Zolpidem Dosing for an 87-Year-Old with Insomnia
For an 87-year-old patient weighing 192 pounds with insomnia, the recommended dose of zolpidem is 5 mg once daily immediately before bedtime. 1
Rationale for Dosing
The FDA drug label for zolpidem clearly states that elderly patients should receive a reduced dose of 5 mg due to:
- Elderly patients have slower drug clearance
- Increased sensitivity to the effects of zolpidem
- Higher risk of adverse effects including falls and cognitive impairment 1
Despite the patient's weight of 192 pounds, age is the primary determining factor for dosing in this case, not weight. The FDA label specifically recommends 5 mg for elderly patients regardless of weight. 1
Important Administration Guidelines
- Administer only once per night immediately before bedtime
- Ensure at least 7-8 hours remain before planned awakening time
- Take as a single dose (do not readminister during the same night)
- The effect may be slowed if taken with or immediately after a meal 1
Special Considerations for This Patient
Previous Medication Experience
The patient experienced wakefulness with diazepam (Valium), which suggests potential sensitivity to benzodiazepine-like medications. This further supports starting with the lower 5 mg dose.
Age-Related Risks
At 87 years old, this patient is at particularly high risk for:
- Falls (zolpidem increases fall risk with OR of 4.28) 2
- Hip fractures (RR 1.92) 2
- Confusion and cognitive impairment 2
- Next-day impairment affecting driving and other activities requiring alertness 1
Duration of Treatment
- Limit pharmacological treatment to 4-5 weeks 3
- Schedule follow-up within 2-4 weeks to assess effectiveness and monitor for side effects 3
Monitoring and Follow-up
- Assess for daytime sedation, falls, and cognitive changes 3
- Monitor for complex behaviors such as sleepwalking, which can occur regardless of dose or history 2
- Evaluate sleep parameters within 2-4 weeks of starting treatment 3
Alternative Approaches to Consider
If zolpidem is ineffective or poorly tolerated, consider:
- Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment 3
- Low-dose doxepin (3-6 mg) for sleep maintenance insomnia 3
- Ramelteon (8 mg) for sleep onset insomnia, which has lower risk of dependence 3
Caution
The American Academy of Sleep Medicine clinical practice guideline notes that while zolpidem is effective for sleep onset and maintenance insomnia, this recommendation is based on trials using 10 mg doses in adults. However, the FDA has subsequently lowered the recommended starting dose to 5 mg for adults and specifically recommends 5 mg for elderly patients. 4, 1