What are the best sleep aids for an individual over 65 years old with insomnia?

Best Sleep Aids for Adults Over 65 Years Old

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for elderly patients with chronic insomnia and should be initiated before any medication is considered. 1, 2

Initial Assessment

Before starting treatment, evaluate the following key factors:

• Medication review: Identify drugs that may cause or worsen insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 3, 1
• Comorbid conditions: Determine whether insomnia is primary or secondary to medical conditions such as cardiac disease, pulmonary disease, pain from osteoarthritis, nocturia, or neurologic deficits 3
• Sleep-impairing behaviors: Assess for daytime napping, excessive time in bed, insufficient physical activity, evening alcohol consumption, and late heavy meals 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I provides superior long-term outcomes with effects sustained for up to 2 years in older adults, making it the mandatory initial intervention. 1, 4

CBT-I combines multiple evidence-based components:

• Sleep restriction/compression therapy: Limits time in bed to match actual sleep time, with compression being better tolerated than immediate restriction in elderly patients 1
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, and maintain consistent sleep/wake times 1
• Cognitive restructuring: Identifies and challenges dysfunctional beliefs about sleep and unrealistic sleep expectations 1, 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing to achieve a calm state conducive to sleep 1
• Sleep hygiene education: Address environmental factors (comfortable temperature, noise reduction, light control), avoid caffeine/nicotine/alcohol in evening, and avoid heavy exercise within 2 hours of bedtime 1

Important caveat: Sleep hygiene education alone is insufficient for chronic insomnia and must be combined with other CBT-I modalities 1, 5

Second-Line Treatment: Pharmacological Options

Pharmacotherapy should only be considered after CBT-I has been unsuccessful, using shared decision-making to discuss benefits, harms, and costs of short-term medication use. 1, 2

Recommended First-Line Medications

For sleep onset insomnia:

• Ramelteon (8 mg): Melatonin receptor agonist with minimal adverse effects, demonstrated efficacy in reducing sleep latency in elderly patients aged 65 and older, and no abuse potential 1, 6, 7

For sleep maintenance insomnia:

• Low-dose doxepin (3-6 mg): Most appropriate for sleep maintenance with demonstrated improvement in total sleep time, wake after sleep onset, and sleep quality 1
• Suvorexant: Orexin receptor antagonist effective for sleep maintenance with mild adverse effects, though residual daytime sedation has been reported 1, 7

For both sleep onset and maintenance:

• Eszopiclone: Effective for both components, though associated with next-morning psychomotor and memory impairment that can persist up to 11.5 hours after dosing 1, 8

Critical Medications to Avoid

Benzodiazepines (including temazepam, triazolam) are absolutely contraindicated or strongly discouraged in elderly patients due to:

• Higher risk of falls, cognitive impairment, and dependence 1, 2
• Increased risk of dementia, particularly with higher doses and longer half-lives 1
• Poorer neurologic function and more daytime hypersomnolence in nursing home residents 1

Other medications to avoid:

• Over-the-counter antihistamines (diphenhydramine, hydroxyzine): Anticholinergic effects can accelerate dementia progression 1, 7
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Should only be used when comorbid depression/anxiety exists, as there is no systematic evidence for effectiveness in primary insomnia 1
• Herbal supplements (valerian, melatonin): Not recommended due to lack of efficacy and safety data 1

Dosing and Monitoring

• Start at the lowest available dose in elderly patients due to reduced drug clearance and increased sensitivity to peak effects 1
• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Employ the lowest effective maintenance dosage and taper when conditions allow 1
• For chronic use: Administration may be nightly, intermittent (three nights per week), or as needed, with consistent follow-up 1

Combination Therapy

Combining CBT-I with pharmacotherapy may provide better short-term outcomes than either modality alone, with medications providing rapid onset relief and behavioral therapy providing longer-term sustained benefit 1. Importantly, medication tapering and discontinuation are facilitated by CBT-I 1.

Long-Term Management

• Avoid long-term pharmacotherapy without concurrent CBT-I trials whenever possible 1
• Regular reassessment is necessary to evaluate treatment effectiveness, monitor for adverse effects, and assess for new or worsening comorbid disorders 1
• Environmental modifications including decreased nighttime noise and light disruption can reduce nighttime arousals 1