes in adults with insomnia disorder. When considering alternatives to diazepam, it is essential to prioritize medications with lower risks of dependence, falls, and cognitive impairment. Non-medication approaches should be tried first, including:
- Consistent sleep schedules
- Avoiding caffeine after noon
- Limiting evening screen time
- Creating a cool dark bedroom environment
- Practicing relaxation techniques like deep breathing or meditation before bed Cognitive behavioral therapy for insomnia (CBT-I) is particularly effective and should be considered before any medication, as it has been shown to improve sleep outcomes in older adults 1. If medication is necessary, it should be used at the lowest effective dose for the shortest duration possible. The American College of Physicians recommends using a shared decision-making approach to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1. It is crucial to weigh the benefits and harms of pharmacologic treatment, as evidence suggests that hypnotic drugs may be associated with infrequent but serious adverse effects, such as dementia, serious injury, and fractures 1. In older adults, eszopiclone, zolpidem, and doxepin have been shown to improve sleep outcomes, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not well established 1. Ultimately, the choice of sleep aid should be individualized, taking into account the patient's medical history, comorbidities, and preferences.
From the Research
Safe Sleep Aids for Older Adults
Alternative sleep aids to diazepam for older adults can be categorized into pharmacological and non-pharmacological interventions.
- Pharmacological interventions:
- Suvorexant, doxepin, and ramelteon have shown promise as effective and safe alternatives for treating insomnia in older adults 2, 3
- Melatonin, diphenhydramine, and valerian are non-FDA-approved hypnotic agents commonly used, but have limited data on benefits and harms 3
- Trazodone, an off-label drug for insomnia, improves sleep quality but carries significant risks 3
- Non-pharmacological interventions:
Considerations for Older Adults
When considering sleep aids for older adults, it is essential to:
- Be aware of the potential risks associated with certain medications, such as diphenhydramine and doxylamine, which are classified as potentially inappropriate for older adults 5
- Consult with healthcare providers to address conditions that impact sleep quality and discuss safe sleep aid options 5, 6
- Recognize that more than a third of older adults use medications or aids to help with sleep, with over-the-counter aids being the most commonly used 6