What is the recommended dosage and usage of Trazodone (antidepressant) in the elderly population?

Trazodone Use in Elderly Patients

Primary Recommendation

Start trazodone at 25 mg daily at bedtime in elderly patients, use it with extreme caution, and reserve it for specific situations such as agitation in dementia or depression with insomnia when other options have failed—not for chronic insomnia alone. 1

Dosing Protocol for Elderly Patients

Initial Dosing

• Begin with 25 mg once daily at bedtime (not the standard adult starting dose of 150 mg) 1
• This lower starting dose is critical in elderly patients due to increased sensitivity and fall risk 1

Titration Schedule

• Increase gradually by 25 mg increments every 5-7 days as tolerated 1, 2
• Monitor closely for orthostatic hypotension, dizziness, and falls during titration 1
• Maximum dose: 200-400 mg daily in divided doses for mood stabilization or agitation control 1, 2

Treatment Duration

• Allow 4-8 weeks at therapeutic dose before concluding treatment failure 2
• After 9 months of treatment, consider dose reduction to reassess ongoing need 2

Discontinuation

• Taper over 10-14 days to limit withdrawal symptoms 2
• Never stop abruptly 3

Clinical Indications in Elderly Populations

Appropriate Uses (Listed by Strength of Evidence)

1. Agitation/Behavioral Disturbances in Dementia

• Trazodone is a reasonable alternative to antipsychotics for severe agitated, repetitive, and combative behaviors in Alzheimer's disease 1
• Carries similar fall/fracture risk as antipsychotics but lower mortality risk 1
• This represents one of the strongest indications for trazodone in elderly patients 1

2. Depression with Comorbid Insomnia or Anxiety

• Appropriate when other antidepressants have failed or when insomnia/anxiety are prominent features 1
• Requires full antidepressant dosing (150-300 mg range), not the low doses used for insomnia alone 2

3. Chronic Insomnia (NOT RECOMMENDED as monotherapy)

• The American Academy of Sleep Medicine explicitly recommends AGAINST trazodone for chronic insomnia 4
• The VA/DoD guidelines also advise AGAINST trazodone for chronic insomnia 4
• Clinical trials at 50 mg showed no improvement in subjective sleep quality versus placebo 4
• The adverse effect profile (daytime drowsiness, dizziness, psychomotor impairment, falls) outweighs limited benefits 4
• Low doses (25-50 mg) used for insomnia are below therapeutic antidepressant range and provide inadequate treatment for depression 4

Significant Safety Concerns in Elderly Patients

High-Priority Risks

• Orthostatic hypotension leading to falls and fractures—risk may equal or exceed alternative agents 1
• Falls and fractures—particularly concerning given elderly patients' baseline vulnerability 1
• Daytime drowsiness and psychomotor impairment—increases fall risk further 4
• Extrapyramidal symptoms—can occur even at low doses in elderly patients 5
• Hyponatremia—elderly patients are at greater risk 3

Monitoring Requirements

• Assess for orthostatic hypotension at each dose increase 1
• Screen for fall risk and implement fall precautions 1
• Monitor for cardiac effects, especially in patients with premature ventricular contractions 2
• Regular follow-up every few weeks initially to assess effectiveness and adverse effects 4

Preferred Alternatives

For Chronic Insomnia

First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 4

Second-line pharmacologic options:

• Eszopiclone 2-3 mg 4
• Zolpidem 10 mg 4
• Ramelteon 8 mg (for sleep onset) 4
• Suvorexant (for sleep maintenance) 4
• Doxepin 3-6 mg (for sleep maintenance) 4

Advantages Over Tricyclic Antidepressants

• Lower anticholinergic effects compared to tricyclics (amitriptyline, imipramine) 1
• This makes trazodone preferable when anticholinergic burden is a concern in elderly patients 1

Administration Guidelines

• Take shortly after a meal or light snack to maximize effectiveness and reduce side effects 3
• Can be swallowed whole or broken along score line 3
• Administer major portion of daily dose at bedtime to minimize daytime sedation 3, 6

Critical Contraindications and Cautions

Avoid or Use Extreme Caution In:

• Patients with compromised respiratory function 4
• Hepatic or heart failure 4, 3
• Pregnancy and nursing 4
• Concurrent use with MAOIs (14-day washout required) 3
• Patients taking strong CYP3A4 inhibitors or inducers (dose adjustment needed) 3

Screen Before Initiating

• Personal or family history of bipolar disorder, mania, or hypomania 3
• Cardiac history, especially premature ventricular contractions 2

Common Pitfalls to Avoid

1. Using trazodone as first-line for primary insomnia in elderly patients—guidelines explicitly recommend against this 4
2. Starting at standard adult doses (150 mg)—elderly patients require 25 mg starting dose 1
3. Failing to implement fall precautions—orthostatic hypotension and falls are major risks 1
4. Using subtherapeutic doses for depression—25-50 mg is inadequate for treating major depression 4
5. Prescribing without attempting CBT-I or FDA-approved hypnotics first for insomnia 4
6. Abrupt discontinuation—always taper over 10-14 days 2, 3

Drug Interactions

• Strong CYP3A4 inhibitors: Consider dose reduction based on tolerability 3
• Strong CYP3A4 inducers: Consider dose increase based on therapeutic response 3
• Other sedating medications: Use with extreme caution due to additive effects 4