What are safe sleeping medication options for a 79-year-old?

Safe Sleeping Medications for a 79-Year-Old

For a 79-year-old patient requiring sleep medication, ramelteon (8mg) or low-dose doxepin (3-6mg) are the safest options, while benzodiazepines and other sedative-hypnotics should be avoided due to significant risks in older adults. 1, 2

First-Line Recommendations

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be attempted before medication, as it provides longer-term sustained benefit compared to pharmacological approaches 3
• Ramelteon (8mg) is recommended for sleep onset insomnia in older adults, as it has not been shown to worsen respiratory parameters and has minimal risk of dependence 1, 2
• Low-dose doxepin (3-6mg) is recommended for sleep maintenance insomnia in older adults, as it has minimal respiratory effects at these doses 2

Medications to Avoid in Older Adults

• Benzodiazepines (including lorazepam) should be avoided in older adults due to risks of:

  • Falls and fractures 4
  • Cognitive impairment and delirium 4
  • Respiratory depression that could worsen sleep-disordered breathing 2
  • Physical dependence and withdrawal symptoms 4
  • Listed on the American Geriatrics Society Beers Criteria as potentially inappropriate medications in older adults 3

• Trazodone is not recommended by the American Academy of Sleep Medicine for insomnia treatment 1

• Antihistamines like diphenhydramine should be avoided due to anticholinergic effects and lack of efficacy evidence 1, 2

Melatonin Considerations

• Evidence for melatonin in older adults is mixed:
  • Some studies show improvement in sleep latency in elderly with documented low melatonin levels 5, 6
  • The American Academy of Sleep Medicine does not recommend melatonin for insomnia treatment due to limited evidence of efficacy 3, 1
  • If considering melatonin, dosing for older adults typically ranges from 1-6mg 7, 8
  • A recent study found that 5mg melatonin significantly increased sleep efficiency in adults over 55 years during both biological day and night 8

Non-Pharmacological Approaches

• Maintain stable bedtimes and rising times 1
• Avoid caffeine, nicotine, and alcohol 1
• Limit daytime napping to 30 minutes and avoid napping after 2pm 1
• Use the bedroom only for sleep and sex 1
• Leave the bedroom if unable to fall asleep and return only when sleepy 1
• Regular physical activity such as walking may improve sleep, though evidence is limited 3

Special Considerations for the 79-Year-Old

• Start with the lowest available dose of any medication due to age-related changes in drug metabolism 3, 2
• Monitor for morning sedation, gait imbalance, and cognitive changes when starting any sleep medication 3
• Consider combination therapy (behavioral and short-term pharmacologic) for better outcomes than either modality alone 3
• Avoid medications that can exacerbate sleep apnea if the patient has or is at risk for sleep-disordered breathing 2

Algorithm for Sleep Medication Selection in a 79-Year-Old

1. Start with non-pharmacological approaches (sleep hygiene, CBT-I) 3
2. If medication is necessary:
   • For sleep onset insomnia: Ramelteon 8mg 1, 9
   • For sleep maintenance insomnia: Doxepin 3-6mg 2, 9
3. If ineffective, consider melatonin 1-2mg (though evidence is limited) 7, 5
4. Avoid benzodiazepines, non-benzodiazepine hypnotics, antihistamines, and trazodone 1, 2, 4