What is the preferred hypnotic agent for a 97-year-old patient receiving comfort care (palliative care) with sleep disturbances in a hospital setting: trazodone (Desyrel) or zopiclone (Imovane)?

From the Guidelines

For a 97-year-old comfort care patient experiencing sleep difficulties in the hospital, trazodone would generally be a better choice than zopiclone due to its better safety profile in the elderly. Start with a low dose of trazodone, typically 25-50 mg taken 30-60 minutes before bedtime. Trazodone is preferred because it has a better safety profile in the elderly, with less risk of falls, confusion, and respiratory depression compared to zopiclone, which belongs to the "Z-drug" class of sedative-hypnotics. Trazodone also lacks the potential for dependence that can occur with zopiclone. In elderly patients, particularly those in comfort care, medication side effects are a significant concern, and trazodone's sedating properties at low doses can improve sleep without the same degree of morning hangover effects or cognitive impairment associated with zopiclone. Additionally, trazodone may provide mild mood benefits, which can be helpful in the hospital setting. Monitor for orthostatic hypotension, especially when the patient gets up during the night, and be prepared to adjust the dose based on response and tolerability, as suggested by the guidelines 1. Some studies suggest that nonbenzodiazepine BZRAs, such as zopiclone, may have benefits that outweigh potential harms, but the risk of serious injuries caused by sleep behaviors associated with these agents should not be overlooked 1. However, the work group advised against use of benzodiazepines or trazodone for treatment of chronic insomnia disorder, citing the widely known harms and adverse effects of benzodiazepines, including risk for dependency and diversion, falls and cognitive impairment in older patients 1. Given the available evidence, trazodone appears to be a safer option for elderly patients in comfort care, despite its own set of limitations and potential adverse effects, as noted in the systematic review 1. Key considerations in the choice between trazodone and zopiclone include the patient's individual risk factors, the potential for drug interactions, and the need for close monitoring of response and tolerability, as emphasized in the clinical practice guidelines 1. Ultimately, the decision to use trazodone or zopiclone should be based on a careful assessment of the patient's specific needs and circumstances, taking into account the latest evidence and guidelines available 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Comparison of Trazodone and Zopiclone for Sleep in a 97-Year-Old Comfort Care Patient

• Trazodone is a commonly used off-label drug for insomnia, which improves sleep quality and sleep continuity but carries significant risks 2.
• Zopiclone, a non-benzodiazepine gamma aminobutyric acid receptor agonist, is an FDA-approved drug for insomnia, but its use in elderly patients is not well-studied in the provided evidence.
• A study on pharmacotherapies for sleep disturbances in Alzheimer's disease found that trazodone 50 mg administered at night for two weeks significantly improved total nocturnal sleep time and sleep efficiency, but there was no clear evidence of any effect on the amount of time spent awake after sleep onset or the number of nocturnal awakenings 3.
• Another study compared the use of melatonin, trazodone, and doxepin in psychiatric patients with sleep disturbances, and found that trazodone was the most effective medication for enhancing sleep quality, but it was associated with frequent adverse effects 4.
• A systematic review of trazodone for insomnia found that there is adequate data supporting the efficacy and general safety of the low-dose use of trazodone for the treatment of insomnia 5.
• A study comparing melatonin and trazodone for the treatment of new-onset insomnia in hospitalized adult patients found that there was no significant difference between the two agents in terms of the primary outcome, and no difference in adverse events was observed 6.

Considerations for the 97-Year-Old Comfort Care Patient

• The patient's advanced age and comfort care status should be taken into account when selecting a medication for sleep.
• Trazodone may be a suitable option for this patient, given its efficacy in improving sleep quality and sleep continuity, but its potential risks and side effects should be carefully considered.
• Zopiclone may not be the best option for this patient, given the lack of evidence on its use in elderly patients and the potential for adverse effects.
• A thorough evaluation of the patient's medical history, current medications, and potential interactions should be conducted before initiating any new medication.