What alternative therapies can be considered for an 86-year-old patient with a history of restless leg syndrome, anxiety, and insomnia, currently taking Ativan (lorazepam) 0.5mg, who has trouble falling asleep due to racing thoughts?

Management of Insomnia and Restless Legs Syndrome in an 86-Year-Old on Lorazepam

This patient should be transitioned from lorazepam to cognitive behavioral therapy for insomnia (CBT-I) combined with gabapentin for her restless legs syndrome, as benzodiazepines are inappropriate for chronic use in older adults and may worsen her racing thoughts and sleep quality.

Immediate Priorities: Address the Benzodiazepine Use

• Lorazepam (Ativan) should be gradually discontinued as benzodiazepines are associated with increased adverse events in older adults, including cognitive impairment, falls, and paradoxical worsening of insomnia with chronic use 1.

• The American College of Physicians strongly recommends CBT-I as the initial treatment for chronic insomnia disorder in all adult patients, with stronger evidence and better long-term outcomes than pharmacological therapy 1.

• Benzodiazepines have higher frequency and severity of adverse effects compared to newer agents, and older adults are at greater risk due to reduced drug clearance and increased sensitivity to peak drug effects 1.

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia

CBT-I should be initiated immediately as it directly addresses the racing thoughts this patient experiences before sleep 1.

Key CBT-I Components for This Patient:

• Stimulus control therapy: Go to bed only when sleepy; if unable to fall asleep, leave the bedroom and return only when sleepy; use the bedroom only for sleep and sex 1.

• Relaxation therapy specifically targets racing thoughts through progressive muscle relaxation, guided imagery, diaphragmatic breathing, and meditation 1.

• Sleep restriction/compression: Limit time in bed to match actual sleep time, gradually increasing by 15-20 minutes every 5 days as sleep efficiency improves 1.

• Sleep hygiene education: Maintain stable bedtimes and rising times; avoid daytime napping (or limit to 30 minutes before 2 PM); avoid caffeine, nicotine, and alcohol; develop a 30-minute relaxation period before bedtime 1.

Treating the Restless Legs Syndrome

The American Academy of Sleep Medicine strongly recommends alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) as first-line therapy for RLS, with moderate certainty of evidence 2.

Specific Recommendations:

• Check serum ferritin and transferrin saturation in the morning after avoiding iron supplements for 24 hours 2.

• Supplement iron if ferritin ≤75 ng/mL or transferrin saturation <20%, as iron deficiency exacerbates RLS symptoms 2.

• Start gabapentin 100-300 mg at bedtime and titrate based on response, as this addresses both RLS and may help with anxiety-related racing thoughts 2.

• Avoid dopamine agonists (ropinirole, pramipexole) as first-line therapy due to risk of augmentation—a paradoxical worsening of symptoms with long-term use 2, 3.

Addressing the Racing Thoughts and Anxiety

• The racing thoughts suggest an anxiety component that CBT-I's cognitive therapy and relaxation techniques directly target 1.

• If pharmacological therapy is needed after CBT-I trial, consider trazodone 25-50 mg at bedtime or mirtazapine 7.5-15 mg at bedtime, which address both insomnia and anxiety without benzodiazepine risks 1.

• Gabapentin for RLS may provide additional benefit for anxiety symptoms, as alpha-2-delta ligands can help treat anxiety and insomnia comorbidities 4.

Medications to Avoid in This Patient

• Continue avoiding or discontinue: Antihistamines, SSRIs, and antipsychotics, as these can worsen RLS symptoms 2.

• Do not use dopamine agonists (pramipexole, ropinirole) as standard treatment due to augmentation risk, which occurs in up to one-third of patients and causes progressive worsening of symptoms 2, 3, 5.

• Avoid continuing benzodiazepines including lorazepam for chronic insomnia, as they have worse long-term outcomes than CBT-I and increased adverse effects in older adults 1.

Practical Implementation Algorithm

1. Week 1-2: Begin CBT-I with focus on stimulus control and relaxation therapy for racing thoughts; check iron studies 1, 2.

2. Week 1: Start gabapentin 100-300 mg at bedtime for RLS; begin iron supplementation if ferritin ≤75 ng/mL 2.

3. Week 2-4: Gradually taper lorazepam by 25% every 1-2 weeks while continuing CBT-I and gabapentin 1.

4. Week 4-8: Titrate gabapentin up to 600-900 mg at bedtime if needed for RLS control 2.

5. Week 8+: If insomnia persists despite CBT-I and RLS treatment, consider adding trazodone 25-50 mg or mirtazapine 7.5-15 mg at bedtime 1.

Critical Pitfalls to Avoid

• Do not abruptly discontinue lorazepam—taper gradually to avoid withdrawal symptoms including rebound insomnia and anxiety 1.

• Do not start dopamine agonists despite their FDA approval for RLS, as current guidelines recommend against their standard use due to augmentation risk 2, 3.

• Do not assume benzodiazepines are helping—they may be contributing to the problem through tolerance, dependence, and disruption of normal sleep architecture 1.

• Monitor for gabapentin side effects including dizziness and somnolence, which may increase fall risk in this 86-year-old patient 2.