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
December 2019
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.
It is important to note that a two-stage or interrupted sleep can be normal.
The Role of Medication 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 therapies, including preventive and behavioral measures should be the first-line approach in this population. These include avoiding or adjusting medications and substances that might be contributing to sleep issues. (Table 1). It is also important to address related conditions such as external stressors, anxiety, bereavement, depression, breathing problems, reflux, urinary urgency, and pain. Medications for sleep should be reserved for instances when non-pharmacological and preventive measures do not meet the patient’s needs, and should be used in combination with these therapies and for a short period, only.
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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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Risk versus Benefit of Pharmacotherapy
Although there may be a modest benefit from a sleep agent, there are numerous potential adverse effects such as addiction, cognitive impairment, confusion, sleep walking, falls, and other accidents. Therefore, benefit-to-risk ratio should be carefully considered and discussed with older patients and caregivers before starting pharmacotherapy. Regular re-assessments with deprescribing should be performed.
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 preferences. 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-term treatment (3-4 weeks) should be used unless chronic insomnia is present due to a chronic illness. After chronic use, many of the medications need to be tapered off to prevent rebound insomnia.
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., short acting melatonin or ramelteon). To improve sleep maintenance, consider trazodone or a sustained release melatonin. Do not try to medicate for 7+ hours of uninterrupted sleep! Most pharmacotherapies have potential drug/herbal/food interactions and adverse effects that need close monitoring. Patient education includes: (a) expectations and treatment goals, (b) safety concerns and potential adverse effects, (d) potential drug interactions, (e) dose escalation plan, (f) rebound insomnia, and (g) non-pharmacological therapies (e.g., cognitive behavioral and sleep hygiene).
Supplements for Sleep
The use of natural products and Complementary and Alternative Medicine (CAM) approaches among Americans are widespread according to the National Health Interview Survey (NHIS). In fact, data from 2012 suggest that at least 40% of adults in the US used at least one CAM approach with a cost in the billions of dollars.
Melatonin Synthesized in the pineal glands during sleep, evidence suggests levels drop significantly in older adults when compared to younger adults. Melatonin supplementation may be beneficial for insomnia due to its effect on the circadian cycle, with onset of action within 40 minutes. It is well tolerated. Vivid dreams, dysphoria in depressed patients or sleep apnea in predisposed patients are possible. Melatonin may have an additive effect with sedatives. Melatonin can also potentiate anticoagulants, reduce insulin sensitivity, and possibly induce orthostatic hypotension. Effects from doses > 4mg may last 10 hours.
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.
Lemon Balm Lemon Balm is “generally recognized as safe” by the FDA when taken by mouth. Clinical research has shown that taking a standardized extract of lemon balm twice daily for 15 days reduced insomnia by 42% in people with sleep disorders. Lemon balm can have an additive effect with other sedating substances and thyroid therapy, and may modestly reduce blood glucose. Lemon Balm taken orally may increase appetite.
References and Resources
- American Geriatrics Society 2019 Beers Criteria Update
- Natural Medicines Comprehensive Database
- Lahteenmaki R, Neuvonen PJ, Puustinen J, et al. Withdrawal from long-term use of zopiclone, zolpidem and temazepam may improve perceived sleep and quality of life in older adults with primary insomnia. https://doi.org/10.1111/bcpt.13144