What are the recommended treatments for insomnia in the elderly?

Insomnia Medication for the Elderly

First-Line Treatment: Non-Pharmacological

Cognitive behavioral therapy for insomnia (CBT-I) must be the initial treatment for elderly patients with chronic insomnia, as it demonstrates superior long-term outcomes compared to medications and carries minimal risk of adverse effects. 1, 2, 3

• CBT-I combines behavioral interventions (sleep restriction, stimulus control, relaxation techniques) with cognitive restructuring to address maladaptive beliefs and behaviors perpetuating insomnia 1, 3
• Effects are sustained for up to 2 years in older adults, unlike medications which lose efficacy after discontinuation 1, 3
• A head-to-head trial demonstrated CBT-I improved sleep efficiency from 81.4% to 90.1% at 6 months, while zopiclone showed no improvement (82.3% to 81.9%) 4

Key CBT-I Components to Implement:

• Sleep restriction/compression: Limit time in bed to match actual sleep time, then gradually increase as sleep efficiency improves (compression is better tolerated than abrupt restriction in elderly) 1, 3
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to sleep within 20 minutes, maintain consistent wake times 1, 3
• Relaxation techniques: Progressive muscle relaxation, guided imagery, diaphragmatic breathing 1
• Sleep hygiene education: Address temperature, noise, light—but only as adjunct, never as standalone treatment 1, 5

Second-Line Treatment: Pharmacological Options

Medications should only be initiated after CBT-I has failed, using shared decision-making to discuss short-term use, and always starting at the lowest available dose due to reduced drug clearance and increased sensitivity in elderly patients. 1, 2, 3

Medication Selection Algorithm Based on Symptom Pattern:

For sleep onset insomnia:

• Ramelteon (melatonin receptor agonist): First-choice medication, particularly safe in patients with glaucoma 1, 2, 6
• Short-acting Z-drugs (zaleplon): Alternative option 1, 6

For sleep maintenance insomnia:

• Suvorexant (orexin receptor antagonist): First-choice medication, safe in glaucoma 1, 2, 6
• Low-dose doxepin (≤6 mg): Alternative option with histamine receptor antagonism 1, 6

For both sleep onset and maintenance:

• Eszopiclone: Demonstrated efficacy in 6-month trials in elderly at 1-2 mg doses 1, 7, 6
• Zolpidem extended-release: Alternative option 1, 6

For middle-of-the-night awakenings:

• Low-dose zolpidem sublingual or zaleplon: Short-acting options for this specific pattern 6

Critical Dosing Considerations:

• Elderly patients require lower doses than standard adult dosing: eszopiclone 1-2 mg (vs. 2-3 mg in adults), zolpidem 5 mg (vs. 10 mg in adults) 7, 8
• Follow patients every few weeks initially to assess effectiveness and side effects, then every 6 months once stable 1, 3
• Limit to short-term use whenever possible; if chronic use is necessary, consider intermittent dosing (three nights per week) or as-needed administration 1

Medications to Absolutely Avoid in Elderly

Benzodiazepines are strongly contraindicated in elderly patients due to high risk of falls, cognitive impairment, dependence, and paradoxical behavioral disinhibition. 1, 2, 3

• Over-the-counter antihistamines (diphenhydramine): Avoid entirely due to anticholinergic effects 1, 2
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Only use when comorbid depression/anxiety exists; no systematic evidence for primary insomnia and risks outweigh benefits 1
• Antipsychotics and anticonvulsants: Unfavorable risk-benefit profiles in elderly 1, 2
• Anticholinergic medications: Absolutely contraindicated in patients with glaucoma 2

Essential Pre-Treatment Assessment

Before initiating any treatment, evaluate these specific factors:

• Medication review: Identify drugs causing/worsening insomnia (β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs) 1, 2
• Sleep-impairing behaviors: Daytime napping, excessive time in bed, insufficient activity, evening alcohol, late heavy meals 1, 2
• Comorbid conditions: Determine if insomnia is primary or secondary to medical/psychiatric conditions 1, 2

Common Pitfalls to Avoid

• Never prescribe long-term pharmacotherapy without concurrent CBT-I trials 1
• Never rely on sleep hygiene education alone—it is insufficient as monotherapy and must be combined with other behavioral interventions 1, 5
• Never continue ineffective treatments without reassessment—regular monitoring is essential to prevent medication-related harms (falls, fractures, cognitive impairment) 3, 9
• Never assume subjective perception matches objective impairment—eszopiclone 3 mg caused psychomotor and memory impairment 7.5-11.5 hours post-dose even when patients did not perceive sedation 7