What is a suitable sleep medication for a 66-year-old female patient with a history of falls, insomnia, and current medications including Lexapro (escitalopram) 10mg and Wellbutrin (bupropion) 150mg daily?

Medication Selection for Insomnia in a 66-Year-Old Female with Fall Risk

Low-dose eszopiclone (1 mg) is the most appropriate medication for this 66-year-old female with insomnia and fall risk, as it has demonstrated efficacy for sleep maintenance issues with a better safety profile than benzodiazepines or trazodone in elderly patients. 1, 2, 3

Patient Assessment Factors

• 66-year-old female with history of falls (high risk)
• Primarily reports sleep maintenance issues
• Currently taking Lexapro 10 mg and Wellbutrin 150 mg daily
• Previous use of trazodone
• Currently in rehabilitation facility

Medication Recommendation

First-Line Option: Eszopiclone

• Dosing: Start with 1 mg at bedtime (elderly-appropriate dose) 2, 3
• Rationale:
  • Demonstrated efficacy for sleep maintenance problems in elderly patients 3
  • FDA-approved for sleep maintenance insomnia 3
  • Superior to placebo on measures of sleep maintenance in elderly patients 3
  • Lower fall risk compared to benzodiazepines and trazodone 1
  • Effective for improving both sleep onset and maintenance 3, 4

Why NOT Other Common Options:

• Trazodone: Despite patient's previous use, trazodone is not recommended due to:

  • Limited evidence supporting efficacy for insomnia 1
  • Adverse effect profile outweighs benefits 1
  • Increased risk of falls in elderly patients

• Benzodiazepines: Strongly advised against due to:

  • Substantially increased fall risk in elderly patients 1
  • Risk for dependency and cognitive impairment 1
  • Harms outweigh benefits, especially in fall-risk patients 1

• Antihistamines: Not recommended due to:

  • Anticholinergic side effects particularly concerning in older adults 2
  • Tolerance develops after 3-4 days of continuous use 1
  • Beers Criteria strongly recommends avoiding in older adults 1

• Antipsychotics (e.g., quetiapine): Not recommended due to:

  • Limited evidence for efficacy 1
  • Significant adverse effects including increased mortality risk in elderly 1

Implementation Guidelines

1. Start with eszopiclone 1 mg at bedtime
2. Schedule follow-up within 7-10 days to evaluate treatment response 2
3. If inadequate response and no adverse effects, may consider increasing to 2 mg
4. Use for shortest possible duration at lowest effective dose
5. Counsel patient on potential side effects:
   • Unpleasant taste (most common side effect) 4, 5
   • Headache and dry mouth 6
   • Risk of next-day impairment (though less than with 3 mg dose) 3

Additional Considerations

• Consider implementing non-pharmacological approaches alongside medication:

  • Cognitive Behavioral Therapy for Insomnia (CBT-I) is first-line treatment 2
  • Sleep hygiene education
  • Regular exercise (shown to improve sleep as effectively as some medications) 7

• Monitor closely for:

  • Falls (given patient's history and rehabilitation setting)
  • Confusion or memory impairment (reported in 1.5-2.5% of elderly patients on 2 mg) 3
  • Interactions with current medications (Lexapro, Wellbutrin)

This approach prioritizes both efficacy for the patient's specific sleep maintenance issues and safety given her age and fall risk history, while providing clear monitoring parameters and dosing guidance.