Is Lunesta (eszopiclone) associated with memory loss in elderly patients with dementia?

Lunesta (Eszopiclone) and Memory Loss in Elderly Patients with Dementia

Lunesta (eszopiclone) is associated with increased risk of memory impairment and confusion in elderly patients with dementia and should be avoided in this population whenever possible. 1, 2

Evidence of Cognitive Impairment with Lunesta

The FDA labeling information for nonbenzodiazepine hypnotics, including eszopiclone (Lunesta), explicitly warns of:

• Daytime memory and psychomotor impairment
• Abnormal thinking and behavioral changes
• Complex behaviors (such as sleep driving)
• Depression and suicidal thoughts 1

Clinical studies have documented specific cognitive adverse effects:

• In a 6-week adult study, confusion was reported by 3% of patients taking eszopiclone 3 mg, compared to 0% with placebo 2
• Memory impairment was reported by 1% of patients taking either 2 mg or 3 mg eszopiclone, compared to 0% with placebo 2
• In elderly patients specifically, a 2-week study found 1.5% of patients taking eszopiclone 2 mg reported memory impairment compared to 0% with placebo 2
• Another 2-week study of elderly insomniacs found 2.5% of patients taking eszopiclone 2 mg reported confusion compared to 0% with placebo 2

Increased Dementia Risk with Hypnotics

Observational data indicates that hypnotic drugs, including both benzodiazepines and nonbenzodiazepines like Lunesta, are associated with dementia with a hazard ratio of 2.34 (95% CI: 1.92 to 2.85) 1, 3. This represents more than double the risk of developing dementia compared to non-users.

Special Considerations for Elderly Patients with Dementia

Elderly patients with dementia are particularly vulnerable to the cognitive side effects of hypnotics due to:

1. Pre-existing cognitive impairment
2. Age-related changes in drug metabolism
3. Higher sensitivity to central nervous system effects
4. Increased risk of falls and fractures

A population-based cohort study found that Z-drugs (including zopiclone, which is chemically related to eszopiclone) were associated with increased risks of:

• Fractures (HR 1.67,95% CI: 1.13-2.46)
• Hip fractures (HR 1.96,95% CI: 1.16-3.31)
• Falls (HR 1.33,95% CI: 1.06-1.66)
• Ischemic stroke (HR 1.88,95% CI: 1.14-3.10) 4

Management Recommendations

1. Avoid Lunesta in patients with dementia whenever possible 3

2. If treatment for insomnia is necessary:

   • Start with non-pharmacological interventions (sleep hygiene, cognitive behavioral therapy for insomnia) 3
   • Consider lower-risk alternatives if medication is required
   • If Lunesta must be used, use the lowest effective dose for the shortest duration
   • Monitor closely for cognitive changes, confusion, and falls

3. For patients already taking Lunesta:

   • Regularly reassess the need for continued therapy
   • Consider gradual tapering to avoid withdrawal symptoms 3
   • Monitor for improvement in cognitive function after discontinuation

Common Pitfalls to Avoid

• Failing to recognize that memory impairment from Lunesta may be mistaken for worsening dementia
• Overlooking the cumulative cognitive burden when Lunesta is combined with other medications with anticholinergic properties
• Neglecting to monitor for falls and fractures, which are increased with Lunesta use in elderly patients with dementia
• Abrupt discontinuation of Lunesta, which may cause withdrawal symptoms including rebound insomnia 2

In conclusion, the risks of Lunesta in elderly patients with dementia generally outweigh the benefits, with clear evidence of increased cognitive impairment, confusion, and physical risks like falls and fractures. Non-pharmacological approaches to insomnia should be prioritized in this vulnerable population.