What alternative medication can be used to treat insomnia in a 90-year-old patient who has tried Ramelteon (rozerem) and is currently taking Clonazepam (klonopin)?

Alternative Medications for Insomnia in a 90-Year-Old Patient

Low-dose doxepin (3-6 mg) is the recommended alternative medication for treating insomnia in a 90-year-old patient who has tried ramelteon and is currently taking clonazepam. 1, 2

Medication Selection Algorithm

First-line option:

• Doxepin (3-6 mg):
  • Specifically recommended for sleep maintenance insomnia in older adults
  • Has a favorable safety profile in elderly patients
  • Does not have significant next-day impairment concerns
  • Minimal risk of dependence or tolerance

Alternative options (if doxepin is ineffective or contraindicated):

1. Suvorexant (5-10 mg):

   • Orexin receptor antagonist effective for sleep maintenance
   • Lower risk of falls and cognitive impairment compared to benzodiazepines
   • Can be used for long-term management 1, 2

2. Eszopiclone (1-2 mg):

   • Effective for both sleep onset and maintenance
   • Use lower doses in elderly (start with 1 mg)
   • Monitor for taste disturbances and daytime sedation 1

Important Considerations for This Patient

Current Medication Concerns:

• Clonazepam: A long-acting benzodiazepine that should be avoided in elderly patients due to:
  • Increased risk of falls and fractures
  • Cognitive impairment and confusion
  • Prolonged sedation due to extended half-life
  • Risk of dependence and withdrawal 3

Age-Specific Factors:

• At 90 years old, this patient is at high risk for medication side effects
• Start with the lowest possible effective dose
• Benzodiazepines should be avoided or used with extreme caution 3, 2
• Previous trial of ramelteon indicates sleep onset insomnia may have been targeted, but was ineffective

Medication Tapering Recommendation

• Consider gradual tapering of clonazepam while introducing the new medication
• Abrupt discontinuation of clonazepam could lead to withdrawal symptoms
• Implement a slow taper (e.g., 10-25% dose reduction every 1-2 weeks) while monitoring for withdrawal symptoms

Non-Pharmacological Approaches

• Implement strict sleep hygiene measures:
  • Consistent sleep-wake schedule
  • Limit daytime napping
  • Avoid caffeine and alcohol
  • Create a quiet, dark, and comfortable sleep environment 3

Monitoring and Follow-up

• Assess effectiveness and side effects within 2-4 weeks of starting new medication
• Use standardized sleep assessment tools to track progress
• Monitor for morning sedation, falls, and cognitive changes
• Consider referral for polysomnography if symptoms persist despite appropriate treatment 3

Common Pitfalls to Avoid

• Avoid using diphenhydramine or other over-the-counter sleep aids due to anticholinergic effects and increased risk of confusion in elderly 1, 2
• Avoid trazodone despite common off-label use, as evidence does not support its efficacy for insomnia 1, 2
• Avoid melatonin as it is not recommended for sleep maintenance insomnia in adults 1
• Do not continue long-term benzodiazepine therapy due to risks outweighing benefits in this age group 3, 2