What medications are recommended for sleep maintenance in the elderly population with insomnia?

From the Guidelines

For elderly patients with sleep maintenance issues, I strongly recommend starting with non-pharmacological approaches and considering low-dose doxepin (3-6 mg) or trazodone (25-50 mg) at bedtime for short-term use (2-4 weeks) as a first-line pharmacological treatment, as suggested by the American College of Physicians guideline 1.

Key Considerations

• Non-pharmacological approaches, such as maintaining a regular sleep schedule, avoiding caffeine and alcohol before bedtime, and creating a comfortable sleep environment, should be the initial step in managing sleep maintenance issues in the elderly.
• If medication is necessary, low-dose doxepin or trazodone can be effective for short-term use, with low-dose doxepin (3-6 mg) or trazodone (25-50 mg) at bedtime being a reasonable option.
• Benzodiazepines and Z-drugs (zolpidem, eszopiclone) should be avoided when possible due to increased risks of falls, confusion, and dependence in the elderly, as highlighted in the guideline 1.
• Medications should be regularly reassessed, as elderly patients are more sensitive to side effects due to altered drug metabolism, reduced renal clearance, and increased brain sensitivity to medications.
• Underlying conditions like sleep apnea, restless leg syndrome, or depression should be addressed, as they commonly contribute to sleep maintenance problems in older adults.

Evidence-Based Recommendations

• The American College of Physicians guideline 1 recommends cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment for adults with chronic insomnia disorder.
• The guideline also suggests that clinicians use a shared decision-making approach to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful.
• Low-dose doxepin (3-6 mg) or trazodone (25-50 mg) at bedtime is recommended for short-term use (2-4 weeks) as a first-line pharmacological treatment, with the lowest effective dose used for the shortest duration.

From the FDA Drug Label

1. Dosage and Administration 2. 1 Dose Selection An initial dose of 150 mg/day in divided doses is suggested. Occurrence of drowsiness may require the administration of a major portion of the daily dose at bedtime or a reduction of dosage.

The trazodone drug label suggests that it can be used for sleep maintenance by administering a major portion of the daily dose at bedtime.

• The initial dose is 150 mg/day in divided doses.
• Drowsiness may require adjusting the dosage. 2

From the Research

Medication for Sleep Maintenance in the Elderly

• The treatment of insomnia in the elderly can involve pharmacological and non-pharmacological strategies 3, 4, 5, 6.
• Non-pharmacological strategies are considered the mainstay of treatment for chronic insomnia, but hypnotics can play a role in treating transient insomnia and chronic insomnia that does not improve with non-pharmacological treatment or treatment of associated primary conditions 3.
• Pharmacological therapy usually consists of benzodiazepines with short half-lives or nonbenzodiazepines such as zolpidem and zaleplon, although the lack of demonstrated efficacy against sleep maintenance difficulties limits the use of these agents 3.
• Emerging nonbenzodiazepine agents such as indiplon and eszopiclone may specifically address sleep maintenance problems in elderly patients 3.
• The choice of a hypnotic agent in the elderly is symptom-based, with ramelteon or short-acting Z-drugs used to treat sleep-onset insomnia, and suvorexant or low-dose doxepin used to improve sleep maintenance 5.
• Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance, while low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings 5.
• Benzodiazepines should not be used routinely due to the risk of adverse effects 5.
• Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks 5.
• Melatonin, diphenhydramine, tryptophan, and valerian are non-FDA-approved hypnotic agents that are commonly used, despite limited data on benefits and harms 5.

Specific Medications for Sleep Maintenance

• Suvorexant and low-dose doxepin can improve sleep maintenance in elderly patients 5.
• Eszopiclone and zolpidem extended release can be used for both sleep onset and sleep maintenance 5.
• Ramelteon and short-acting Z-drugs can treat sleep-onset insomnia, while low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings 5.
• Melatonin may slightly improve sleep onset and sleep duration, but product quality and efficacy may vary 5.
• Tryptophan decreases sleep onset in adults, but data in the elderly are not available 5.
• Valerian is relatively safe but has equivocal benefits on sleep quality 5.

Considerations for Medication Use in the Elderly

• The elderly are at greater risk for comorbid insomnia, which results from, or occurs in conjunction with another medical or psychiatric condition 4.
• Cognitive behavioral therapy for insomnia has been shown to be an effective treatment method for difficulty sleeping in elderly individuals and should be the first-line treatment due to its efficacy and safety profile 6.
• Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies 5.
• The choice of medication should be based on the individual's specific symptoms and medical history, and should be used in conjunction with non-pharmacological strategies whenever possible 5.