What medication can be given as needed (PRN) for sleep in a 72-year-old female patient with Generalized Anxiety Disorder (GAD) who is currently on 0.5mg Clonazepam (clonazepam) at night and will be started on Doxepin (doxepin) 10mg in the morning?

PRN Sleep Medication for Elderly Patient with GAD

For a 72-year-old female patient with GAD who is on clonazepam 0.5mg at night and starting doxepin 10mg in the morning, low-dose trazodone (25-50mg) is the most appropriate PRN medication for sleep disturbance. 1

Medication Selection Algorithm

1. First-line option: Trazodone 25-50mg PRN

   • Sedating antidepressant with established efficacy for sleep maintenance
   • Lower risk profile in elderly compared to benzodiazepines
   • Compatible with existing clonazepam and doxepin regimen 1

2. Alternative options (if trazodone is contraindicated):

   • Low-dose quetiapine (25mg) for refractory insomnia 1
   • Mirtazapine (7.5-15mg) especially if patient has comorbid depression and anorexia 1

Rationale for Recommendation

Why Trazodone is Preferred

• Benzodiazepines (including additional doses of clonazepam) should be avoided in older patients due to:

  • Decreased cognitive performance in elderly patients 1
  • Risk of dependence and tolerance 2
  • Patient already on clonazepam 0.5mg nightly

• Zolpidem carries risks in elderly patients:

  • Next-morning impairment requiring lower doses in elderly 1
  • FDA required dose reduction for safety concerns 1

• Low-dose doxepin (3-6mg) would be ideal for sleep maintenance but:

  • Patient is already starting doxepin 10mg in the morning for GAD 3
  • Adding nighttime doxepin could lead to excessive daytime sedation 3

Dosing Considerations

• Start trazodone at 25mg 30 minutes before bedtime
• May increase to 50mg if needed and tolerated
• Use only when needed (PRN) 1

Important Monitoring Considerations

• Potential side effects to monitor:

  • Daytime sedation - assess morning alertness 1
  • Orthostatic hypotension - monitor blood pressure 1
  • Anticholinergic effects - assess for dry mouth, constipation, urinary retention 1

• Medication interactions:

  • Monitor for excessive sedation with concurrent clonazepam use 1
  • Assess for serotonin syndrome with doxepin combination (though risk is low at these doses) 3

Non-Pharmacological Approaches to Complement Medication

• Maintain stable bedtimes and rising times 1
• Avoid daytime napping, especially after 2pm 1
• Use bedroom only for sleep 2
• Leave bedroom if unable to fall asleep within 20 minutes 2
• Consider relaxation techniques before bedtime 1

Common Pitfalls to Avoid

• Avoid diphenhydramine despite its common use, as it:

  • Has limited efficacy data in elderly 1
  • Carries significant anticholinergic burden 1
  • Can worsen cognitive function in elderly 1

• Avoid adding another benzodiazepine or Z-drug due to:

  • Increased fall risk in elderly 1
  • Potential for cognitive impairment 1
  • Risk of dependence 2