How to manage a patient with impaired renal function, anxiety, and depression, who has trouble staying asleep and experiences frequent daytime blackouts, while taking medications including lorazepam, melatonin, trazodone, and gabapentin?

Management of Sleep Disturbances and Daytime Blackouts in an Elderly Patient with Renal Impairment

This patient's current medication regimen is likely causing the daytime blackouts and falls, and requires immediate deprescribing of lorazepam and dose reduction of gabapentin, while transitioning to cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment. 1, 2

Immediate Safety Concerns

Medication-Induced Falls and Blackouts

• Lorazepam is the most dangerous medication in this regimen and should be tapered and discontinued, as benzodiazepines cause respiratory depression, confusion, falls, and next-day cognitive impairment in elderly patients, with the American Geriatrics Society recommending extreme caution and 50% dose reduction when absolutely necessary—but this patient should not be on it at all given the fall risk. 2, 3

• Gabapentin requires immediate dose adjustment for the 37% GFR, as gabapentin is renally excreted and plasma clearance is directly proportional to creatinine clearance, with reduced clearance in elderly patients and those with impaired renal function leading to accumulation and toxicity. 4

• Gabapentin overdose causes drowsiness, lethargy, ataxia, and sedation—symptoms matching this patient's daytime blackouts and falls. 4

• With GFR 37%, this patient likely has creatinine clearance 30-60 mL/min, requiring gabapentin dose reduction to 200-700 mg twice daily (rather than three times daily), and for CrCl 15-30 mL/min, dosing should be 200-700 mg once daily. 4

Polypharmacy Contributing to Sleep Disruption

• Multiple medications in this regimen disrupt sleep: carvedilol (β-blocker), chlorthalidone (diuretic causing nocturia), duloxetine (SNRI causing or exacerbating insomnia), and hydralazine all contribute to sleep disturbances. 1

• The combination of lorazepam, trazodone, melatonin, and gabapentin represents excessive polypharmacy for sleep, with overlapping sedative effects causing daytime impairment. 1

First-Line Treatment Approach

Non-Pharmacological Interventions (Primary Recommendation)

• Cognitive behavioral therapy for insomnia (CBT-I) should be initiated immediately as the most effective treatment with sustained benefits up to 2 years, combining sleep restriction therapy (limiting time in bed to actual sleep time), stimulus control (leaving bedroom if unable to sleep within 15-20 minutes), and maintaining consistent sleep-wake times. 2, 5

• Sleep hygiene education should include regular morning or afternoon exercise, daytime bright light exposure, keeping the sleep environment dark and quiet, and avoiding heavy meals near bedtime. 1

• This approach is particularly important because pharmacological options are severely limited by this patient's renal impairment, extensive drug allergies, and high fall risk. 1

Medication Deprescribing and Optimization

Immediate Actions

• Taper and discontinue lorazepam using a slow reduction schedule (reduce by 25% every 1-2 weeks) to avoid withdrawal seizures, while monitoring for rebound anxiety and insomnia. 2, 3

• Reduce gabapentin dose based on calculated creatinine clearance, with close monitoring for continued sedation, confusion, and ataxia. 4

• Continue trazodone at current dose as it shows moderate improvement in subjective sleep quality (SMD -0.34) with relatively better safety profile than benzodiazepines, though monitor for morning grogginess and orthostatic hypotension. 6

• Continue melatonin as it has the safest profile with minimal adverse effects in elderly patients, though evidence for efficacy is limited. 2

Medication Review for Sleep-Disrupting Agents

• Consider timing chlorthalidone (diuretic) in the morning rather than evening to reduce nocturia-related sleep disruption. 1

• Evaluate whether duloxetine (SNRI) is contributing to insomnia, as SSRIs and SNRIs commonly cause or exacerbate insomnia through serotonin-2 receptor stimulation. 1, 7

• Review carvedilol timing, as β-blockers contribute to sleep disruptions. 1

Addressing Underlying Comorbidities

Sleep Disorder Screening

• Screen for obstructive sleep apnea (OSA) given the daytime sleepiness and blackouts, asking: "Have you been told you gasp or stop breathing at night?" and "Do you wake up without feeling refreshed?" 1

• If OSA is suspected, refer for sleep study (polysomnography), as OSA requires treatment with continuous positive airway pressure rather than sedative medications. 1

• Evaluate for restless legs syndrome (RLS) by asking about uncomfortable leg sensations worse at night and improved with movement, and check ferritin levels (treat if <45-50 ng/mL). 1

Depression and Anxiety Management

• The combination of depression, anxiety, OCD, and insomnia suggests comorbid psychiatric illness, with untreated insomnia being a risk factor for recurrent depression. 1

• Duloxetine may be addressing depression but worsening insomnia—consider whether a sedating antidepressant like mirtazapine (which blocks serotonin-2 receptors) would be more appropriate, though this requires careful consideration given renal impairment. 7, 8

Nocturia and Cardiovascular Factors

• Evaluate for peripheral edema and congestive heart failure, as ankle swelling and shortness of breath suggest fluid retention causing nocturia and sleep disruption. 1

• The combination of hypertension medications (carvedilol, chlorthalidone, hydralazine, lisinopril) suggests difficult-to-control hypertension, which is associated with sleep complaints. 1

Monitoring Parameters

Critical Safety Monitoring

• Monitor vigilantly for: respiratory depression, confusion or delirium, falls and fractures, next-day cognitive impairment, and worsening dementia symptoms during any medication changes. 2, 3

• Track fall frequency, blackout episodes, and daytime functioning as primary outcome measures. 1

• Monitor renal function (creatinine clearance) regularly, as declining kidney function will require further gabapentin dose adjustments. 4, 8

Sleep Quality Assessment

• Use a 72-hour bladder diary to quantify nocturia and overnight urine volume. 1

• Assess sleep efficiency (time asleep as percentage of time in bed), with <80% efficiency associated with increased mortality risk in older adults. 1

• Monitor for sleep latency >30 minutes, which is associated with increased mortality. 1

Common Pitfalls to Avoid

• Never start with pharmacotherapy instead of CBT-I in elderly patients with multiple comorbidities and renal impairment. 2, 5

• Never use standard adult doses of sedative medications in elderly patients with renal impairment—always reduce by at least 50%. 2, 3

• Never abruptly discontinue benzodiazepines due to seizure risk—always taper slowly. 2

• Never ignore underlying causes such as OSA, RLS, nocturia from heart failure, or medication-induced sleep disruption. 1

• Never prescribe multiple sedating medications simultaneously without clear justification, as this patient's current regimen demonstrates dangerous polypharmacy. 1, 2

Specific Algorithm for This Patient

1. Week 1-2: Initiate CBT-I, reduce gabapentin dose based on CrCl calculation, begin lorazepam taper (reduce by 25%)
2. Week 3-4: Continue lorazepam taper (reduce by another 25%), monitor for fall reduction
3. Week 5-6: Continue lorazepam taper (reduce by another 25%), screen for OSA and RLS
4. Week 7-8: Complete lorazepam discontinuation, reassess sleep quality and daytime functioning
5. Ongoing: Continue CBT-I, maintain trazodone and melatonin, optimize timing of diuretic and other medications

1, 2, 4