What non-benzodiazepine hypnotic is preferred for a geriatric patient?

From the Guidelines

For geriatric patients requiring a hypnotic medication, ramelteon (Rozerem) is generally the preferred non-benzodiazepine option due to its favorable safety profile in older adults. The typical dose is 8 mg taken within 30 minutes of bedtime. Unlike other sleep medications, ramelteon works as a melatonin receptor agonist rather than affecting GABA receptors, which results in fewer concerning side effects for older adults. It doesn't cause significant next-day sedation, respiratory depression, physical dependence, or increased fall risk - all particularly important considerations in geriatric patients.

Key Considerations

• Ramelteon's mechanism of action as a melatonin receptor agonist contributes to its safer profile in older adults compared to other hypnotics that affect GABA receptors 1.
• Other non-benzodiazepine options like zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata) should be used with caution in older adults, and if prescribed, should be started at the lowest possible dose (typically half the adult dose) 1.
• For example, if zolpidem is used, start with 5 mg immediate-release or 6.25 mg extended-release, considering the potential for adverse effects such as next-morning impairment and sleep driving 1.
• Non-pharmacological approaches should always be tried first, including sleep hygiene education, maintaining regular sleep schedules, avoiding caffeine and alcohol near bedtime, and cognitive behavioral therapy for insomnia (CBT-I) 1.

Safety and Efficacy

• Evidence from studies suggests that while ramelteon may have a favorable safety profile, all hypnotic drugs may be associated with infrequent but serious adverse effects, such as dementia, serious injury, and fractures 1.
• The FDA recommends dosages lower than those used in many studies, especially for older adults, and suggests that patients should not continue using these drugs for extended periods beyond 4 to 5 weeks 1.

From the FDA Drug Label

The pharmacokinetics of eszopiclone have been investigated in healthy subjects (adult and elderly) and in patients with hepatic disease or renal disease. Compared with non-elderly adults, subjects 65 years and older had an increase of 41% in total exposure (AUC) and a slightly prolonged elimination of eszopiclone (t1/2 approximately 9 hours) Cmax was unchanged. Therefore, in elderly patients the dose should not exceed 2 mg.

Eszopiclone is a non-benzodiazepine hypnotic that may be preferred for geriatric patients due to its pharmacokinetic profile.

• The dose of eszopiclone in elderly patients should not exceed 2 mg to minimize adverse effects.
• Zolpidem is also a non-benzodiazepine hypnotic, and the recommended dose in geriatric patients is 5 mg regardless of gender. However, eszopiclone may be a better option due to its lower dose requirement in elderly patients 2.

From the Research

Non-Benzodiazepine Hypnotics for Geriatric Patients

• Non-benzodiazepine hypnotics are preferred over benzodiazepines for geriatric patients due to their safer profile and lower risk of dependence and abuse 3, 4, 5, 6, 7.
• The choice of a hypnotic agent in the elderly is symptom-based, with options including ramelteon, short-acting Z-drugs, suvorexant, low-dose doxepin, eszopiclone, and zolpidem extended release 4.
• Non-benzodiazepine hypnotics, such as zolpidem, zolpidem-controlled release, zaleplon, zopiclone, and eszopiclone, are generally well-tolerated and have a favorable safety profile compared to older benzodiazepines and barbiturates 5.
• These agents are associated with some risk for dependence and abuse, but concerns regarding such risks appear to be greater than warranted by empirical evidence 5.

Safety Considerations

• The safety profile of non-benzodiazepine hypnotics is improved compared to benzodiazepines, with a lower risk of tolerance, dependence, abuse, and residual effects 4, 5, 7.
• Next-day residual effects, potential for abuse, tolerance, and dependence are important safety considerations when prescribing sleep medications 7.
• Modified-release formulations, such as zolpidem extended-release, demonstrate a comparable safety profile to original zolpidem but have an additional sleep maintenance benefit 7.

Alternative Therapies

• Non-pharmacological approaches, such as sleep restriction-sleep compression therapy and cognitive behavioral therapy for anxiety or insomnia, are alternative options for treating insomnia and anxiety in older adults 6.
• Alternative pharmacological agents, such as melatonin and ramelteon, may also be considered, but their efficacy and safety profiles vary 4, 7.