What sleep medications are recommended for an adult over 70 years with insomnia?

Recommended Sleep Medication for Adults Over 70 Years

Low-dose doxepin (3–6 mg) is the first-choice pharmacological agent for elderly patients with insomnia, offering the best balance of efficacy and safety with fewer adverse effects than other sleep medications. 1

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

Before prescribing any medication, CBT-I must be initiated as the standard of care for chronic insomnia in older adults. 1, 2

• CBT-I demonstrates superior long-term outcomes compared to pharmacotherapy, with sustained benefits lasting up to 2 years after treatment ends in elderly patients. 3, 2
• Core components include: stimulus control therapy (getting out of bed when unable to sleep), sleep restriction (limiting time in bed to actual sleep time plus 30 minutes), relaxation techniques (progressive muscle relaxation, guided imagery), and cognitive restructuring of negative thoughts about sleep. 3, 1
• CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 3, 1

First-Line Pharmacological Option: Low-Dose Doxepin

If CBT-I alone is insufficient after 4–8 weeks, add low-dose doxepin 3 mg at bedtime. 1, 2

Why Doxepin is Preferred in Elderly Patients

• Proven efficacy: Reduces wake after sleep onset by 22–23 minutes, improves sleep efficiency, total sleep time, and sleep quality with moderate-quality evidence. 1, 2
• Minimal anticholinergic effects at hypnotic doses (3–6 mg), unlike higher doses or other anticholinergic agents. 1, 2
• No abuse potential and no DEA scheduling, making it safe for long-term use when needed. 1, 2
• No black box warnings or significant safety concerns associated with benzodiazepines and Z-drugs. 1, 2
• Particularly effective for sleep maintenance insomnia, which is the predominant complaint in elderly patients. 2

Dosing Strategy

• Start with 3 mg at bedtime due to altered pharmacokinetics and increased sensitivity to side effects in patients over 70. 1, 2
• If insufficient improvement after 1–2 weeks, increase to 6 mg while maintaining the favorable safety profile. 1
• Take within 30 minutes of bedtime with at least 7 hours remaining before planned awakening. 1

Alternative Second-Line Options (If Doxepin Fails or Is Contraindicated)

For Sleep Maintenance Insomnia

• Suvorexant 10 mg: Orexin receptor antagonist that reduces wake after sleep onset by 16–28 minutes with moderate-quality evidence; lower risk of cognitive and psychomotor impairment than benzodiazepines. 1, 2
• Eszopiclone 1–2 mg (NOT 2–3 mg): Maximum dose in elderly is 2 mg due to increased sensitivity and fall risk; improves both sleep onset and maintenance. 1, 4

For Sleep Onset Insomnia

• Ramelteon 8 mg: Melatonin receptor agonist with minimal adverse effects, no dependence risk, and no DEA scheduling; appropriate for patients with substance use history. 1, 2
• Zaleplon 5 mg (NOT 10 mg): Very short half-life for rapid sleep initiation with minimal next-day sedation; elderly dose is half the adult dose. 1, 2
• Zolpidem 5 mg (NOT 10 mg): Maximum dose in elderly is 5 mg due to heightened sensitivity and fall risk; reduces sleep latency by approximately 25 minutes. 1, 5

Medications to AVOID in Patients Over 70

Benzodiazepines (Strongly Contraindicated)

All benzodiazepines—including temazepam, lorazepam, clonazepam, diazepam, and triazolam—must be avoided in elderly patients. 1, 2

• Unacceptable risks include: dependency, falls, cognitive impairment, respiratory depression, increased dementia risk, and fractures. 1, 2
• The American Geriatrics Society Beers Criteria strongly recommends against all benzodiazepines in elderly patients regardless of indication. 1
• Long half-lives lead to drug accumulation, prolonged daytime sedation, and markedly increased fall risk. 1

Trazodone (Not Recommended)

Trazodone should NOT be used for insomnia in elderly patients despite widespread off-label prescribing. 1, 2

• Minimal benefit: Only 10-minute reduction in sleep latency and 8-minute reduction in wake after sleep onset. 1
• No improvement in subjective sleep quality compared to placebo. 1
• Adverse events occur in 75% of older adults, including headache (30%) and somnolence (23%). 1
• The American Academy of Sleep Medicine explicitly recommends against trazodone for insomnia treatment. 3, 1

Over-the-Counter Antihistamines (Strongly Contraindicated)

Diphenhydramine (Benadryl), doxylamine, and all OTC sleep aids containing antihistamines must be avoided. 1, 2

• Strong anticholinergic effects cause confusion, urinary retention, constipation, fall risk, daytime sedation, and delirium. 1, 2
• Tolerance develops within 3–4 days, rendering them ineffective for chronic use. 1
• The American Geriatrics Society Beers Criteria includes a strong recommendation against antihistamine use in elderly patients. 1

Antipsychotics (Contraindicated)

Quetiapine, olanzapine, and other antipsychotics should never be used for insomnia in elderly patients. 1

• Sparse evidence for insomnia benefit with small sample sizes. 1
• Known harms include: weight gain, metabolic dysregulation, extrapyramidal symptoms, QTc prolongation, and increased mortality risk in elderly populations with dementia. 1

Critical Assessment Before Prescribing

Review Current Medications

Many medications commonly prescribed to elderly patients disrupt sleep and should be reviewed first. 3, 2

• Sleep-disrupting agents include: β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs. 3, 2
• Consider timing adjustments (e.g., moving diuretics to morning dosing) before adding sleep medication. 3

Screen for Underlying Medical Conditions

Insomnia in elderly patients is often secondary to treatable medical conditions. 3, 2

• Cardiac and pulmonary disease: Shortness of breath from CHF or COPD disrupts sleep. 3
• Pain syndromes: Osteoarthritis, cancer pain, diabetic neuropathy all contribute to insomnia. 3, 2
• Nocturia: Enlarged prostate or overactive bladder causes frequent awakenings. 3
• Neurologic deficits: Parkinson's disease, stroke sequelae, restless legs syndrome. 3
• Depression: Commonly presents with insomnia in elderly patients; untreated insomnia is a risk factor for new-onset depression. 2

Evaluate Sleep Hygiene

Poor sleep habits are common in elderly patients and must be addressed. 2

• Frequent daytime napping (limit to single 15–20 minute nap before 3 PM). 1
• Excessive time in bed (should match actual sleep time plus 30 minutes). 1
• Caffeine after noon and alcohol in the evening. 1
• Heavy meals within 3 hours of bedtime. 1
• Insufficient daytime physical activity. 3

Treatment Algorithm for Elderly Patients

Step 1: Initiate CBT-I Immediately

All patients over 70 with chronic insomnia should receive CBT-I as initial treatment. 1, 2

• Implement stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring. 3, 1
• Address sleep hygiene: stable bedtimes, avoid daytime napping, limit sleep-fragmenting substances. 3

Step 2: Add Low-Dose Doxepin if CBT-I Insufficient After 4–8 Weeks

Start doxepin 3 mg at bedtime for sleep maintenance insomnia. 1, 2

• Reassess after 1–2 weeks for efficacy on sleep latency, total sleep time, nocturnal awakenings, and daytime functioning. 1
• Monitor for adverse effects including morning sedation, cognitive impairment, and falls. 1
• If insufficient improvement, increase to 6 mg. 1

Step 3: Switch to Alternative First-Line Agent if Doxepin Fails After 2 Weeks at 6 mg

For persistent sleep maintenance: Switch to suvorexant 10 mg. 1

For sleep onset difficulty: Switch to ramelteon 8 mg or zaleplon 5 mg. 1, 2

For combined onset and maintenance: Consider eszopiclone 1 mg (increase to 2 mg maximum if needed). 1

Step 4: Reassess for Underlying Sleep Disorders if Insomnia Persists Beyond 7–10 Days of Treatment

Evaluate for: Sleep apnea, restless legs syndrome, periodic limb movement disorder, circadian rhythm disorders. 1

Safety Monitoring and Duration

Monitor Closely for Adverse Effects

All hypnotics carry risks that are amplified in elderly patients. 1, 2

• Next-day impairment: Morning sedation, cognitive slowing, decreased alertness. 1
• Falls and fractures: Observational data link hypnotic use to increased fracture risk. 1
• Complex sleep behaviors: Sleep-driving, sleep-walking, sleep-eating; discontinue medication immediately if these occur. 1
• Cognitive impairment: Memory problems, confusion, delirium. 1, 2

Limit Duration of Pharmacotherapy

Use the lowest effective dose for the shortest necessary duration. 1, 2

• FDA labeling recommends short-term use (typically less than 4 weeks for acute insomnia). 3, 1
• Evidence for long-term safety beyond 4 weeks is insufficient for most hypnotics. 3, 1
• Attempt medication taper when conditions allow, facilitated by concurrent CBT-I. 1
• Conduct periodic reassessment every 4–6 weeks to determine whether the hypnotic can be discontinued. 1

Combination Therapy Provides Best Outcomes

Combining behavioral and pharmacologic therapy provides better outcomes than either modality alone. 1, 2

• Medications provide short-term relief while CBT-I provides longer-term sustained benefit. 2
• Never use pharmacotherapy in isolation without concurrent behavioral interventions. 1

Common Pitfalls to Avoid

• Using adult dosing in elderly patients: All hypnotics require dose reduction (e.g., zolpidem maximum 5 mg, eszopiclone maximum 2 mg). 1, 5
• Prescribing benzodiazepines "just this once": Even short-term use carries unacceptable risks in elderly patients. 1, 2
• Continuing trazodone because "the patient has been on it for years": Switch to evidence-based alternatives. 1
• Failing to initiate CBT-I before or alongside medication: Behavioral therapy is the standard of care. 1, 2
• Combining multiple sedative agents: Markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 1
• Not reassessing pharmacotherapy regularly: Evaluate every 2–4 weeks for efficacy, side effects, and need for continuation. 1