From the Guidelines
For an older adult with hypertension and insomnia, melatonin would be the most appropriate initial medication choice. Melatonin is a natural hormone that helps regulate sleep-wake cycles and is generally considered safe for older adults with comorbidities like hypertension 1. It has minimal side effects, no significant drug interactions, and doesn't cause dependence or morning hangover effects. The other options present various concerns for this patient population: hydroxyzine and diphenhydramine (antihistamines) can cause anticholinergic effects, cognitive impairment, and may worsen hypertension; temazepam and lorazepam (benzodiazepines) carry risks of dependence, falls, cognitive impairment, and rebound insomnia.
Some key points to consider when prescribing melatonin for this patient population include:
- Starting with low-dose melatonin (0.5-1mg) taken 1-2 hours before bedtime is recommended, with potential to increase to 3-5mg if needed 1.
- Melatonin has been shown to improve sleep outcomes in older adults, including reduced sleep onset latency and improved sleep efficiency 1.
- The evidence for other pharmacologic interventions, such as benzodiazepines and antihistamines, is limited and associated with significant risks and harms 1.
- Cognitive behavioral therapy for insomnia (CBT-I) is also a recommended treatment approach for older adults with insomnia, and may be used in conjunction with melatonin therapy 1.
Overall, the use of melatonin as a first-line treatment for insomnia in older adults with hypertension is supported by the available evidence and is a safe and effective approach to managing this common condition.
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) Overall, at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg), eszopiclone significantly decreased sleep latency and improved measures of sleep maintenance
Eszopiclone is suitable for an older adult with hypertension and insomnia, as it has been studied in elderly patients and shown to be effective in reducing sleep latency and improving sleep maintenance at a dose of 1 to 2 mg 2.
- Key considerations:
- Dose: 1 to 2 mg for elderly patients
- Efficacy: significantly decreased sleep latency and improved measures of sleep maintenance
- Population: studied in elderly patients (ages 65 to 86) with chronic and transient insomnia However, it is essential to consult with a healthcare professional to determine the best course of treatment, as hypertension is not directly addressed in the provided drug label.
From the Research
Medication Options for Older Adults with Hypertension and Insomnia
- Controlled-release melatonin and low-dose doxepin are recommended as first-line agents for older adults with insomnia 3
- Ramelteon, a selective MT1, MT2 receptor agonist, has been found effective in improving sleep quality, sleep efficacy, and reducing sleep onset time 4
- The choice of a hypnotic agent in the elderly is symptom-based, with options including:
- Ramelteon or short-acting Z-drugs for sleep-onset insomnia
- Suvorexant or low-dose doxepin for sleep maintenance
- Eszopiclone or zolpidem extended release for both sleep onset and sleep maintenance 5
- Benzodiazepines are not recommended due to their high abuse potential and availability of better alternatives 3, 5
Considerations for Older Adults with Hypertension
- Pharmacologic options for older adults with insomnia should be carefully selected and initiated with a low dose, with careful monitoring of the patient to minimize common unwanted side effects 6
- The use of hypnotics in older adults is not well studied, and the magnitude of the medication benefit is usually not impressive 6
- A well-informed clinician can help patients navigate the risks and benefits of both pharmacologic and behavioral options for insomnia 7