Is Trazodone (an antidepressant medication) listed on the Beers list for potentially inappropriate medication use in older adults?

Is Trazodone on the Beers List?

Yes, trazodone is included in the American Geriatrics Society Beers Criteria as a medication to avoid for chronic insomnia treatment in older adults due to insufficient efficacy evidence and concerning adverse effects, particularly falls, orthostatic hypotension, and cognitive impairment. 1

Specific Beers Criteria Recommendation

• The American Geriatrics Society explicitly recommends avoiding trazodone for the treatment of chronic insomnia in older adults, citing an unfavorable benefit-risk ratio 1
• The VA/DoD guidelines further support this recommendation, advising against trazodone for chronic insomnia disorder based on systematic reviews showing no differences in sleep efficiency or discontinuation rates compared to placebo 1
• The evidence supporting trazodone efficacy for insomnia is low-quality, with studies averaging only 1.7 weeks duration and follow-up of 1-4 weeks, making long-term safety and efficacy unclear 1

Important Context About Trazodone's Beers Status

Trazodone's inclusion in the Beers Criteria is specifically for insomnia treatment, not for its use as an antidepressant. 1 This is a critical distinction:

• Unlike tricyclic antidepressants, which are broadly listed in the Beers Criteria due to anticholinergic effects and orthostatic hypotension 2, trazodone's problematic designation is indication-specific
• When used for depression treatment, trazodone is not categorically listed as a medication to avoid in the Beers Criteria 1

Key Safety Concerns Driving the Recommendation

The specific adverse effects that warrant trazodone's inclusion for insomnia include:

• Falls risk: Falls were the most frequent adverse event, occurring in 30% of older adults using trazodone in long-term care settings 3
• Orthostatic hypotension: This requires systematic monitoring of orthostatic vital signs at baseline and after dose changes when trazodone cannot be avoided 1
• Cognitive impairment: This contributes to the overall unfavorable risk profile in older adults 1
• High discontinuation rates: There is a high incidence of discontinuation due to side effects such as sedation, dizziness, and psychomotor impairment 4

Clinical Application

When trazodone is prescribed for insomnia in older adults:

• Deprescribing should be prioritized: Trazodone ranks among medications requiring removal when used for indications with unfavorable benefit-risk ratios, and should be tapered gradually to discontinuation when prescribed for insomnia without depression 1
• Non-pharmacological alternatives are preferred: The American Academy of Sleep Medicine recommends substituting trazodone with environmental modifications and sleep hygiene as first-line alternatives for insomnia treatment 1
• If continuation is unavoidable: Implement systematic safety monitoring including orthostatic vital signs assessment and fall risk screening at every visit using validated tools 1

Common Pitfall to Avoid

Do not assume trazodone is completely contraindicated in all older adults—its Beers Criteria listing is indication-specific for chronic insomnia, not for depression treatment where it may still have a role when other antidepressants are not tolerated or effective. 1, 5