What medications are effective for treating nightmares in elderly patients with post-traumatic stress disorder (PTSD)?

From the Guidelines

Prazosin is the most effective medication for treating nightmares in elderly patients with PTSD, typically started at a low dose of 1mg at bedtime and gradually increased to 3-15mg as tolerated, with most elderly patients responding to lower doses (2-6mg) 1.

Medication Options

Several medications can effectively treat nightmares in elderly patients with PTSD. The following options are considered:

• Prazosin: an alpha-1 adrenergic receptor antagonist that works by blocking the effects of norepinephrine in the brain, which is often elevated during nightmares.
• Trazodone (25-100mg at bedtime): has sedative properties that can improve sleep quality while reducing nightmares.
• Low-dose doxepin (3-6mg): helps with sleep maintenance.
• Atypical antipsychotics like quetiapine (25-200mg) or olanzapine (2.5-10mg): may be considered for treatment-resistant cases but should be used cautiously due to their side effect profile in the elderly.

Important Considerations

When prescribing these medications to elderly patients, it's essential to:

• Start at lower doses than used in younger adults.
• Monitor for side effects like orthostatic hypotension (especially with prazosin).
• Regularly assess treatment effectiveness.
• Consider non-pharmacological approaches such as cognitive behavioral therapy for insomnia and nightmares alongside medication for optimal results.

Evidence-Based Recommendations

The American Academy of Sleep Medicine position paper 1 recommends prazosin as a first-line treatment for PTSD-associated nightmares, with a typical dose range of 1-15mg at bedtime. Another study 1 supports the use of prazosin, with a mean dose of 13 ± 3 mg/day, and reports a significant decrease in nightmare frequency and distress. However, a more recent study 1 found no significant difference in outcome measures between prazosin and placebo, leading to a downgrade in the recommendation for prazosin use. Despite this, prazosin remains a commonly used and effective treatment for nightmares in elderly patients with PTSD.

From the Research

Medications for Nightmares in Elderly Patients with PTSD

• Prazosin is a medication that has been studied for the treatment of nightmares related to post-traumatic stress disorder (PTSD) 2, 3, 4, 5, 6.
• The evidence suggests that prazosin is effective in reducing the frequency and severity of nightmares in patients with PTSD, including those with combat-related and non-combat-related trauma 2, 3, 5.
• Prazosin has been shown to be well-tolerated, with the most common adverse event being orthostatic hypotension 2, 6.
• Other medications that have been studied for the treatment of nightmares in PTSD include doxazosin, clonidine, tricyclic antidepressants, trazodone, mirtazapine, atypical antipsychotics, gabapentin, topiramate, and cyproheptadine 4.
• However, the evidence for these medications is limited, and large randomized controlled trials are needed to establish their efficacy and safety 4.

Dosage and Administration

• The optimal dose of prazosin for the treatment of nightmares in PTSD is unknown, but doses as low as 1 mg daily have been shown to be effective 2, 6.
• Prazosin can be started at a low dose and gradually increased as needed and tolerated 6.
• Clinicians should monitor patients for orthostatic hypotension, particularly when starting prazosin therapy 2, 6.

Treatment Considerations

• The treatment of nightmares in PTSD should be individualized, taking into account the patient's medical history, comorbidities, and concurrent medications 4.
• Prazosin may be a useful treatment option for patients with PTSD who have not responded to other treatments or who have contraindications to other medications 2, 3.
• Further research is needed to establish the long-term efficacy and safety of prazosin and other medications for the treatment of nightmares in PTSD 4, 5.