What is the recommended treatment for insomnia in a geriatric patient already taking trazodone (triazolopyridine antidepressant)?

From the Guidelines

For geriatric patients with insomnia who are already taking trazodone, I recommend stopping trazodone and initiating cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, given its strong evidence base and lack of adverse effects, as suggested by 1 and 1. The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia disorder in adults, including older adults, due to its effectiveness in improving sleep outcomes and reducing symptoms of insomnia, as shown in studies 1. Some key points to consider in the management of insomnia in geriatric patients include:

• Avoiding benzodiazepines and Z-drugs (zolpidem, eszopiclone) due to increased risk of falls, cognitive impairment, and dependence in older adults, as warned by 1 and 1.
• Implementing non-pharmacological approaches, such as strict sleep hygiene practices, regular physical activity during daytime hours, and education on sleep habits, as recommended by 1 and 1.
• Addressing underlying conditions that may contribute to insomnia, such as pain, nocturia, depression, or sleep apnea, as suggested by 1 and 1.
• Regularly reassessing treatment every 1-3 months to determine ongoing need and effectiveness, as recommended by 1 and 1. It's also important to note that the American Academy of Sleep Medicine suggests that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia in adults, as stated in 1. Therefore, stopping trazodone and initiating CBT-I, along with non-pharmacological approaches and addressing underlying conditions, is the recommended treatment approach for geriatric patients with insomnia, as supported by the highest quality evidence from 1 and 1.

From the FDA Drug Label

14.1 Transient Insomnia ... Normal elderly adults (mean age 68) experiencing transient insomnia (n=35) during the first two nights in a sleep laboratory were evaluated in a double-blind, crossover, 2-night trial comparing four doses of zolpidem (5,10,15 and 20 mg) and placebo All zolpidem doses were superior to placebo on the two primary PSG parameters (sleep latency and efficiency) and all four subjective outcome measures (sleep duration, sleep latency, number of awakenings, and sleep quality).

For a geriatric patient already on trazodone, the recommended treatment for insomnia is zolpidem at a dose of 5 mg 2. This dose is considered safe and effective for elderly patients, as it was shown to be superior to placebo in improving sleep latency, efficiency, and subjective measures of sleep quality, without nearby evidence of next-day residual effects. Caution should be used when co-administering zolpidem with other medications that may cause CNS depression, such as trazodone.

From the Research

Treatment Options for Insomnia in Geriatric Patients

The treatment of insomnia in geriatric patients, particularly those already on trazodone, involves a careful consideration of various factors, including the patient's medical history, current medications, and potential risks associated with different treatment options.

• Pharmacological treatment options for insomnia in the elderly include:
  • Orexin agonists
  • Histamine receptor antagonists
  • Non-benzodiazepine gamma aminobutytic acid receptor agonists
  • Benzodiazepines, although their use is generally discouraged due to the risk of adverse effects such as falls and injuries 3, 4, 5
• The choice of a hypnotic agent in the elderly is symptom-based, with options such as:
  • Ramelteon or short-acting Z-drugs for sleep-onset insomnia
  • Suvorexant or low-dose doxepin for sleep maintenance
  • Eszopiclone or zolpidem extended release for both sleep onset and sleep maintenance 3
• Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks, including the potential for adverse interactions with other medications 3, 4
• Non-pharmacological interventions, such as sleep hygiene practices and cognitive behavioral therapy, are recommended as the first-line therapy for adults with chronic insomnia, with short-term drug therapy considered as an alternative or add-on treatment 6

Considerations for Geriatric Patients on Trazodone

Geriatric patients on trazodone require careful monitoring due to the potential risks associated with this medication, including:

• Significant risks, such as adverse interactions with other medications 3, 4
• The need for frequent and regular monitoring for adverse events to prevent detrimental outcomes 6
• The importance of discussing the risks and benefits of pharmacotherapy with patients and caregivers prior to treatment initiation 6

Alternative Treatment Options

Alternative treatment options for insomnia in geriatric patients on trazodone may include:

• Eszopiclone, which appears to be an efficient drug with moderate effects on sleep onset and maintenance, although increased caution is required in elderly individuals with cognitive and motor impairments 7
• Dual orexin receptor antagonists, which are newer classes of hypnotics that are better tolerated and can be explored as a potential treatment for insomnia in the elderly 5