What sleep medications are safe for elderly patients with potential impaired renal function or other comorbidities, such as hypotension or tachycardia?

From the Guidelines

Elderly patients with potential impaired renal function or other comorbidities, such as hypotension or tachycardia, should avoid using benzodiazepines and non-benzodiazepine hypnotics, and instead consider low-dose melatonin (1-2mg) or ramelteon for short-term insomnia management, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.

When considering sleep medications for elderly patients, it is essential to prioritize their safety and minimize potential harms. The guidelines advise against using benzodiazepines or trazodone for treatment of chronic insomnia disorder due to their adverse effect profiles, which include risk for dependency, falls, and cognitive impairment in older patients 1.

Some key points to consider when managing insomnia in elderly patients include:

• Avoiding benzodiazepines and non-benzodiazepine hypnotics, such as zolpidem, due to their increased risk of falls, confusion, and memory problems in older adults 1
• Using low-dose melatonin (1-2mg) or ramelteon for short-term insomnia management, as they have a more favorable safety profile in elderly patients 1
• Starting with non-pharmacological approaches, such as sleep hygiene improvements, before considering medication 1
• Monitoring patients closely for potential adverse effects, such as daytime drowsiness, cognitive impairment, and drug interactions, when using any sleep medication 1

Overall, the management of insomnia in elderly patients requires a cautious and individualized approach, taking into account their unique needs and potential comorbidities. By prioritizing their safety and minimizing potential harms, healthcare providers can help elderly patients manage their insomnia effectively while maintaining their overall health and well-being.

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 may be a safe option for elderly patients with potential impaired renal function or other comorbidities, such as hypotension or tachycardia, at a dose of 1 to 2 mg.
• However, the FDA drug label for eszopiclone does not directly address the safety of this medication in patients with impaired renal function or other comorbidities.
• Suvorexant does not have direct information in its label regarding safe use in patients with impaired renal function or other comorbidities, such as hypotension or tachycardia.
• No conclusion can be drawn regarding the safety of suvorexant in elderly patients with potential impaired renal function or other comorbidities. 2 3

From the Research

Safe Sleep Medications for Elderly Patients

Elderly patients with potential impaired renal function or other comorbidities, such as hypotension or tachycardia, require careful consideration when selecting sleep medications. The following options are recommended:

• Controlled-release melatonin and doxepin are recommended as first-line agents in older adults 4
• Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia 5
• Suvorexant or low-dose doxepin can improve sleep maintenance 5
• Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance 5
• Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings 5

Medications to Avoid

Certain medications should be avoided in elderly patients due to their potential risks and side effects:

• Benzodiazepines should not be used routinely due to their high abuse potential and availability of better alternatives 4, 6, 7
• Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition 4
• Trazodone, a commonly used off-label drug for insomnia, carries significant risks 5
• Tiagabine is not effective and should not be utilized 5
• Diphenhydramine should be avoided in the elderly 7

Considerations for Renal Function and Comorbidities

When selecting sleep medications for elderly patients with impaired renal function or other comorbidities, the following considerations should be taken into account:

• The pharmacokinetics of agents used to treat insomnia may be altered in elderly patients 7
• Medications with minimal adverse effect profiles, such as ramelteon, may be valuable first-line options 7
• Cognitive behavioral therapy and sleep hygiene practices should be considered as initial treatments 6, 7