What sleep medication can be prescribed for a 75-year-old female, given that doxepin (Sinequan) is not covered by insurance?

Sleep Medication Recommendations for a 75-Year-Old Female

For a 75-year-old female patient requiring sleep medication, low-dose trazodone (25-100 mg at bedtime) is the recommended first-line option when doxepin is not covered by insurance. 1

First-Line Options

Trazodone

• Starting dose: 25 mg at bedtime
• Titration: Increase gradually as needed
• Maximum dose: 100 mg at bedtime
• Benefits: Well-tolerated in elderly, non-habit forming, improves sleep quality 1
• Potential side effects: Morning grogginess (15%), orthostatic hypotension (10%) 2

Alternative First-Line Options

Mirtazapine

• Starting dose: 7.5 mg at bedtime
• Maximum dose: 30 mg at bedtime
• Benefits: Promotes sleep, appetite, and weight gain 1
• Particularly useful for: Elderly patients with poor appetite or weight loss

Second-Line Options

Non-benzodiazepine Benzodiazepine Receptor Agonists (BzRAs)

• Options:
  • Zolpidem: 5 mg at bedtime (reduced dose for elderly) 1
  • Eszopiclone: 1 mg at bedtime (reduced dose for elderly) 1
• Caution: Risk of falls, cognitive impairment, and complex sleep behaviors (sleep walking, sleep driving) 1
• Important safety note: Use lowest effective dose for shortest duration possible

Ramelteon

• Dose: 8 mg at bedtime
• Benefits: Non-scheduled medication, primarily for sleep onset insomnia 1
• Advantage: No risk of dependence or withdrawal

Medications to Avoid in This Patient

• Benzodiazepines (lorazepam, temazepam): High risk of falls, cognitive impairment, and dependency in elderly patients 1
• Antihistamines: Anticholinergic effects particularly problematic in elderly; tolerance develops quickly 1
• Antipsychotics (quetiapine): Limited evidence for insomnia treatment; risk of metabolic and extrapyramidal side effects 1

Implementation Strategy

1. Start with trazodone 25 mg at bedtime

   • Lower starting dose appropriate for elderly patients
   • Monitor for morning drowsiness and orthostatic hypotension

2. If inadequate response after 2 weeks:

   • Increase trazodone to 50 mg at bedtime
   • Further titration to 75-100 mg if needed and tolerated

3. If trazodone is ineffective or poorly tolerated:

   • Switch to mirtazapine 7.5 mg at bedtime
   • OR consider zolpidem 5 mg at bedtime (with appropriate counseling about risks)

4. Combine with non-pharmacological approaches:

   • Stimulus control (go to bed only when sleepy, maintain regular schedule)
   • Sleep restriction (limit time in bed to actual sleep time)
   • Relaxation techniques
   • Avoid caffeine, alcohol, and daytime napping 1

Special Considerations for Elderly Patients

• Start low, go slow: Use lower initial doses than in younger adults
• Monitor for adverse effects: Morning sedation, falls, cognitive impairment
• Avoid anticholinergic medications: Can worsen cognitive function
• Evaluate for sleep apnea: Common in elderly and may require specific treatment
• Review medication interactions: Elderly patients often take multiple medications

Recent evidence suggests trazodone demonstrates significant improvements in sleep quality with moderate side effect profile compared to other options 2, 3, making it particularly suitable for elderly patients when doxepin is not available.