From the Guidelines
For elderly women over 80 years old with potential impaired renal function and polypharmacy, low-dose melatonin (0.5-1 mg) taken 1-2 hours before bedtime is generally the safest medication for inducing sleep, as it has minimal side effects compared to prescription sleep medications 1.
Key Considerations
- The use of benzodiazepines or trazodone is advised against due to their potential harms and adverse effects, including risk for dependency and diversion, falls and cognitive impairment in older patients, hypoventilation in patients with respiratory conditions, and neuromuscular diseases 1.
- Non-benzodiazepine BZRA, if prescribed, should be administered at the lowest effective dose and for the shortest possible duration, with all patients counseled on the potential risks 1.
- Antihistamines and antipsychotics are not recommended for treatment of chronic insomnia disorder due to their adverse effect profiles and lack of evidence supporting their efficacy 1.
Alternative Options
- If melatonin is insufficient, a low-dose sedating antihistamine like diphenhydramine (Benadryl) 12.5-25 mg can be used occasionally, but not regularly due to anticholinergic side effects that can affect cognition in the elderly.
- For prescription options, short-acting medications like ramelteon (Rozerem) 8 mg or low-dose trazodone (25-50 mg) may be appropriate under medical supervision, as suggested by the 2008 clinical guideline for the evaluation and management of chronic insomnia in adults 2.
Non-Medication Approaches
- Maintaining regular sleep schedules, avoiding caffeine and alcohol before bedtime, limiting daytime napping, and creating a comfortable sleep environment should always be tried first.
- Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the initial treatment for chronic insomnia disorder, with moderate-quality evidence supporting its effectiveness 3, 4.
Important Notes
- Any sleep medication should be discussed with a healthcare provider who knows the individual's complete medical history and medication list to avoid potentially dangerous interactions.
- The FDA recommends short-term use of sleep medications, although many patients may continue their use for extended periods, highlighting the need for careful monitoring and regular reassessment 4.
From the Research
Safest Pharmacological Agents for Inducing Sleep in Elderly Women
The safest pharmacological agent for inducing sleep in elderly women over 80 years old with potential impaired renal function and polypharmacy is a topic of concern due to the increased risk of adverse effects associated with many sleep aids.
- Melatonin is a hormone that has been shown to increase sleep duration in older adults, particularly when administered in high doses (5.0 mg) 30 minutes before bedtime 5.
- Non-benzodiazepine sedative-hypnotics, such as eszopiclone, zolpidem, and zaleplon, are also effective for treating insomnia in elderly persons, but their use should be approached with caution due to the risk of adverse effects such as cognitive impairment, daytime sedation, and increased risk of falls 6, 7.
- Ramelteon, a melatonin agonist, is another option for treating sleep-onset insomnia in elderly women, and it has a relatively safe profile compared to benzodiazepines 7.
- The use of benzodiazepines, such as triazolam and temazepam, is generally not recommended for elderly women due to the high risk of adverse effects, including cognitive impairment, daytime sedation, and increased risk of falls 6, 7.
Considerations for Elderly Women with Impaired Renal Function and Polypharmacy
When selecting a pharmacological agent for inducing sleep in elderly women with impaired renal function and polypharmacy, it is essential to consider the potential for drug interactions and the risk of adverse effects.
- Melatonin is generally considered safe and well-tolerated, even in patients with impaired renal function, and it has a low potential for drug interactions 5, 8.
- Non-benzodiazepine sedative-hypnotics, such as eszopiclone and zolpidem, should be used with caution in patients with impaired renal function, as they may require dose adjustments to minimize the risk of adverse effects 7.
- Ramelteon is also considered safe for use in patients with impaired renal function, but it may interact with other medications, such as fluvoxamine and rifampin, which can affect its efficacy and safety 7.