From the Guidelines
For a 55-year-old male with insomnia, I strongly recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, as it has been shown to improve global outcomes and sleep quality with minimal harms 1. If medication is needed, low-dose melatonin 1-3mg taken 1-2 hours before bedtime is a recommended option for adults over 55 years, due to its gentle nature and fewer side effects 1. Other medications such as zolpidem (Ambien) 5mg or eszopiclone (Lunesta) 1-2mg taken 30 minutes before bedtime for short-term use (2-4 weeks) may be considered, but their use should be accompanied by a discussion of the benefits, harms, and costs using a shared decision-making approach 1. Some key points to consider when treating insomnia include:
- Addressing underlying causes of insomnia such as sleep apnea, depression, or anxiety
- Avoiding alcohol and limiting caffeine after noon
- Consulting with a healthcare provider before starting any medication, as individual health conditions and medication interactions need to be considered
- Using non-pharmacological approaches such as sleep hygiene improvements and CBT-I before considering medications
- Considering the potential side effects of prescription sleep medications, including morning grogginess, dizziness, and rarely complex sleep behaviors.
From the FDA Drug Label
The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Two of these trials were in elderly patients (n=523) Overall, at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg), eszopiclone significantly decreased sleep latency and improved measures of sleep maintenance (objectively measured as wake time after sleep onset [WASO] and subjectively measured as total sleep time).
Eszopiclone may be considered for the treatment of insomnia in a 55-year-old male, as it has been shown to be effective in reducing sleep latency and improving sleep maintenance in adult subjects, including those in the elderly population.
- The recommended adult dose is 2 to 3 mg.
- However, it is essential to consider the potential for next-day residual effects, such as psychomotor and memory impairment, and withdrawal-emergent anxiety and insomnia. 2
From the Research
Medication Options for Insomnia
The following medications are commonly used to treat insomnia:
- Non-benzodiazepine hypnotics such as zolpidem, eszopiclone, zaleplon 3
- Melatonin receptor agonist, ramelteon 3
- Benzodiazepines, although their use is discouraged in the geriatric population, especially for long-term use 4
Safety and Efficacy of Medications
The safety and efficacy of medications used to treat insomnia in older adults have been reviewed 4. The results suggest that:
- Ramelteon has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time 4
- Non-benzodiazepine receptor agonists (non-BzRAs) have improved safety profiles compared with benzodiazepines, but their side effects include dementia, serious injury, and fractures 4
- Zolpidem has been associated with an increased risk of falls, hip fractures, and complex sleep-related behaviors 5
Treatment Recommendations
The recommended first-line treatment for insomnia in older adults is cognitive-behavioral therapy for insomnia (CBT-I), which includes stimulus control, sleep restriction, sleep hygiene, and cognitive therapy 6, 7. Medications should be used as a last resort, and the choice of medication should be based on the individual patient's needs and medical history.
Considerations for 55-Year-Old Males
For a 55-year-old male, the choice of medication for insomnia should take into account the potential risks and benefits of each medication. Zolpidem, for example, has been shown to be effective in treating insomnia, but it also has a risk of falls, hip fractures, and complex sleep-related behaviors 5. Ramelteon, on the other hand, has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time 4. The decision to prescribe a particular medication should be made on a case-by-case basis, considering the patient's medical history, lifestyle, and other factors.