What alternative treatment options are available for a 65-year-old male (YOM) with insomnia, characterized by difficulty initiating and maintaining sleep, who has tried Dayvigo (Lemborexant) but experiences bothersome vivid dreams?

Alternative Treatment for Insomnia After Dayvigo Discontinuation

For this 65-year-old male with both sleep initiation and maintenance insomnia who discontinued lemborexant (Dayvigo) due to vivid dreams, switch to eszopiclone 2-3 mg or zolpidem 5 mg (given his age) as first-line pharmacotherapy, while simultaneously implementing Cognitive Behavioral Therapy for Insomnia (CBT-I). 1, 2

Recommended Treatment Algorithm

Step 1: Initiate or Optimize CBT-I

• CBT-I should be started immediately as it represents the standard of care with superior long-term efficacy compared to medications alone 1
• Implement stimulus control therapy, sleep restriction therapy, and cognitive restructuring—not just sleep hygiene education alone, which is insufficient as monotherapy 1, 2
• CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules, all showing effectiveness 1, 2

Step 2: Select Appropriate Pharmacotherapy

For combined sleep onset AND maintenance insomnia (this patient's presentation):

First-Line Options:

• Eszopiclone 2-3 mg: Addresses both sleep initiation and maintenance with moderate-quality evidence 1, 2
• Zolpidem 5 mg (reduced dose for age 65+): Effective for both sleep onset and maintenance, though FDA advises lower dosing in older adults 1, 2, 3
• Temazepam 15 mg: Alternative benzodiazepine receptor agonist for both sleep complaints 1, 2

Second-Line Options if First-Line Fails:

• Low-dose doxepin 3-6 mg: Specifically for sleep maintenance insomnia with strong evidence (reduces wake after sleep onset by 22-23 minutes) 1, 2, 4
• Ramelteon 8 mg: For predominant sleep onset difficulty, works through melatonin receptors with favorable safety profile 1, 2, 5
• Suvorexant: Another orexin receptor antagonist like lemborexant, but may carry similar risk of vivid dreams 1, 2

Step 3: What to Avoid in This Patient

Do NOT use the following:

• Trazodone: Not recommended by AASM guidelines for sleep onset or maintenance insomnia 1, 2
• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data and cause anticholinergic effects, daytime sedation, and delirium risk in older adults 1, 2
• Melatonin supplements: Insufficient evidence for efficacy in chronic insomnia 1, 2
• Valerian or other herbal supplements: Not recommended due to lack of efficacy evidence 1, 2
• Long-acting benzodiazepines: Increased risks without clear benefit, particularly falls and cognitive impairment in older adults 1, 2

Critical Safety Considerations for Age 65+

• Use lowest effective doses: Zolpidem maximum 5 mg (not 10 mg) in older adults due to increased sensitivity and fall risk 1, 2
• Monitor for cognitive and behavioral changes: All hypnotics carry risks including driving impairment, complex sleep behaviors (sleep-walking, sleep-driving), falls, and fractures 1
• Observational studies suggest associations between chronic hypnotic use and increased risk of dementia, fractures, and major injury 1
• Avoid benzodiazepines as first-line in elderly patients due to unacceptable risk-benefit ratio with increased fall and cognitive impairment risk 4, 6

Implementation Strategy

Dosing and Duration:

• Start with lowest effective dose for shortest duration possible 2, 6
• Typical short-term use is 2-4 weeks, though some agents have been studied up to 35 days 3, 7
• Pharmacotherapy should supplement—not replace—CBT-I 1, 2

Monitoring Schedule:

• Reassess after 1-2 weeks to evaluate efficacy on sleep latency, sleep maintenance, and daytime functioning 2, 4
• If insomnia persists beyond 7-10 days of appropriate treatment, evaluate for underlying sleep disorders such as sleep apnea or restless legs syndrome 2, 6
• Monitor for adverse effects including morning sedation, cognitive impairment, and complex sleep behaviors 1

Common Pitfalls to Avoid

• Failing to implement CBT-I alongside medication: Behavioral interventions provide more sustained effects than medication alone 1
• Using doses appropriate for younger adults: This 65-year-old requires age-adjusted dosing (e.g., zolpidem 5 mg maximum) 1, 2
• Continuing pharmacotherapy long-term without reassessment: Regular follow-up essential to assess ongoing need and prevent dependence 2, 6
• Switching to another orexin receptor antagonist (suvorexant) immediately: May have similar vivid dream side effects as lemborexant given same mechanism of action 1, 2
• Prescribing multiple sedative medications simultaneously: Significantly increases risks of cognitive impairment, falls, and complex sleep behaviors 2

Why Not Continue Orexin Antagonists?

Since this patient experienced bothersome vivid dreams with lemborexant (Dayvigo), switching to suvorexant (another orexin receptor antagonist) may reproduce the same adverse effect given the shared mechanism of action 1, 2. The vivid dreams are a class effect of orexin receptor antagonists. Therefore, switching to a different mechanism (benzodiazepine receptor agonist like eszopiclone or zolpidem, or melatonin receptor agonist like ramelteon) is the appropriate strategy 1, 2, 8.