Discontinuing Zolpidem Before Surgery in Older Adults
Yes, it is safe and actually recommended to discontinue zolpidem 2-3 days before surgery in a 68-year-old woman using it PRN for sleep, as this will reduce her risk of postoperative delirium without causing withdrawal effects.
Why Stopping Zolpidem is the Right Decision
Zolpidem Increases Delirium Risk
The American Geriatrics Society strongly recommends avoiding sedative-hypnotics like zolpidem perioperatively to prevent postoperative delirium in older adults 1. Sedative-hypnotics including zolpidem are specifically identified as medications that should be avoided postoperatively because they induce delirium 1. This recommendation applies to benzodiazepines, anticholinergics, and sedative-hypnotics as a class, with the strength of recommendation being "strong" despite low-quality evidence 1.
PRN Use Minimizes Withdrawal Risk
Since this patient takes zolpidem "as needed" rather than nightly, she is at extremely low risk for withdrawal symptoms 2, 3. Withdrawal concerns with zolpidem primarily occur with:
- Daily use at high doses (450-600 mg/day, though cases reported as low as 160 mg/day) 3
- Chronic continuous use leading to dependence 2, 4
The FDA labeling confirms that zolpidem treatment should be "as short as possible because the risk of dependence increases the longer you are being treated" 2. PRN use does not create the physiological dependence that leads to withdrawal seizures or severe symptoms.
Rebound Insomnia is Minimal and Temporary
While rebound insomnia can occur after stopping zolpidem, the evidence shows:
- Sleep onset latency increases by only 13 minutes on the first night after discontinuation (95% CI 4.3-21.7 minutes) 3
- The risk of rebound insomnia with recommended doses is low 4
- This minor sleep disruption for 1-2 nights is far less concerning than the 8.1-28.8% risk of postoperative delirium if sedative-hypnotics are continued 1, 5
The Delirium Prevention Priority
Postoperative delirium is the most common postoperative complication in older adults and is preventable in up to 40% of cases 1. Delirium is associated with:
- Prolonged hospitalization 6, 5
- Increased morbidity and mortality 1, 6, 7
- Falls and injuries 1, 3
- Worse long-term outcomes 1
The American Geriatrics Society guideline emphasizes that avoiding inappropriate medications like sedative-hypnotics is a cornerstone of delirium prevention 1.
Practical Implementation
Stop the zolpidem 2-3 days before surgery without tapering 2. For PRN users:
- No taper is needed given intermittent use pattern
- The patient may experience 1-2 nights of slightly longer sleep onset (approximately 13 additional minutes) 3
- This temporary inconvenience is vastly outweighed by reducing postoperative delirium risk from potentially 28.8% to 8.1% 5
Important Caveats
The one exception would be if this patient has been taking zolpidem daily at high doses chronically, which contradicts the "PRN" description in your question. In that rare scenario, consult regarding a brief taper to avoid withdrawal 2. However, for true PRN use, abrupt discontinuation 2-3 days preoperatively is both safe and strongly recommended 1.
The elderly are particularly vulnerable to zolpidem's CNS effects, with women achieving up to 63% higher serum concentrations than men 8. At age 68, this patient is at the age where delirium prevention should take absolute priority over short-term sleep continuity 1.