What are the recommended first-line sleep medications for the geriatric population?

From the Guidelines

For the geriatric population, low-dose melatonin (1-2 mg) taken 1-2 hours before bedtime is often recommended as a first-line option due to its favorable safety profile. When considering sleep medications for this population, it's essential to prioritize those with the least risk of adverse effects, given the increased sensitivity of older adults to medication side effects and their altered drug metabolism 1.

Key Considerations

• Non-pharmacological approaches should be tried first for insomnia.
• If medications are necessary, the choice should be based on the lowest risk of adverse effects.
• Benzodiazepines should generally be avoided due to increased risks of falls, cognitive impairment, and dependence 1.
• Short-acting Z-drugs like zolpidem or zaleplon may be used very cautiously for brief periods (1-2 weeks) but with careful consideration of their potential risks.

Recommended Medications

• Low-dose melatonin (1-2 mg) is a first-line option due to its favorable safety profile.
• Ramelteon (8 mg) is another option with minimal side effects.
• Mirtazapine (7.5-15 mg) can be useful particularly in elderly patients with comorbid depression and poor appetite, but its use should be carefully considered due to potential side effects.

Important Guidance

• All medications should be started at the lowest possible dose (typically half the standard adult dose) and used for the shortest duration necessary, with regular reassessment 1.
• Patients should be counseled on the potential risks of sleep medications, including the risk of disruptive sleep-related behaviors associated with benzodiazepine receptor agonistic modulators 1.

From the FDA Drug Label

In the elderly, the dose for zolpidem tartrate should be 5 mg [see WARNINGS AND PRECAUTIONS (5), DOSAGE AND ADMINISTRATION (2)] This recommendation is based on several studies in which the mean Cmax, T1/2, and AUC were significantly increased when compared to results in young adults.

The recommended first-line sleep medication for the geriatric population is zolpidem tartrate at a dose of 5 mg 2.

• The dose is recommended due to increased mean Cmax, T1/2, and AUC in elderly subjects compared to young adults.
• Zolpidem tartrate is a GABA A receptor positive modulator that exerts its therapeutic effects in the short-term treatment of insomnia.
• Key considerations for use in the geriatric population include potential for increased sensitivity to the drug and increased risk of adverse effects, such as next-day residual effects and anterograde amnesia.

From the Research

Recommended First-Line Sleep Medications for the Geriatric Population

The following medications are recommended as first-line treatments for insomnia in the elderly:

• Ramelteon: effective for sleep-onset latency and increased total sleep time, with a minimal adverse effect profile 3
• Suvorexant: improves sleep maintenance, with mild adverse effects, including somnolence 3
• Low-dose doxepin (≤ 6 mg): recommended for short-term use, with benefits for sleep maintenance 4, 5
• Non-benzodiazepine gamma aminobutyric acid receptor agonists (e.g., eszopiclone, zolpidem, zaleplon): may be used for sleep-onset insomnia, but with caution due to potential side effects 4, 3

Medications to Avoid or Use with Caution

The following medications are not recommended as first-line treatments for insomnia in the elderly, or should be used with caution:

• Benzodiazepines: should not be used routinely, due to risks of adverse effects, tolerance, and dependence 4, 6, 3, 5
• Trazodone: may improve sleep quality, but carries significant risks, including next-day sedation and increased risk of falls 4, 7
• Antipsychotic agents, pramipexole, and tiagabine: have considerable adverse effects and limited evidence for efficacy in older adults 3
• Diphenhydramine: should be avoided in the elderly, due to anticholinergic effects and increased risk of adverse events 3

Non-Pharmacologic Interventions

Non-pharmacologic interventions, such as cognitive behavioral therapy and sleep hygiene practices, are recommended as first-line treatments for insomnia in the elderly 3, 5