What sleeping pills are safe to use in older adults with central sleep apnea (CSA)?

Sleeping Pills for Older Adults with Central Sleep Apnea

Most sleeping pills should be avoided in older adults with central sleep apnea (CSA) due to risks of respiratory depression that could worsen sleep-disordered breathing. 1

First-Line Approach: Non-Pharmacological Interventions

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for insomnia in older adults with CSA before considering medication 2
• Sleep hygiene education, including maintaining regular sleep schedules, avoiding daytime napping, and limiting caffeine and alcohol should be implemented 2
• Relaxation techniques such as progressive muscle relaxation and diaphragmatic breathing can be beneficial 2

Treating the Underlying Central Sleep Apnea

Before addressing insomnia pharmacologically, the underlying CSA should be treated:

• Continuous positive airway pressure (CPAP) is suggested as first-line therapy for CSA 3
• Adaptive servo ventilation (ASV) may be considered for CSA, though careful monitoring is needed in patients with heart failure 3
• Low-flow oxygen therapy may be beneficial, particularly in CSA due to heart failure 3
• Oral acetazolamide may be considered for CSA treatment 3, 4

Pharmacological Options for Insomnia in CSA Patients

Potentially Safer Options:

• Low-dose doxepin (3-6mg) may be the safest option for sleep maintenance insomnia in older adults with CSA, as it has minimal respiratory effects at these doses 2
• Ramelteon (8mg) may be considered for sleep onset insomnia as it has not been shown to worsen respiratory parameters 2, 5

Medications to Avoid:

• Benzodiazepines should be strictly avoided as they can depress upper airway tone and worsen sleep-disordered breathing 1
• Opiates should be avoided as they can exacerbate CSA 1
• Alcohol and sedative-hypnotics can depress upper airway tone and worsen sleep apnea 1
• Over-the-counter antihistamines (including diphenhydramine) should be avoided due to anticholinergic effects and lack of efficacy evidence 2, 6

Special Considerations for Older Adults with CSA

• Older adults are more sensitive to medication side effects due to altered pharmacokinetics 2
• Start with the lowest possible effective dose and titrate slowly 2
• Monitor closely for adverse effects including next-day impairment, falls, confusion, and respiratory depression 2
• If congestive heart failure is present alongside CSA, optimizing heart failure treatment may improve both conditions 1
• Weight loss should be encouraged in obese patients as it may improve both CSA and sleep quality 1

Evidence on Specific Medications

• While some older literature suggested zolpidem might not worsen CSA 7, more recent guidelines recommend caution with all sedative-hypnotics in sleep apnea 1
• Melatonin has shown only small effects on sleep latency with little effect on wake after sleep onset or total sleep time, and is not recommended by the American Academy of Sleep Medicine 6
• Herbal supplements like valerian have inconsistent results and are not recommended 6

Remember that CSA is a serious condition that can worsen with inappropriate medication choices. The primary focus should be on treating the underlying CSA while using the safest possible approaches for managing insomnia symptoms.