What is the best sleep aid for a 66-year-old patient on donepezil (Aricept)?

Best Sleep Aid for a 66-Year-Old Patient on Donepezil

For a 66-year-old patient on donepezil, non-pharmacological approaches should be the first-line treatment for insomnia, with short-acting medications at reduced doses used only when necessary due to potential interactions with donepezil and risks in elderly patients. 1

Non-Pharmacological Approaches (First-Line)

• Implement stimulus control therapy to strengthen the association between sleep and the bedroom by:

  • Developing a sleep ritual such as a 30-minute relaxation period before bedtime 1
  • Going to bed only when sleepy 1
  • Leaving the bedroom if unable to fall asleep 1
  • Maintaining stable bedtimes and rising times 1

• Address sleep hygiene factors that may impair sleep:

  • Avoid daytime napping or limit to 30 minutes before 2 pm 1
  • Avoid caffeine, nicotine, and alcohol, especially in the evening 1
  • Avoid late evening exercise (within 2 hours of bedtime) 1
  • Ensure the bedroom is comfortable, quiet, and dark 1

• Consider relaxation techniques:

  • Progressive muscle relaxation, guided imagery, diaphragmatic breathing 1
  • Meditation or biofeedback 1

Pharmacological Options (If Non-Pharmacological Approaches Fail)

Important Considerations with Donepezil

• Donepezil may cause nightmares when taken at bedtime, which can worsen sleep quality 2
• Consider administering donepezil in the morning if nighttime administration is causing sleep disturbances 2

Recommended Medications (Short-Term Use Only)

1. Melatonin receptor agonist (First choice)

   • Safer option with minimal adverse effects and less risk of cognitive impairment 1
   • Start at the lowest available dose 1

2. Short-acting non-benzodiazepines (Second choice)

   • Zolpidem: Start at 5 mg for elderly patients 3
   • Eszopiclone: Dose should not exceed 2 mg in elderly patients 4
   • Use with caution as these medications can worsen dementia and increase fall risk 1

3. Avoid or Use with Extreme Caution:

   • Benzodiazepines: Not recommended in elderly patients due to increased risk of adverse effects 5
   • Zolpidem in higher doses: Can cause excessive daytime somnolence 1
   • Antihistamines like diphenhydramine: Should be avoided in elderly patients 6

Monitoring and Follow-Up

• Monitor for adverse effects including:

  • Excessive daytime somnolence, which may worsen with both sleep medications and donepezil 2
  • Confusion, delirium, or worsening cognitive function 5
  • Increased risk of falls 1

• Reassess sleep medication regularly:

  • Use for the shortest duration possible 5
  • Gradually taper when discontinuing to avoid withdrawal symptoms 5

Pitfalls and Caveats

• Avoid adding benzodiazepines in patients with cognitive impairment as they can further decrease cognitive performance 2
• Be aware that agents like zolpidem may not maintain sleep throughout the night and can cause daytime somnolence 1
• Remember that donepezil combined with certain sleep medications may increase the risk of bradycardia 1
• Antipsychotics carry an FDA boxed warning about increased mortality risk when used in patients with dementia and should not be used for sleep 2