From the Guidelines
For an 81-year-old seeking a sleep aid, I recommend starting with non-medication approaches first, such as maintaining a consistent sleep schedule, avoiding caffeine and alcohol before bedtime, and creating a comfortable sleep environment. If these are insufficient, low-dose melatonin (0.5-1mg) taken 1-2 hours before bedtime is a reasonable first medication option, as supported by the American Academy of Sleep Medicine clinical practice guideline 1. For short-term use, a low dose of trazodone (25-50mg) at bedtime may be considered, although its efficacy is not well-established in older adults 1. Avoid diphenhydramine (Benadryl) and other anticholinergic medications, as well as benzodiazepines like lorazepam, which can increase fall risk and cognitive impairment in older adults 1. Prescription sleep medications like zolpidem (Ambien) should be used cautiously at reduced doses (2.5-5mg) if at all, and only for brief periods, due to the risk of adverse effects in older adults 1. Older adults metabolize medications more slowly and are more sensitive to side effects, particularly daytime drowsiness, dizziness, and confusion, which can lead to falls. Any sleep medication should be started at the lowest possible dose and used for the shortest duration necessary, with regular reassessment by a healthcare provider. Cognitive behavioral therapy for insomnia (CBT-I) is also a recommended treatment option, as it has been shown to be effective in improving sleep outcomes in older adults 1.
Some key points to consider when treating insomnia in older adults include:
- Non-medication approaches should be tried first
- Low-dose melatonin may be a reasonable first medication option
- Trazodone may be considered for short-term use, but its efficacy is not well-established in older adults
- Diphenhydramine and benzodiazepines should be avoided due to the risk of adverse effects
- Prescription sleep medications should be used cautiously and at reduced doses
- CBT-I is a recommended treatment option for older adults with insomnia.
It's also important to note that the American College of Physicians recommends that all patients with chronic insomnia receive CBT-I as the initial treatment intervention, and that a shared decision-making approach be employed by clinicians in determining whether pharmacotherapy should be employed for those patients who did not achieve adequate response with CBT-I 1.
From the FDA Drug Label
The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Two of these trials were in elderly patients (n=523) Overall, at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg), eszopiclone significantly decreased sleep latency and improved measures of sleep maintenance Elderly subjects (ages 65 to 86) with chronic insomnia were evaluated in two double-blind, parallel-group trials of 2 weeks duration One study (n=231) compared the effects of eszopiclone with placebo on subjective outcome measures, and the other (n=292) on objective and subjective outcome measures. The first study compared 1 mg and 2 mg of eszopiclone with placebo, while the second study compared 2 mg of eszopiclone with placebo. All doses were superior to placebo on measures of sleep latency. In both studies, 2 mg of eszopiclone was superior to placebo on measures of sleep maintenance.
For an 81-year-old patient, eszopiclone may be recommended as a sleep aid, with a dose of 1 to 2 mg. This is based on the studies that showed eszopiclone to be effective in elderly patients with chronic insomnia, with significant improvements in sleep latency and maintenance 2.
- Key points:
- Eszopiclone is effective in elderly patients with chronic insomnia
- Recommended dose for elderly patients is 1 to 2 mg
- Eszopiclone improves sleep latency and maintenance in elderly patients
Note: Zolpidem may also be considered, but the provided information does not specify the dose for an 81-year-old patient as clearly as eszopiclone 3.
From the Research
Sleep Aids for 81-Year-Olds
- The choice of a hypnotic agent in the elderly is symptom-based 4.
- For sleep-onset insomnia, ramelteon or short-acting Z-drugs can be used 4.
- Suvorexant or low-dose doxepin can improve sleep maintenance 4.
- Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance 4.
- Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings 4.
Considerations for Zolpidem
- Zolpidem has a wide variety of adverse effects, including an increased risk of falls, hip fractures, and complex behaviors such as sleepwalking and hallucinations 5.
- The dose of zolpidem should be adjusted for elderly patients due to their slower drug metabolism 5.
- Zolpidem is considered a reasonable choice of therapy because it has a lower incidence of residual daytime sleepiness and risk of falls when compared to other drugs 5.
Alternative Therapies
- Cognitive behavioral therapy for insomnia (CBT-I) combined with eszopiclone can be an effective treatment for sleep disorders 6.
- CBT-I alone or in combination with eszopiclone can improve sleep quality and reduce symptoms of insomnia 7.
- The combination of eszopiclone with CBT-I resulted in comparable improvement in sleep quality of life to that achieved with CBT-I-only therapy 7.
Safety and Tolerability
- Newer treatment options for insomnia, including non-benzodiazepine hypnotics and melatonin receptor agonists, are generally well tolerated and present favorable safety profiles 8.
- However, these agents can be associated with some risk for dependence and abuse, and can cause rare but serious adverse events such as anaphylaxis, angio-oedema, and complex sleep-related behaviors 8.