What are suitable hypnotic medications for the elderly?

From the Guidelines

Elderly patients should be prescribed the lowest effective dose of eszopiclone, 1 mg at bedtime, as a first-line treatment for insomnia, due to its intermediate-acting properties and relatively safer profile compared to other options. When considering sleeping medications for the elderly, it's crucial to prioritize their safety and minimize potential adverse effects, given their increased sensitivity to medication side effects and higher risk of falls, confusion, and other complications 1.

Key Considerations

• The choice of medication should be based on the specific type of insomnia (sleep-onset or maintenance) and the patient's overall health status, including any comorbid conditions such as hepatic impairment or respiratory issues.
• Non-benzodiazepine receptor agonists like eszopiclone and zolpidem are generally preferred over traditional benzodiazepines due to their shorter half-lives and lower risk of dependence and withdrawal symptoms 1.
• Melatonin receptor agonists, such as ramelteon, may also be considered, especially for patients with sleep-onset insomnia, but their efficacy and safety in the elderly population need to be carefully evaluated.
• It's essential to advise patients about the potential risks of sleep-related behaviors associated with benzodiazepine receptor agonists, such as sleepwalking or driving, and to caution them against combining these medications with alcohol or other sedatives 1.

Alternative Approaches

• Before initiating pharmacotherapy, healthcare providers should encourage good sleep hygiene practices, including maintaining a regular sleep schedule, avoiding caffeine and screen time before bedtime, and creating a conducive sleep environment.
• Addressing underlying issues that may be contributing to insomnia, such as pain, depression, or sleep apnea, is also crucial in managing insomnia in the elderly population.
• Certain antidepressants, like trazodone or mirtazapine, may be used off-label for insomnia, but their use should be carefully considered due to potential side effects and the lack of FDA approval for this indication 1.

From the FDA Drug Label

The dose of zolpidem tartrate in elderly patients is 5 mg to minimize adverse effects related to impaired motor and/or cognitive performance and unusual sensitivity to sedative/hypnotic drugs [see WARNINGS AND PRECAUTIONS (5.2)]. Use in Elderly and/or Debilitated PatientsImpaired motor and/or cognitive performance after repeated exposure or unusual sensitivity to sedative/hypnotic drugs is a concern in the treatment of elderly and/or debilitated patients. The dose should not exceed 2 mg in elderly or debilitated patients [see Dosage and Administration (2. 2)].

Recommended dosages for elderly patients:

• Zolpidem: 5 mg
• Eszopiclone: 2 mg (do not exceed) The recommended dosage for elderly patients is lower than for younger adults to minimize the risk of adverse effects, such as impaired motor and cognitive performance. 2 3

From the Research

Sleeping Medications for Elderly

• The choice of sleeping medication for elderly patients should be based on shared decision-making between the practitioner and the patient, with limited prescription 4.
• Nonpharmacological management for chronic insomnia and some sleep disorders may consist of cognitive behavioral therapy, sleep hygiene education, relaxation therapy, sleep restriction, light therapy, and stimulus control therapy 4.
• Pharmacological treatment options for insomnia include non-benzodiazepine hypnotics such as zolpidem, zolpidem-controlled release, zaleplon, zopiclone, eszopiclone, and the melatonin receptor agonist ramelteon 5.
• These compounds are generally well tolerated and present favorable safety profiles in comparison with the older benzodiazepines and barbiturates 5.
• However, they are associated with some risk for dependence and abuse, and concerns regarding such risks appear to be greater than warranted by empirical evidence 5.

Treatment Options

• Sedating antidepressants such as mirtazapine, nefazodone, or tricyclic antidepressants may be used to treat insomnia comorbid with mild to moderate depression 6.
• Behavioral therapies, particularly multicomponent cognitive-behavioral therapy, and lifestyle changes show significant long-term efficacy as treatments for chronic insomnia 6.
• Melatonin and the melatonin-receptor agonist ramelteon have not had adequate study in psychiatric patients to define their use, but small studies suggest benefit 6.
• Prescription of adjunctive trazodone (50-150 mg) is a common clinical practice to treat comorbid insomnia during antidepressant therapy, but published data are surprisingly limited 6.

Novel Treatment Options

• Novel drugs that do not target the GABAergic system, such as suvorexant, low-dose doxepin, and ramelteon, may be used to treat insomnia disorders 7.
• These drugs have a different side effect profile than the benzodiazepines and Z-drugs, and may be used to treat sleep maintenance insomnia or sleep onset insomnia 7.
• The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia 7.