Jeannie Lee, PharmD, BCPS, CGP, College of Pharmacy, University of Arizona
Karen D'Huyvetter, ND, RN-MS, MS-HES, Center for Integrative Health and Healing, Seal Beach, CA
April 2016
TIPS FOR USING SLEEP PHARMACOTHERAPY IN OLDER ADULTS
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Older adults frequently report sleep-related complaints and have questions about appropriate sleep therapies. A previous edition of Elder Care,"Cognitive Behavioral Interventions for Insomnia in Older Adults," discusses the use of non-pharmacological, preventive, and behavioral strategies for treatment of sleep disorders in older adults.
The Role of Drug Therapy
Because many sleep agents are not appropriate for older adults as specified in the Beers Criteria, it is vital to remember that non-drug therapy and preventive/behavioral measures should be the first-line approach in this population. One of the preventive measures related to drug therapy is to identify medications or substances used that might be contributing to sleep problems, and avoiding them or adjusting dosing times to avoid interference with sleep (Table 1). Drug therapy should be reserved for when non-pharmacological and preventive measures fail.
Risk versus Benefit of Pharmacotherapy
An older adult may receive modest sleep benefit from a sleep agent but also experience adverse effects such as cognitive impairment, confusion, sleep walking, falls, etc. Therefore, benefit-to-risk ratio should be carefully considered and explained to older patients and caregivers before starting pharmacotherapy. Current evidence supports treating underlying causes of the sleep problem and initiating a behavioral intervention or a combination of them as first-line treatment. Pharmacological therapy should be reserved for when those measures fail.
Pharmacotherapy Recommendations
The choice of a sleep medication should be directed by several factors including: (a) insomnia pattern, (b) goals of therapy, (c) past treatment responses, (d) comorbidities, (e) contraindications, (f) side -effects, (g) drug interactions, (h) cost, and (i) patient preference. The lowest effective dose of the chosen agent should be used with regular follow-up to assess effectiveness, adverse effects, and need for continued use. Intermittent dosing (2-4 times/week) may be used. Again, short-course treatment (3-4 weeks) should be used unless chronic insomnia is present due to a chronic illness. After chronic use, the medication should be tapered to prevent rebound insomnia.
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Table 1. Common Medications/Substances that Cause or Aggravate Sleep Disorders in Older Adults |
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| Agents | Effects and Advice |
| Alcohol |
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| Antidepressants (e.g., SSRIs, SNRIs, bupropion) |
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| ß-blockers, α-agonist (e.g., atenolol, clonidine) |
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| Caffeine, Decongestants (e.g., pseudoephedrine) |
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| Corticosteroids (e.g., prednisone) |
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| Diuretics (e.g., furosemide) |
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| Levodopa |
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| Nicotine |
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| Phenytoin |
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| Thyroid supplements |
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Table 2 describes sleep pharmacotherapy options, and Table 3 notes medications to avoid in older adults.
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Table 2. Medications to Use
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Melatonin Receptor Agonists - No abuse potential or morning-after effects
Antidepressants - especially for patients with comorbid depression. These drugs have orthostatic side-effect. Tricyclic antidepressants should not be used.
Gabapentin (Neurontin®) - For patients with neuropathic pain or restless legs syndrome, use gabapentin 100 mg to start, and then titrate as needed. Dose must be adjusted in renal insufficiency.
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Table 3. Medications to Avoid
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To improve sleep latency, use a shorter-acting agent (e.g., ramelteon or over-the-counter melatonin). To improve sleep maintenance, use a longer-acting agent like trazodone. Most pharmacotherapies have potential drug/ herbal/ food interactions and adverse effects that need close monitoring. Patient education is key:
- expectation and treatment goals,
- safety concerns,
- potential adverse effects,
- potential drug interactions,
- dose escalation plan,
- rebound insomnia, and
- consider non-pharmacological approaches (e.g., cognitive behavioral therapy).
Supplements for Sleep
Complementary and alternative medicine (CAM) use increases with age. A 2005 report found that 30% of people over 65 report using CAM, and 70% of those are 85 and older. Several supplements are used for sleep.
Melatonin Synthesized endogenously in the pineal gland, evidence suggests that older adults may have melatonin deficiency when compared to younger adults, and melatonin supplementation may be beneficial for insomnia. It is generally well-tolerated, but may exacerbate dysphoria in depressed patients, and have an additive effect with sedatives. Melatonin can also increase the effectiveness of anti-coagulants, may reduce glucose tolerance and insulin sensitivity, and may cause orthostatic hypotension.
Valerian Thought to have sedative-hypnotic, anxiolytic, antidepressant, anticonvulsant and antispasmodic effects, valerian modestly reduces sleep latency and improves subjective sleep quality. It is generally well tolerated, but cases of headache, gastrointestinal upset, excitability, and cardiac problems have been reported. It may have hypotensive effects, and has an additive effect with sedatives.
Passionflower The FDA has given passionflower a "generally recognized as safe" status for use in foods. Preliminary research indicates that drinking one cup of passionflower tea an hour before going to bed improves sleep quality. It has no effect on sleep latency or nighttime awakenings, however. It can cause dizziness, confusion, sedation, and ataxia in some patients. One case of cardiac side effects has been reported. Passionflower may have an additive effect with sedatives.
References and Resources
- American Geriatrics Society 2015 Beers Criteria Update
- Natural Medicines Comprehensive Database
- Martin JL, Fung CH. Quality indicators for the care of sleep disorders in vulnerable elders. JAGS. 2007:55:S424-430.
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