Trazodone Use in Older Adults: Beers Criteria Considerations
Direct Recommendation
Trazodone should be avoided for the treatment of chronic insomnia in older adults due to insufficient efficacy evidence and concerning adverse effects, particularly falls, orthostatic hypotension, and cognitive impairment. 1, 2
Beers Criteria Status and Rationale
While trazodone is not explicitly listed as a standalone medication to avoid in the Beers Criteria, it falls under problematic prescribing patterns in older adults:
The VA/DoD guidelines advise against trazodone for chronic insomnia disorder based on systematic reviews showing no differences in sleep efficiency or discontinuation rates compared to placebo, with only subjective sleep quality improvements that do not outweigh the adverse effect profile 1
The evidence supporting trazodone efficacy for insomnia is low-quality, with studies averaging only 1.7 weeks duration and follow-up of 1-4 weeks, making long-term safety and efficacy unclear 1
Primary Risks in Older Adults
Falls represent the most significant adverse event, occurring in approximately 30% of older adults using trazodone in long-term care settings 3:
Orthostatic hypotension is particularly problematic in elderly patients or those with pre-existing heart disease, increasing fall and fracture risk 4, 5
Sedation and drowsiness are the most commonly reported adverse effects, contributing to daytime impairment and fall risk 4, 5
Cognitive impairment can occur, though anticholinergic effects are notably lower than with tricyclic antidepressants 6
Rare but serious risks include cardiac arrhythmias, QT prolongation, and priapism 4, 5
When Trazodone May Be Considered
Trazodone remains appropriate for its FDA-approved indication of major depressive disorder in older adults, with dosing typically limited to 150-300 mg/day (lower than the 400 mg maximum in younger adults) 4, 7:
For depression treatment, trazodone demonstrates comparable efficacy to tricyclic antidepressants, SSRIs, and SNRIs, with potentially better tolerability than older tricyclics 6, 5
Single nighttime dosing (150 mg at bedtime, increased to 200-300 mg as needed) is preferred to minimize daytime sedation while leveraging sleep-promoting effects 7
In long-term care settings, trazodone showed partial or total effectiveness in over 90% of residents when used for agitation, depression, anxiety, and behavioral symptoms in dementia 3
Clinical Decision Algorithm
Apply this hierarchy when evaluating trazodone in older adults:
For chronic insomnia alone: Avoid trazodone; use cognitive behavioral therapy for insomnia (CBT-I) as first-line 1
For major depressive disorder with insomnia: Consider trazodone as it addresses both conditions, using single nighttime dosing 7, 5
For behavioral symptoms in dementia: Trazodone may be used cautiously when non-pharmacological approaches fail, recognizing the 30% fall risk 3
For patients with cardiovascular disease: Use with extreme caution due to orthostatic hypotension and arrhythmia risk; consider alternative antidepressants 4, 5
Monitoring Requirements
Implement systematic safety monitoring when trazodone cannot be avoided:
Assess orthostatic vital signs at baseline and after dose changes, particularly in patients ≥75 years 4
Screen for fall risk at every visit using validated tools, as falls occur in nearly one-third of older users 3
Review medication lists for drug-drug interactions, especially with other CNS depressants 2
Apply Beers Criteria systematically at every care transition to reassess appropriateness 2, 8
Deprescribing Considerations
When trazodone is being used off-label for insomnia or behavioral management, prioritize deprescribing:
Trazodone ranks among medications requiring removal when used for indications with unfavorable benefit-risk ratios 8
Taper gradually to discontinuation when prescribed for insomnia without depression, as tolerance to sedative effects develops after 3-4 days of continuous use 1
Substitute with non-pharmacological interventions (environmental modifications, sleep hygiene) as first-line alternatives 9
Critical Pitfalls to Avoid
Do not prescribe trazodone as a routine hypnotic in older adults without depression, as this represents off-label use with insufficient evidence and significant harm potential 1, 10
Do not ignore the 30% fall rate documented in real-world long-term care settings when weighing risks versus benefits 3
Do not combine with other CNS depressants (benzodiazepines, opioids) without compelling indication, as this amplifies fall and cognitive impairment risk 2
Do not use maximum adult doses (400 mg/day) in older adults; limit to 300 mg/day maximum, preferably 150-200 mg 4, 7