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) In the first study, adults with chronic insomnia (n=308) were evaluated in a double-blind, parallel-group trial of 6 weeks’ duration comparing eszopiclone 2 mg and 3 mg with placebo. Elderly subjects (ages 65 to 86) with chronic insomnia were evaluated in two double-blind, parallel-group trials of 2 weeks duration 14. 1 Transient Insomnia Healthy adults were evaluated in a model of transient insomnia (n=436) in a sleep laboratory in a double-blind, parallel-group, single-night trial comparing two doses of eszopiclone and placebo.
For short-term insomnia in individuals over 75 years old, the recommended treatment approach is to use eszopiclone at a dose of 1 to 2 mg. This is based on studies that have shown eszopiclone to be effective in reducing sleep latency and improving sleep maintenance in elderly patients with chronic and transient insomnia 1.
- Key considerations:
- The dose for elderly patients is lower than for adult patients
- Eszopiclone has been shown to be effective for short-term treatment of insomnia
- The medication should be used with caution due to the potential for next-day residual effects and memory impairment. It is also important to note that zolpidem has been studied for the treatment of insomnia in the elderly, and the recommended dose is 5 mg for patients over 65 years old 2 2.
From the Research
For short-term insomnia in individuals over 75 years old, non-pharmacological approaches should be tried first, including sleep hygiene practices, cognitive behavioral therapy for insomnia (CBT-I), and relaxation techniques. If medication becomes necessary, low-dose options should be considered for limited duration (generally 2-4 weeks maximum). Appropriate medications include low-dose trazodone (25-50mg), low-dose mirtazapine (7.5-15mg), or melatonin (1-2mg) 3. Traditional sedative-hypnotics like benzodiazepines and Z-drugs (zolpidem, eszopiclone) should generally be avoided due to increased risk of falls, cognitive impairment, and dependence in older adults, as highlighted in a study published in 2021 4. When prescribing any sleep medication for elderly patients, the principle of "start low, go slow" applies, with careful monitoring for side effects. Medication should be used temporarily while continuing to implement behavioral strategies. This conservative approach is recommended because older adults experience more pronounced side effects from sleep medications, have altered drug metabolism, and often take multiple medications that may interact with sleep aids. Additionally, addressing underlying causes of insomnia such as pain, nocturia, or depression is essential for effective management, as supported by a systematic review and network meta-analysis published in 2022 5. Non-pharmacological interventions, such as cognitive-behavioral therapy for insomnia, have been shown to be effective in managing insomnia in older adults, with a study published in 2020 finding that combined treatments, including benzodiazepines combined with CBT, were generally superior to other monotherapies 6. A study published in 2018 also emphasized the importance of cognitive-behavioral therapy for insomnia as the recommended first-line treatment of insomnia in older adults 7. Overall, a comprehensive approach that incorporates non-pharmacological and pharmacological interventions, as well as addressing underlying causes of insomnia, is necessary for effective management of short-term insomnia in individuals over 75 years old. Key considerations include:
- Non-pharmacological approaches as first-line treatment
- Low-dose medication options for limited duration
- Avoidance of traditional sedative-hypnotics
- Careful monitoring for side effects
- Addressing underlying causes of insomnia
- Implementation of behavioral strategies alongside medication use.