What are the safest sleep medications for older adults?

Safest Sleep Medications for Older Adults

For older adults with sleep problems, cognitive behavioral therapy for insomnia (CBT-I) should be considered first-line treatment before any medication, as it is effective and has minimal adverse effects compared to pharmacological options. 1

First-Line Approach: Non-Pharmacological Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• Moderate-quality evidence shows CBT-I improves sleep outcomes in older adults, including:
  • Reduced sleep onset latency
  • Improved sleep efficiency
  • Reduced wake time after sleep onset 1
• CBT-I can be delivered through:
  • Individual or group therapy
  • Telephone or web-based modules
  • Self-help books 1

Sleep Hygiene Practices

1. Develop a consistent sleep ritual (30-minute relaxation before bedtime)
2. Create a comfortable bedroom environment
3. Go to bed only when sleepy
4. Avoid heavy exercise within 2 hours of bedtime
5. Avoid caffeine, nicotine, and alcohol
6. Use bedroom only for sleep and sex
7. Maintain consistent bed and wake times
8. Limit daytime napping to 30 minutes before 2pm 1

Other Non-Pharmacological Approaches

• Regular physical activity (walking, Tai Chi) has shown benefits for sleep quality 1, 2
• Relaxation techniques (progressive muscle relaxation, guided imagery, diaphragmatic breathing) 1
• Bright light therapy, particularly morning exposure 1

Second-Line Approach: Pharmacological Options

If CBT-I alone is unsuccessful, pharmacological therapy may be considered using a shared decision-making approach that discusses benefits, harms, and costs 1.

Safest Medication Options for Older Adults:

1. Low-dose doxepin (3-6mg)

   • Moderate-quality evidence shows improved sleep outcomes in older adults
   • Lower risk of next-day impairment compared to other options 1

2. Ramelteon

   • Low-quality evidence shows decreased sleep onset latency in older adults
   • Melatonin receptor agonist with no significant effects indicating potential for abuse or cognitive impairment 1

3. Short-acting non-benzodiazepines (z-drugs)

   • Low-quality evidence shows eszopiclone improved global and sleep outcomes
   • Zolpidem decreased sleep onset latency
   • Should be used at the lowest possible dose
   • Higher risk of adverse effects than non-pharmacological approaches 1

Medications to Use with Extreme Caution:

1. Benzodiazepines (temazepam, lorazepam)

   • Associated with significant risks in older adults:
     • Physical dependence and withdrawal reactions
     • Increased risk of falls and fractures
     • Cognitive impairment and memory problems
     • Potential for abuse and addiction 3, 4
   • If used, should be at lowest possible dose for shortest duration 1

2. Diphenhydramine and other antihistamines

   • Associated with poorer performance on neurologic function tests
   • Increased daytime hypersomnolence in nursing home residents 1
   • Strong anticholinergic effects particularly problematic for older adults

Important Considerations for Medication Use

1. Start with lowest available dose for any medication selected 1

2. Short-term use only - FDA has approved pharmacologic therapy for only 4-5 weeks 1

3. Monitor for adverse effects - especially:

   • Daytime impairment
   • "Sleep driving" and other complex sleep behaviors
   • Behavioral abnormalities
   • Worsening depression 1

4. Evaluate effectiveness - if insomnia does not improve within 7-10 days, reevaluate 1

5. Avoid polypharmacy - assess for drug interactions with existing medications

Special Considerations for Nursing Home Residents

• Sleep problems are particularly common in nursing home settings
• Environmental modifications are important (reducing nighttime noise/light)
• Physical activity programs have shown benefits for sleep in this population
• Medication risks may be heightened in this vulnerable population 1

Conclusion

The safest approach to managing sleep problems in older adults follows a stepwise algorithm:

1. Begin with comprehensive CBT-I and sleep hygiene practices
2. Add other non-pharmacological approaches (exercise, relaxation techniques)
3. If unsuccessful, consider low-dose doxepin or ramelteon as safest pharmacological options
4. Use short-acting non-benzodiazepines at lowest effective dose only when necessary
5. Avoid benzodiazepines and antihistamines whenever possible
6. Limit any medication use to short-term (4-5 weeks maximum)

This approach prioritizes safety while addressing the significant impact that sleep problems have on quality of life, morbidity, and mortality in older adults.