How to treat insomnia in an elderly patient with mixed anxiety disorder taking fluoxetine (20mg), bromazepam (1.5mg, 2-3 times a week) and pregabalin (75mg, twice daily)?

Treatment of Insomnia in This Elderly Patient

Immediate Priority: Initiate Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be started immediately as the primary treatment for this patient's insomnia, as it provides superior long-term outcomes with effects sustained for up to 2 years in older adults without adding medication-related risks to an already complex polypharmacy regimen. 1

• The American College of Physicians recommends CBT-I as first-line treatment for elderly patients with chronic insomnia due to proven efficacy, long-lasting effects, and minimal side effects compared to pharmacological options 1
• CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules, making it accessible even for elderly patients 2
• Key components to implement include: sleep restriction/compression therapy (limiting time in bed to match actual sleep time), stimulus control (using bedroom only for sleep/sex, leaving if unable to sleep within 20 minutes), sleep hygiene modifications, and relaxation techniques 1

Critical Medication Review

The fluoxetine 20mg is likely contributing significantly to this patient's insomnia and must be addressed before adding another sleep medication. 1

• SSRIs, including fluoxetine, are well-documented to cause or worsen insomnia in elderly patients 1
• Fluoxetine is generally not recommended for older adults due to its long half-life and side effects; safer SSRI alternatives include sertraline, or consider switching to venlafaxine, vortioxetine, or mirtazapine 1
• The pregabalin 75mg twice daily for anxiety is appropriate and has demonstrated efficacy in elderly patients with GAD, with favorable safety and tolerability profiles 3
• The bromazepam 1.5mg 2-3 times per week represents intermittent benzodiazepine use that should be tapered and discontinued due to risks of falls, cognitive impairment, and dependence in elderly patients 1, 4

If Pharmacotherapy Becomes Necessary

If insomnia persists despite CBT-I and medication optimization, low-dose doxepin (3-6mg) is the optimal first-choice medication for this elderly patient. 4, 2

First-Line Pharmacological Option:

• Low-dose doxepin (3-6mg) is the most appropriate medication for sleep maintenance insomnia in older adults, with demonstrated improvement in total sleep time, wake after sleep onset, and sleep quality 5, 4
• Doxepin has a favorable efficacy and safety profile without the black box warnings or significant safety concerns of other sleep medications 4
• Start at 3mg and increase to 6mg only if needed, taken 30 minutes before bedtime 5

Alternative First-Line Options Based on Insomnia Pattern:

• Ramelteon 8mg for predominant sleep-onset difficulty, with minimal adverse effects and no dependency risk 4, 2
• Suvorexant 10mg (not higher doses) for sleep maintenance problems, though evidence in elderly is more limited than doxepin 4

Medications to Absolutely Avoid

The following medications should never be used in this elderly patient: 1, 4

• All benzodiazepines (including temazepam, triazolam, diazepam) due to unacceptable risks of dependency, falls, cognitive impairment, respiratory depression, and increased dementia risk 4, 2
• Antihistamines (diphenhydramine, doxylamine, hydroxyzine) due to strong anticholinergic effects causing confusion, urinary retention, fall risk, and potential acceleration of dementia 1, 4
• Trazodone despite widespread off-label use, due to limited efficacy evidence and significant adverse effect profile 4
• Antipsychotics (quetiapine, risperidone, olanzapine) due to lack of evidence and known harms including increased mortality risk 4

Practical Implementation Algorithm

Step 1: Initiate CBT-I immediately with sleep log, stimulus control, and sleep restriction 1, 2

Step 2: Address fluoxetine-induced insomnia by switching to a more appropriate antidepressant for elderly patients (sertraline, venlafaxine, or mirtazapine) 1

Step 3: Taper and discontinue bromazepam over 2-4 weeks while maintaining pregabalin for anxiety management 1, 3

Step 4: Reassess after 4 weeks of CBT-I and medication optimization 2

Step 5: Only if insomnia persists, add low-dose doxepin 3mg at bedtime, with shared decision-making discussion about short-term use 4, 2

Step 6: Follow up every 2-4 weeks initially to assess effectiveness and adverse effects, then every 6 months to attempt medication taper 2

Critical Pitfalls to Avoid

• Do not add a hypnotic medication before attempting CBT-I and addressing the fluoxetine, as behavioral interventions are more effective long-term and avoid polypharmacy risks 1
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities for chronic insomnia 1
• Do not continue benzodiazepines long-term even at low intermittent doses, as observational data shows association with dementia, particularly with higher doses and longer half-lives 5
• Do not use standard adult doses of any sleep medication—elderly patients require the lowest available doses due to reduced drug clearance and increased sensitivity 1, 4