What are the recommended medications and interventions for managing sleep disturbances in the elderly?

Sleep Medications for the Elderly

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for sleep disturbances in older adults, with pharmacotherapy reserved only when CBT-I has failed, using the lowest effective doses for the shortest duration possible. 1, 2

Initial Assessment Before Any Treatment

Before considering medications, conduct a targeted evaluation:

• Review all current medications that commonly disrupt sleep, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs, and cholinesterase inhibitors 1, 2
• Screen for primary sleep disorders such as obstructive sleep apnea (24% prevalence), restless legs syndrome (12% prevalence), and periodic limb movements (45% prevalence) 2
• Identify sleep-impairing behaviors including excessive daytime napping, prolonged time in bed, insufficient physical activity, evening alcohol consumption, late heavy meals, and clock-watching 1, 3
• Assess medical comorbidities such as pain, nocturia, gastroesophageal reflux, and neurodegenerative disorders that exacerbate sleep disruption 2

First-Line Treatment: Non-Pharmacological Interventions

CBT-I provides superior long-term outcomes with effects sustained for up to 2 years, far exceeding medication benefits while avoiding polypharmacy risks. 1, 2

Core CBT-I Components to Implement

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time, with sleep compression being better tolerated by elderly patients than immediate restriction 3
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep and wake times 3
• Sleep hygiene modifications: Ensure comfortable bedroom temperature, reduce noise and light, avoid caffeine/nicotine/alcohol in evening, avoid heavy exercise within 2 hours of bedtime 3
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve calm state at bedtime 3
• Cognitive restructuring: Address unrealistic sleep expectations and anxiety about sleep 3

Additional Non-Pharmacological Strategies

• Bright light therapy during daytime combined with structured physical and social activity can help regulate circadian rhythms 2
• Physical activities may slightly increase total nocturnal sleep time and sleep efficiency, and may reduce total time awake at night 4
• Environmental modifications including decreased nighttime noise and light disruption reduce nighttime arousals 5

Pharmacological Treatment: When CBT-I Has Failed

Medications should only be considered after an adequate trial of CBT-I, using shared decision-making that discusses benefits, harms, and costs of short-term use. 2, 3

Recommended Medication Algorithm by Symptom Type

For sleep onset insomnia:

• Ramelteon (melatonin receptor agonist) is the preferred first choice due to safer profile and minimal adverse effects 2
• Short-acting Z-drugs (zolpidem) as alternative, starting at lowest dose 2

For sleep maintenance insomnia:

• Low-dose doxepin (3-6 mg) is effective with minimal side effects 2
• Suvorexant (orexin receptor antagonist) as alternative 2

For both onset and maintenance:

• Eszopiclone or extended-release zolpidem 2

Critical Dosing Principles

• Start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak effects 3, 6
• For temazepam specifically, initiate with 7.5 mg in elderly or debilitated patients until individual responses are determined 6
• Follow patients every few weeks initially to assess effectiveness and side effects 3
• Limit to short-term use whenever possible and employ the lowest effective maintenance dosage 3

Medications to AVOID in the Elderly

The following medications have unfavorable risk-benefit profiles and should be avoided:

• Benzodiazepines (including temazepam): Higher risk of falls, cognitive impairment, dependence, and worsening dementia 2, 3
  • Despite FDA approval, a randomized trial showed diphenhydramine and temazepam caused poorer neurologic function and more daytime hypersomnolence in nursing home residents 5
• Over-the-counter antihistamines (diphenhydramine): Anticholinergic effects and lack of efficacy data 2, 3
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Should only be used when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia and risks outweigh benefits 2, 3
• Barbiturates, chloral hydrate, and herbal supplements (valerian): Lack of efficacy and safety data 3

Special Considerations for Nursing Home Residents

Nursing home residents face unique challenges requiring specialized interventions:

• Increase bright light exposure during daytime while reducing time in bed 1
• Increase daytime physical activity and minimize nighttime interruptions 1
• Review and optimize medication timing 1
• Multicomponent interventions combining increased daytime physical activity, sunlight exposure, decreased time in bed during day, bedtime routine, and decreased nighttime noise/light may decrease duration of nighttime awakenings 5

Common Pitfalls to Avoid

• Do not prescribe hypnotics before attempting CBT-I, as behavioral interventions are more effective long-term and avoid polypharmacy risks 3
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities for chronic insomnia 3
• Do not use long-term pharmacotherapy without concurrent CBT-I trials whenever possible 3
• Medication side effects may be more pronounced in elderly due to reduced clearance and increased sensitivity, requiring regular reassessment 3

Tapering and Discontinuation

• Use a gradual taper to discontinue medications or reduce dosage to minimize withdrawal reactions 6
• If withdrawal reactions develop, pause the taper or increase dosage to previous level, then decrease more slowly 6
• Medication tapering and discontinuation are facilitated by CBT-I 3

Long-Term Management Strategy

• For patients requiring chronic hypnotic medication due to severe or refractory insomnia, administration may be nightly, intermittent (three nights per week), or as needed 3
• Patients should receive an adequate trial of CBT-I during long-term pharmacotherapy whenever possible 3
• Combining CBT-I with pharmacotherapy may provide better short-term outcomes than either modality alone, with medications providing rapid onset relief and behavioral therapy providing longer-term sustained benefit 3
• Regular reassessment is necessary to evaluate treatment effectiveness, monitor for adverse effects, and assess for new or worsening comorbid disorders 3