What medication is recommended for a patient with insomnia and difficulty staying asleep, considering factors such as medical history and age?

Medication for Sleep Maintenance Insomnia

Low-dose doxepin (3-6 mg) is the most appropriate medication for keeping patients asleep through the night, with superior efficacy for sleep maintenance insomnia and a favorable safety profile. 1

First-Line Pharmacological Choice

Low-dose doxepin (3-6 mg) should be prescribed specifically for sleep maintenance problems, as it:

• Reduces wake after sleep onset by 22-23 minutes with moderate-to-high quality evidence 2, 1
• Improves total sleep time, sleep efficiency, sleep latency, and overall sleep quality 1
• Has no black box warnings or significant safety concerns compared to other sleep medications 1
• Does not carry the dependency, fall risk, or cognitive impairment risks associated with benzodiazepines 1
• Shows no significant difference in adverse events versus placebo 3

Alternative First-Line Options for Sleep Maintenance

If doxepin is ineffective or contraindicated, consider:

Suvorexant (10 mg in elderly, 10-20 mg in younger adults):

• Reduces wake after sleep onset by 16-28 minutes with moderate-quality evidence 2, 1
• Works through orexin receptor antagonism, a different mechanism than other hypnotics 3
• Has lower risk of cognitive and psychomotor effects compared to benzodiazepines 3
• May cause mild somnolence but has minimal abuse potential 1

Eszopiclone (1-2 mg in elderly, 2-3 mg in younger adults):

• Effective for both sleep onset and maintenance with moderate-to-large improvements 2, 3
• Increases total sleep time by 28-57 minutes 3
• Well-tolerated in trials up to 12 months duration 4
• Most common adverse effect is unpleasant taste 4

Critical Requirement: Combine with Behavioral Therapy

Pharmacotherapy must be combined with Cognitive Behavioral Therapy for Insomnia (CBT-I), not used in isolation, as:

• CBT-I provides superior long-term outcomes with sustained benefits after medication discontinuation 1, 5
• Combining behavioral and pharmacologic therapy provides better outcomes than either modality alone 1
• CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive restructuring 5
• Can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules 1

Medications to Explicitly Avoid

Benzodiazepines (temazepam, lorazepam, clonazepam, diazepam) should not be used due to:

• Unacceptable risks of dependency, falls, cognitive impairment, and respiratory depression 1, 5
• Association with increased dementia risk (hazard ratio 2.34) 2
• Increased risk of fractures and major injuries 2
• Rebound insomnia upon discontinuation 1

Trazodone is explicitly not recommended despite widespread off-label use:

• Limited efficacy evidence with no improvement in subjective sleep quality 3
• Significant adverse effect profile with harms outweighing benefits 3
• The American Academy of Sleep Medicine explicitly recommends against its use 1

Over-the-counter antihistamines (diphenhydramine, doxylamine) should be avoided due to:

• Strong anticholinergic effects causing confusion, urinary retention, constipation, and fall risk 1
• Tolerance development with continued use 1
• Lack of efficacy data for insomnia treatment 5

Special Considerations for Elderly Patients

For patients ≥65 years old, the treatment approach requires modification:

Start with the lowest available doses due to altered pharmacokinetics and increased sensitivity:

• Doxepin 3 mg (can increase to 6 mg if needed) 1
• Suvorexant 10 mg maximum 1
• Eszopiclone 1 mg (can increase to 2 mg if needed) 3
• Zolpidem 5 mg maximum if used 1

Monitor closely for adverse effects including:

• Next-day impairment and morning sedation 1
• Falls and fractures (particularly with any benzodiazepine receptor agonists) 2
• Confusion and behavioral abnormalities 1
• Complex sleep behaviors (sleep-walking, sleep-driving) 5

Duration and Monitoring Strategy

Limit pharmacotherapy to short-term use when possible:

• Typically less than 4 weeks for acute insomnia 1, 5
• Use the lowest effective dose for the shortest duration 5
• Reassess after 2-4 weeks of treatment to evaluate effectiveness and adverse effects 1

Regular follow-up should assess:

• Improvement in wake after sleep onset and total sleep time 1
• Daytime functioning and quality of life 1
• Adverse effects including morning sedation, cognitive impairment, and fall risk 1
• Ongoing need for medication versus CBT-I alone 1

Attempt medication taper when conditions allow, facilitated by concurrent CBT-I, which provides sustained benefit after discontinuation 1

Common Pitfalls to Avoid

• Using benzodiazepines as first-line treatment when safer alternatives with better evidence exist 1, 5
• Prescribing trazodone off-label despite explicit guideline recommendations against its use 1, 3
• Failing to initiate CBT-I alongside medication, which provides superior long-term outcomes 1, 5
• Using doses appropriate for younger adults in elderly patients without age-adjusted dosing 1
• Continuing pharmacotherapy long-term without periodic reassessment of ongoing need 1, 5
• Prescribing multiple CNS depressants simultaneously, which significantly increases risks of respiratory depression, cognitive impairment, and falls 3