From the Guidelines
Elderly patients with insomnia who are non-responsive to Lunesta (eszopiclone) should be considered for treatment with low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists (BZRAs) such as zolpidem or suvorexant.
Key Considerations
- Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered first-line treatment for adults with chronic insomnia disorder, including elderly patients, as it has been shown to improve global outcomes and sleep outcomes in this population 1.
- Pharmacologic treatment should be considered for patients who are unable or unwilling to receive CBT-I, or for those who have not responded to CBT-I alone 1, 2.
- Low-dose doxepin (3 or 6 mg) has been shown to improve sleep outcomes in older adults with insomnia disorder, with minimal adverse events 3.
- Nonbenzodiazepine BZRAs such as zolpidem and suvorexant have also been shown to improve sleep outcomes in adults with insomnia disorder, although they may be associated with a higher risk of adverse events such as cognitive and behavioral changes, and sleep behaviors like sleepwalking and sleep driving 2, 3.
Treatment Options
- Low-dose doxepin: 3 or 6 mg, taken orally before bedtime
- Zolpidem: 5 or 10 mg, taken orally before bedtime
- Suvorexant: 5 or 10 mg, taken orally before bedtime It is essential to weigh the benefits and harms of pharmacologic treatment and to use a shared decision-making approach with patients to decide whether to add pharmacological therapy 1.
From the Research
Effective Sleep Medications for Elderly Patients with Insomnia
Elderly patients with insomnia who are non-responsive to Lunesta (eszopiclone) may be treated with alternative sleep medications. The following options are considered:
- Suvorexant: improves sleep maintenance with mild side effects 4
- Doxepin: provides sustained sleep improvement with a safety profile comparable to placebo 4
- Ramelteon: slightly improves sleep latency 4
- Low-dose zolpidem sublingual tablets or zaleplon: can alleviate middle-of-the-night awakenings 5
- Melatonin: slightly improves sleep onset and sleep duration, but product quality and efficacy may vary 5, 4
Safety Considerations
When treating insomnia in elderly patients, safety considerations are of paramount importance. Benzodiazepines and benzodiazepine receptor agonists are associated with adverse events, such as dementia, serious injury, and fractures 6, 7. Non-benzodiazepine hypnotics, such as zolpidem, zaleplon, and eszopiclone, have improved safety profiles compared to benzodiazepines, but may still cause side effects like somnolence and residual daytime sedation 5, 8.
Pharmacological Treatment Options
The choice of a hypnotic agent in the elderly is symptom-based. The following pharmacological treatment options are available: