What are the recommended medications and treatments for insomnia in older adults?

Medications for Insomnia in Older Adults

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all older adults with chronic insomnia before considering any medication, as it provides superior long-term efficacy with sustained benefits up to 2 years and minimal adverse effects. 1

First-Line Treatment Approach

• Start with CBT-I immediately as it is a strong recommendation with moderate-quality evidence showing improved sleep onset latency, wake after sleep onset, and sleep efficiency in older adults. 1
• CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 1, 2
• CBT-I combines sleep restriction therapy, stimulus control (using bed only for sleep/sex, leaving bedroom if unable to sleep within 15-20 minutes), cognitive restructuring of unhelpful beliefs about sleep, and sleep hygiene education. 1, 3
• Effects are sustained for up to 2 years after treatment completion, unlike medications which lose efficacy upon discontinuation. 1, 4

When Pharmacotherapy Is Necessary

If CBT-I alone is unsuccessful after 4-6 weeks, add short-term pharmacotherapy using shared decision-making, but continue CBT-I alongside medication. 1, 2

First-Line Medication Options for Older Adults:

For sleep onset insomnia:

• Ramelteon 8 mg has minimal adverse effects and no risk of dependence, making it an excellent first-line choice. 2, 5
• Zolpidem 5 mg (reduced dose mandatory for elderly) for sleep onset and maintenance. 1, 2

For sleep maintenance insomnia:

• Low-dose doxepin 3-6 mg has the strongest evidence for sleep maintenance with moderate-quality data showing improved Insomnia Severity Index scores and reduced wake after sleep onset in older adults. 1, 2, 6
• Eszopiclone 2 mg (not 3 mg in elderly) improves both global and sleep outcomes in older adults with low-quality evidence. 1, 2
• Temazepam 7.5-15 mg for combined sleep onset and maintenance. 2, 4

Second-Line Options:

• Suvorexant (orexin antagonist) for sleep maintenance with moderate-quality evidence, though limited data in elderly populations. 1, 2

Critical Safety Considerations in Older Adults

Benzodiazepines and non-benzodiazepine receptor agonists carry serious risks in elderly patients that often outweigh benefits:

• Observational studies show associations with dementia, serious injury, fractures, falls, and cognitive impairment. 1, 5
• FDA warnings include daytime impairment, "sleep driving," behavioral abnormalities, complex sleep behaviors, and worsening depression. 1, 4
• Always use the lowest FDA-recommended doses which are lower than those used in many clinical trials—specifically zolpidem maximum 5 mg (not 10 mg) in elderly. 1, 2, 6
• Increased sensitivity to peak drug effects and reduced clearance in older adults necessitates dose reduction. 1, 5

Medications to Avoid in Older Adults

Never use these agents:

• Diphenhydramine and other antihistamines lack efficacy data and cause daytime sedation, anticholinergic effects, and delirium risk. 1, 2, 7
• Trazodone is not recommended by the American Academy of Sleep Medicine for insomnia treatment. 2
• Long-acting benzodiazepines (flurazepam, quazepam) carry increased risks without clear benefit. 2, 5
• Benzodiazepines as first-line therapy should be avoided due to dependency, falls, cognitive impairment, and respiratory depression. 2, 6, 5
• Melatonin supplements have insufficient evidence for efficacy in older adults. 1

Treatment Algorithm

1. Assess for contributing factors: Review all medications (β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs/SNRIs) that disrupt sleep; evaluate medical comorbidities (cardiac disease, COPD, pain, nocturia, neurologic deficits); screen for depression and anxiety. 1, 6

2. Implement CBT-I first with specific behavioral interventions: maintain stable bedtimes/wake times, limit time in bed to actual sleep time, avoid daytime napping (or limit to 30 minutes before 2 PM), eliminate caffeine after noon, avoid evening alcohol, ensure bedroom is dark/quiet/cool. 1

3. If CBT-I insufficient after 4-6 weeks, add pharmacotherapy based on insomnia pattern:

   • Sleep onset only: Ramelteon 8 mg or zolpidem 5 mg 2
   • Sleep maintenance only: Doxepin 3-6 mg 2, 6
   • Both onset and maintenance: Eszopiclone 2 mg or temazepam 7.5 mg 2, 4

4. Prescribe for short-term use only (4-5 weeks maximum as FDA-approved), using lowest effective dose. 1, 2, 7

5. Monitor closely for next-day impairment, falls, confusion, complex sleep behaviors, and cognitive changes. 1, 4, 6

6. Reassess after 1-2 weeks: If insomnia persists beyond 7-10 days, evaluate for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders). 2, 4

Common Pitfalls to Avoid

• Using standard adult doses instead of reduced elderly doses—this significantly increases fall and cognitive impairment risk. 1, 2, 6
• Prescribing medication without implementing CBT-I—behavioral interventions provide more sustained effects than medication alone. 1, 2, 4
• Continuing pharmacotherapy long-term without periodic reassessment—FDA approval is for short-term use only. 1, 2
• Failing to educate patients about realistic expectations, safety concerns (especially morning driving impairment), and the importance of behavioral treatments as the foundation. 2, 4
• Combining multiple sedative medications—this significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures. 2
• Relying on subjective perception of impairment—studies show patients on eszopiclone 3 mg had objective psychomotor and memory impairment at 7.5 and 11.5 hours post-dose, even when they subjectively felt unimpaired. 8

Special Considerations for Comorbid Depression

If the older adult has comorbid depression and insomnia:

• Treat depression first with an SSRI (sertraline preferred for lower cardiac risk). 6
• If insomnia persists after 2-4 weeks despite improved mood, add low-dose doxepin 3-6 mg rather than switching antidepressants. 6
• Avoid using sedating antidepressants as monotherapy for insomnia without depression—they are not FDA-approved for insomnia and efficacy is not well-established. 4